Florida State University Libraries

Electronic Theses, Treatises and Dissertations The Graduate School

2018

The Effects of Functional Impact Training

and Yin Yoga on Cognition and Quality of
Life in Breast Cancer Survivors
Rachael Leigha Hunt

Follow this and additional works at the DigiNole: FSU's Digital Repository. For more information, please contact lib-ir@fsu.edu
 FLORIDA STATE UNIVERSITY

COLLEGE OF HUMAN SCIENCES

THE EFFECTS OF FUNCTIONAL IMPACT TRAINING

AND YIN YOGA ON COGNITION AND QUALITY OF LIFE

IN BREAST CANCER SURVIVORS

By

RACHAEL HUNT

A Thesis submitted to the

Department of Nutrition, Food & Exercise Sciences
in partial fulfillment of the
requirements for the degree of
Master of Science

2018
Rachael Hunt defended this thesis on March 7, 2018.
The members of the supervisory committee were:

Lynn Panton
Professor Directing Thesis

Jeong-Su Kim
Committee Member

Laurie Grubbs
Committee Member

The Graduate School has verified and approved the above-named committee members, and
certifies that the thesis has been approved in accordance with university requirements.

ii
 ACKNOWLEDGMENTS

I, first and foremost, would like to thank Ashley Artese for her help throughout this project. My
thesis was a small portion of her dissertation and I wouldn’t have been able to do this without her
guidance and eager helpfulness. I would like to thank Dr. Lynn Panton for years of mentorship
but especially the past two as my major professor. Many thanks to Dr. Jeong-Su Kim and Dr.
Laurie Grubbs for agreeing to be on my committee and providing valuable feedback. I would
like to thank Dan Marshall for helping me and Ashley throughout the entire project, from
participant testing and helping with the exercise classes to data entry. A special thanks to our
undergraduates Jordan Giles, Morgan Nixon, Julian Melchor, and Grace Manno who gave their
free time to help us with this project. Of course I would also like to thank our participants who
came to classes even when they might not have wanted to but kept cheerful attitudes; it was a joy
seeing them every time. Many thanks to our valuable departmental and college administrative
staff for always being available and patient: Tara Hartman, Mary-Sue McLemore, David Parish,
Christine Apgar, Dr. Chester Ray. This would not be possible without the American College of
Sports Medicine Foundation Doctoral Student Research Grant and the National Strength
Conditioning Association Foundation Graduate Student Research Grant that were awarded to
Ashley Artese for her dissertation. Finally, a huge thanks to my dear friends Wesley Anderson,
Margaret Morrissey, Jacob Kisiolek, Kyle Smith, Brandon Willingham, Kyle Cesareo, Tristan
Ragland, and Justin Mason for being there from start to finish and making this fun; it was a
wonderful journey and I can’t wait to see what we do next.

iii
 TABLE OF CONTENTS

List of Tables ...................................................................................................................................v

Abstract .......................................................................................................................................... vi

1. INTRODUCTION ......................................................................................................................1

2. REVIEW OF LITERATURE ......................................................................................................7

3. METHODS ................................................................................................................................27

4. RESULTS AND DISCUSSION ...............................................................................................33

APPENDICES ...............................................................................................................................50

A. IRB APPROVAL ......................................................................................................................50

B. APPROVED INFORMED CONSENT ....................................................................................51
C. MEDICAL HISTORY QUESTIONNAIRE .............................................................................56
D. PHYSICIAN CONSENT FORM..............................................................................................62
E. QUESTIONNAIRES/TESTS ...................................................................................................63
F. FUNCTIONAL IMPACT TRAINING PROTOCOL...............................................................81
G. YIN YOGA PROTOCOL .........................................................................................................82

References ......................................................................................................................................83

Biographical Sketch .......................................................................................................................91

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 LIST OF TABLES

Table 1. Baseline Participant Demographics (N=45) ....................................................................36

Table 2. Baseline Participant Frequencies for Race, Cancer Stage, and Type of Treatment
(N=45) ......................................................................................................................................36

Table 3. Intent-To-Treat Fitness Changes for Participants in Fitness Measures (N=45) ..............38

Table 4. Fitness Measures for Participants Who Completed the Study (N=32) ............................39

Table 5. Intent-To-Treat Cognitive and QOL Measures (N=45)...................................................40

Table 6. Cognitive and QOL Measures of Participants Who Completed the Study (N=32) .........41

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 ABSTRACT

Although cognition declines with age, cancer may increase that decline, either through cancer
treatment or decreased quality of life (QOL) accompanied with increased anxiety and depression.
Cross-sectional research shows that more active breast cancer survivors (BCS) have higher
cognitive function and better QOL; however, longitudinal data are needed. Purpose: This study
evaluated the effects of 3 months of functional impact training (FIT) on cognition and QOL
compared to yin yoga in BCS. It was hypothesized that FIT would experience greater
improvements in cognition compared to yin yoga, but similar improvements in QOL compared
to yin yoga. Methods: Forty-five BCS (60.5±8.3 yrs; BMI: 29.2±7.1 kg/m2) were recruited to
complete Trail-Making Test A and B [TMTA (processing speed), TMTB (executive function)],
Digit Span Forward (attention) and Backward (working memory), and Controlled Oral Word
Association Test [COWAT (executive function)] to assess cognitive domains. QOL was
measured using the 36-item Short Form Survey (SF-36). The BCS were stratified by breast
cancer stage, type of cancer treatment, and lean mass to participate in either FIT or yin yoga.
Participants assigned to the FIT group completed 3 months of supervised exercise training
sessions consisting of exercises that were performed using body weight, dumbbells, step
benches, stability balls, and mats. These exercises were high impact and included jumping and
hopping. Each exercise session lasted approximately 45 minutes and was completed twice per
week. The intensity of the exercise program started out low to prevent injury and to introduce
participants to the exercises and then intensity was gradually increased over the course of the 3
months. Exercises performed included squat jumps, jump lunges, push-ups, dumbbell rows,
shoulder presses, biceps curls, triceps extensions, and planks. The participants progressed to
more high impact versions of these exercises throughout the duration of the exercise program.
All sessions were monitored and led by a certified fitness professional, and all exercise sets and
repetitions were recorded. Participants assigned to the yin yoga group completed 3 months of
supervised yin yoga training sessions, which consisted of exercises that focus on stretching and
relaxation. Exercises were lying or seated and were performed on a yoga mat using equipment
such as yoga blocks, straps, and bolsters. Each yin yoga session lasted approximately 45 minutes
and was completed twice per week. Baseline and 3-month changes in cognitive function and
QOL were assessed using group by time repeated measures analysis of variance (ANOVA).

vi
Significance was accepted at p≤0.05. Results: There were no group by time differences on any
of the cognitive or QOL measures in the intent-to-treat analysis or for those who completed the
study. There were no significant differences from baseline to post testing on any of the cognitive
measures for FIT; however, yin yoga significantly improved in the COWAT Total score from
baseline to post testing (p=0.03). There were significant time effects for the QOL measures for
the different domains of the SF36 for the FIT and yin yoga groups. From baseline to 3 months,
FIT significantly improved in role limitations/physical (p=0.04), emotional well-being (p=0.01),
and general health (p=0.01) while yin yoga had significant improvements in physical functioning
(p=0.03), emotional well-being (p=0.03), and general health (p=0.02) domains within the SF-36.
Conclusion: In conclusion, our findings indicate that neither a FIT, combining resistance and
aerobic training, nor a yin yoga program had significant improvements in cognition over 3
months. Both FIT and yin yoga may be viable options for maintenance of cognition during
aging, since both showed neither a significant increase or decrease in scores. FIT and yin yoga
did however demonstrate significant improvements in QOL over the 3 months of the study.
Along with recent literature, it seems that exercise and yoga may both be non-pharmaceutical
options for improving QOL in BCS. Further research with a longer intervention duration is
needed to examine the effects of FIT and yin yoga on cognition in BCS. Future research should
also focus on cognitive changes before, during, and after cancer treatment to examine when
cognition may return to normal function.

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 CHAPTER 1

INTRODUCTION

Introduction

Breast cancer accounts for nearly 1 in 3 cancers, making it the second most common
cancer diagnosed among women in the United Sates (US).1 It was estimated that there were
232,670 new breast cancer cases in 2014, however, the incidence rate has leveled off and the
survival rate continues to improve.2 The population of breast cancer survivors (BCS) is estimated
at more than 3.1 million women, with about 72% of all BCS aged 60 years or older.3 Although
improvements in screening and treatment methods for breast cancer have increased survivorship,
the treatments have increased the number of adverse side effects. Some of the side effects
include decrements in cognition and quality of life (QOL).4–7 Other consequences of cancer
treatments can include increases in physical pain, depression, and anxiety.8
Even though cognitive function declines naturally as part of the aging process, BCS may
be at a slightly higher risk for deficits in comparison to women without cancer.9 The main
domains of cognition that are affected by cancer treatments are executive function, processing
speed, and memory. Executive function is described as one’s ability to plan, initiate or carry out
goal-directed behavior, while processing speed is a measure of one’s ability to perform relatively
easy tasks and memory is concerned with immediate and conscious processing. Cancer
treatments such as chemotherapy, surgery, radiotherapy, and endocrine therapy may all play a
role in the cognitive decline observed in BCS.6,10 Research regarding BCS and cognition thus far
has revolved around measuring cognition before and after cancer treatment, measuring cognitive
differences after varying doses of cancer treatments, comparing cognitive changes between BCS
and healthy individuals, and/or looking at associations between general physical activity levels
of BCS and cognition.
Women who have been diagnosed with cancer have been shown to have greater levels of
depression when compared to healthy controls.11 Additionally, BCS typically have higher levels
of depression compared to current breast cancer patients undergoing treatment.11 A study with
1
145 BCS found that pain symptoms from treatment were associated with lower physical activity
and had a positive correlation with both depression and negative affect.8 These psychological
factors such as poor QOL, depression, and anxiety have been linked to decrements in
cognition12, and can contribute to self-reported, and possibly objective, cognitive declines.
One non-pharmacological intervention used for attempting to attenuate some of the side
effects of cancer treatment is exercise. Both aerobic and resistance training exercise programs
have been associated with improved cognition, QOL, and fatigue in BCS.13–16 A study that
measured physical activity using accelerometers showed that BCS participating in moderate to
vigorous physical activity had a positive association with the information processing speed
domain of cognition.16 Hartman et al. also found that higher levels of physical activity were
associated with better performance on computerized tests measuring executive function and
attention domains.17 Improvements in QOL could be due to a variety of things such as decreased
body fat, increased strength, as well as increased overall independence, while mechanisms
behind improvements in cognition are still debated. Furthermore, group exercise programs in
particular have promoted functional and psychological benefits for women of all ages with early
stage breast cancer.18 Although physical activity of any kind has many benefits, only 29-37% of
BCS meet the general recommendations as of 201319, while even fewer meet the general
recommendations for resistance training. This can be due to a number of factors including busy
schedules, lack of equipment, lack of access to facilities, or lack of enjoyment from exercise.19
Yoga has also become a popular alternative treatment for alleviating some of the side
effects from cancer treatment. For current cancer patients receiving chemotherapy or
radiotherapy, yoga has been shown to improve nausea, physical functioning, QOL, mental
health, and depression.20–22 Cancer patients and survivors have been shown to experience
positive psychological benefits after yoga interventions23, as well as decreased anxiety and
increased emotional and social function.24 Additionally, yoga has been found to reduce
menopausal symptoms such as fatigue, joint pain, and negative mood in BCS.25
Current evidence shows that due to perpetuating side effects from treatment, BCS tend to
have decreased cognitive functioning and QOL. Exercise (aerobic and resistance) and yoga have
demonstrated significant impacts on the physical and mental wellbeing of BCS. Therefore, the
purpose of the present study was to evaluate 3 months of functional impact training (FIT) on
cognition and QOL compared to yin yoga in BCS. A FIT program, similar to high-intensity

2
interval training (HIT) in regards to circuits of aerobic and resistance training, was used for the
exercise group classes because FIT is designed specifically to help individuals improve
performance and movements used for activities of daily living (ADL). FIT training may be more
entertaining than traditional resistance training and the social support of the group exercise might
enhance adherence and add psychological benefits to the exercise program.26 For the current
study, yin yoga was used for the yoga group consisting of seated and lying postures that were
held for three to five minutes. Because of this social support, it was anticipated that the FIT and
yin yoga groups would both elicit more enjoyment for the participants. Cognition, specifically
executive function, attention, working memory, and processing speed domains, were measured
objectively through five different tests. It was hypothesized that FIT would have greater
improvements in executive function, attention, working memory, and processing speed measures
of cognition compared to yin yoga however QOL would improve in both the FIT and yin yoga
and would not be significantly different between the two groups.

Specific Aims

This study was designed to answer the following research questions.

Specific Aim 1
To determine to what extent three months of FIT would affect cognition of executive function,
attention, working memory, and processing speed compared to yin yoga in post-menopausal
BCS. Executive function was measured using Trails Making Test B (TMTB) and the Controlled
Oral Word Association Test (COWAT). Attention was assessed using Digit Span Forward.
Working memory was measured using Digit Span Backward while processing speed was
assessed using Trails Making Test A (TMTA).
Hypothesis: BCS participating in FIT would experience greater improvements in executive
function, attention, working memory, and processing speed compared to BCS participating in yin
yoga.
Specific Aim 2
To determine to what extent three months of FIT would affect QOL measures compared to yin
yoga in post-menopausal BCS. QOL was measured by the 36-item Short Form Survey (SF-36).

3
Hypothesis: BCS participating in FIT would experience similar improvements in QOL measures
compared to BCS participating in yin yoga.

Limitations

1. Since only female BCS who have been diagnosed with stages 0–III cancer and have
completed primary treatment were able to participate in the study, results may not be
generalizable to women diagnosed with stage IV breast cancer, BCS who have not
undergone primary treatment, women currently undergoing treatment, and/or male BCS.
2. Participants who agreed to participate in the study might have felt well enough to perform
exercise or be more motivated to begin an exercise program than those who did not wish
to participate, and therefore results of this study may not be generalizable to the entire
BCS population.
3. Since participants were recruited from the Tallahassee, Florida and surrounding areas,
results may not be generalizable to BCS living in other areas.

Delimitations

1. BCS who have been diagnosed with stages 0-III cancer and who have completed primary
treatment for breast cancer were eligible to participate. Therefore, women diagnosed with
stage IV breast cancer, BCS who have not undergone primary treatment, women
currently undergoing treatment, or male BCS were not eligible to participate in the study.
2. Women with other chronic conditions including hypo or hyperthyroidism, uncontrolled
hypertension (>160/100 mmHg), uncontrolled diabetes, and uncontrolled heart disease
were not eligible to participate in the study.
3. In order to measure the effects of the specific exercise intervention proposed in this
study, BCS who were not participating in an exercise program were eligible to
participate. Therefore, women who were currently participating in an exercise program
(resistance training ≥ one time per week, aerobic training ≥ two times per week, or yoga
≥ two times per week) were not eligible to participate in the study.

4
 4. BCS who were currently undergoing treatment or were less than 3 months post-treatment
were not eligible to participate. Women who had surgery within the past three months
were not eligible to participate.

Assumptions

1. All participants accurately reported their age, breast cancer diagnosis, treatment type and
length, menopausal status, physical activity history, and health history.
2. All participants experienced similar body composition side effects due to the cancer
treatment.
3. All participants followed the researchers’ instructions regarding physical activity and
maintaining daily nutrient intake outside of the prescribed exercise intervention.
4. All equipment and testing procedures provided valid and reliable measurements
throughout the course of the study.

Definition of Terms

1. Adjuvant Chemotherapy: Chemotherapy that is used after primary treatments such as

surgery or radiation, which has removed the visible cancer cells. This treatment, given by
mouth, injection, infusion, or on the skin, stops the growth of cancer cells by destroying
the cells or arresting the cell cycle to prevent cancer cells from dividing (mayoclinic.org).
2. Aromatase Inhibitors: A drug that prevents the formation of estrogen from androgens by
blocking the enzyme aromatase (breastcancer.org).
3. Attention: The ability to focus on incoming stimuli.5
4. Body Composition: The relative proportions of muscle, fat, water, and mineral contents in
the body (http://medical-dictionary.thefreedictionary.com).
5. Breast Cancer: Cancer that forms in the breast tissue. It can occur in the lining of the milk
ducts (ductal carcinoma) or in the lobules, also known as milk glands (lobular carcinoma)
of the breast. Invasive breast cancer occurs when the breast cancer has spread from where
it began in the milk ducts of lobules to normal tissue in the surrounding area (cancer.gov).

5
6. Cognition: The mental action or process of acquiring knowledge and understanding
through thought, experience, and the senses (en.oxforddictionaries.com).
7. Executive Function: The ability to plan, perform abstract reasoning, solve problems, focus
despite distractions and shift focus when appropriate (alz.org).
8. Functional Impact Training: Performing impact exercises that include hopping, skipping,
and jumping that are designed to improve the performance of activities and movements
that can improve ADL (Artese, 2016).
9. Functional Resistance Training: Performing exercises where muscles work against a
resistance in a manner that the increases in strength directly improve the performance of
movements so that an individual can perform ADL with greater ease
(www.acefitness.org).
10. Menopause: The period in a woman’s life that marks the end of menstrual cycles. It is
defined as occurring 12 months after the last menstrual period (mayoclinic.org).
11. Muscular Strength: The maximal amount of force a muscle can exert against a
resistance.27
12. Physical Function: The ability to complete ADL, which are required for safe independent
living.28
13. Processing Speed: A measure of how long it takes for someone to perform relatively
simple tasks or the time between receiving and responding to a stimulus (cognifit.com).
14. Quality of Life (QOL): Individual perceptions of positions in life in relation to goals,
expectations, standards, and concerns in the context of an individual’s culture and value
systems. It may encompass physical health, psychological states, levels of independence,
social relationships, and personal beliefs (World Health Organization).
15. Radiation Therapy: A type of primary treatments that uses high-powered energy beams,
such as x-rays, to destroy cancer cells (mayoclinic.org).
16. Resistance Training: A mode of exercise that uses external resistance to cause the muscles
to contract with the goal of building muscle strength, tone, mass and endurance.27
17. Working Memory: Memory that involves storing, focusing attention on, and manipulating
information for a relatively short period of time (merriam-webster.com).
18. Yin Yoga: A form of yoga that involves variations of seated and lying postures that are
typically held for three to five minutes (yogajournal.com).

6
 CHAPTER 2

REVIEW OF LITERATURE

Introduction

Breast cancer accounts for nearly 1 in 3 cancers, making it the second most common
cancer diagnosed among women in the US.1 It was estimated that there were 232,670 new breast
cancer cases in 2014; however, the incidence rate has leveled off and the survival rate continues
to improve.2 The population of BCS is estimated to be more than 3.1 million women, with about
72% of all BCS aged 60 years or older.3 Although improvements in screening and treatment
methods for breast cancer have increased survivorship, the treatments have increased the number
of adverse side effects. Some of the side effects include decrements in body composition,
physical functioning, cognitive functioning, and QOL.4,5 Other consequences of cancer
treatments can include increases in physical pain, depression, and anxiety.8

Stages of Breast Cancer

Once a tumor has been detected in the breast, the stages of cancer are determined by the
size of the tumor, whether the cancer is invasive or non-invasive, whether the cancer is in the
lymph nodes, and the degree of metastasis. “Local” is a term used to describe when the cancer is
confined to the breast, “regional” describes when the cancer has reached the lymph nodes or the
armpit, and “distant” is used when the cancer is found in other body parts.29 The stages of breast
cancer range from 0-IV, with the most advanced stage being IV. Stage 0 is when the cancer is
non-invasive and there is no evidence of cancer cells outside of where the cancer has started. In
stage I, the cancer is considered invasive and describes a small tumor that has not spread or a
small cluster of cancer cells that have spread to the lymph nodes. Stage II is divided into
subcategories IIA and IIB and ranges from no tumor in the breast but cancer has spread to 1-3
lymph nodes to a large tumor, greater than 5 centimeters, that has not spread to the lymph nodes.
Stage III is considered advanced cancer and includes the cancer invading surrounding tissues
7
near the breast. Finally, stage IV is characterized by the cancer spreading to other areas of the
body.30

Treatment Options for Breast Cancer

There are five standard types of breast cancer treatment: surgery, radiation therapy,
chemotherapy, hormone therapy, and targeted therapy.3 Radiation therapy, chemotherapy,
hormone therapy, and targeted therapy can all be given before (neoadjuvant) or after (adjuvant)
surgery.31 Surgery and radiation therapy can be used locally without affecting the rest of the
body, while chemotherapy, hormone therapy and targeted therapy are used for systemic
treatment if the cancer has spread to other body parts.31 Breast surgery can be divided into two
main categories: breast-conserving and mastectomy.31 Breast-conserving surgery is when only
the part of the breast containing the cancer is removed (as known as a lumpectomy), while a
mastectomy involves removing the entire breast and sometimes, nearby tissues.31 Lymph nodes
can also be removed via surgery, with the number of lymph nodes removed depending on the
severity of the cancer.31
While most women will have some form of surgery to remove the tumor, treatment after
removal is based on the individual’s diagnosis.32 Those who are diagnosed with stages I to III
will most likely receive radiotherapy before and/or after surgery, sometimes in combination with
chemotherapy or hormone therapy; this is to help lower the chances of recurrence.32 Radiation
therapy uses high-energy rays to destroy cancer and can be external or internal, having side
effects that include swelling or skin changes in the treated area, fatigue, and/or infection.32
Chemotherapy is a drug given intravenously or orally, before, during, or after treatment and
works to attack all rapidly growing cells.32 Chemotherapy is found to be most effective when
given in a combination of two or more drugs.32 Hormone therapy is used for estrogen receptor-
positive breast cancer cells.32 This means that the cancer cells have receptors that bind estrogen
to help them grow and hormone therapy drugs work to lower estrogen levels or stop estrogen
binding so that the cancer cannot grow.32 The two most common hormone therapy drugs used are
tamoxifen, which blocks estrogen receptors, and aromatase inhibitors, which lowers estrogen
levels.32 Furthermore, there are several targeted therapies, which target specific genes and
proteins found in cancer cells or in other cells that contribute to cancer growth.32 These work in

8
specific ways to block or arrest cancer growth, unlike chemotherapy which blocks the growth of
both cancer cells and healthy cells.32

Side Effects of Cancer Treatment

Although cancer treatments can be effective for most patients, the aftermath of those
chemicals and combination therapies can leave a patient with several additional obstacles. The
severity and number of side effects vary depending on the stage of breast cancer and amount(s)
and type(s) of treatments. Surgery can cause soreness at the surgery site and potentially lead to
infection. Radiation therapy side effects can include swelling or skin changes in the treated area,
fatigue, and/or infection. Chemotherapy has side effects that include hair loss, nausea, and
vomiting. Chemotherapy can also negatively affect bone growth and increase the risk of
infections. Treatment using aromatase inhibitors may cause bone loss due to its suppressive
effect on estrogen levels in order to reduce tumor growth, while treatment with tamoxifen may
lead to hot flashes, mood swings, and fatigue. Target therapy can cause shortness of breath, leg
swelling, and heart damage.3,32
Treatment for breast cancer is needed shortly after diagnosis leaving little to no time for
trying less invasive treatments. Because of this and the fact that exercise might be
uncomfortable, breast cancer patients are typically given traditional cancer treatments which are
followed by the previously mentioned side effects. Inactivity from not exercising, however,
results in further decreased bone density and muscle mass, increased fat mass, and decreased
strength and QOL. Furthermore, these changes can lead to greater increases in anxiety and
depression and decreases in positive body image33, providing additional exercise barriers.19 A
recently studied topic that is a side effect of cancer treatment and often associated with
depression is cognitive decline, which will be discussed in the following section.

Cognitive Domains and Definitions

Cognition involves the mental action or process of acquiring knowledge and

understanding through thought, experience, and sense.34 Because it can be challenging to test or
measure cognition as a whole, this complex subject is broken down into many different domains

9
or categories. These domains may have slight overlap but some common cognitive domains
include executive function, attention, working memory, and processing speed.5,6,10,35,36 Executive
function describes one’s ability to plan, initiate, and carry out goal-directed behavior. Attention
can be described as the ability to focus on incoming stimuli. Working memory is concerned with
immediate, conscious processing, while processing speed is a measure of how long it takes for
someone to perform relatively simple tasks or the time between receiving and responding to a
stimulus.
Countless tests and questionnaires have been developed in order to measure these
different domains and monitor improvement or decline. A cognitive battery is a set of tests or
questionnaires that a researcher chooses to measure specific cognitive domains. Because many of
these domains slightly overlap, there is some discrepancy around what each test measures;
however, there is consensus around a few tests. Common cognitive tests include the Trail
Making Test A (TMTA), Trail Making Test B (TMTB), Digit Span Forwards and Backwards,
and Controlled Oral Word Association Test (COWAT). Both TMTA and TMTB tests are similar
but measure different domains. While TMTA typically assesses processing speed7,10,37,38 or
attention35,38,39, TMTB assesses executive function.7,10,35,37–39 Digit Span as a whole has been
defined by researchers as measuring attention10,40, working memory7,41, and executive function.38
Individually, Digit Span Forwards assesses attention35,37, while Digit Span Backwards assesses
executive function35 as well as working memory.37,39 Furthermore, the COWAT has been defined
as measuring executive function.35,38
The TMTA is a test used to assess processing speed and is typically administered on
paper. The TMTB is also usually given to the participant on paper and is used to assess executive
function. Both parts of the TMT consist of 25 circles distributed over a sheet of paper. In Part A,
the circles are numbered 1 – 25, and the participant draws lines to connect the numbers in
ascending order.42 In Part B, the circles include both numbers (1 – 13) and letters (A – L); as in
Part A, the participant draws lines to connect the circles in an ascending pattern, but with the
added task of alternating between the numbers and letters (i.e., 1-A-2-B-3-C, etc.).42 The
participant is instructed to connect the circles as quickly as possible, without lifting the pen or
pencil from the paper.42 The Digit Span Forwards and Backwards are typically administered
verbally or on a computer and are used to assess attention and working memory respectively.43
For both Forwards and Backwards, a researcher recites a series of numbers in a specific order to

10
the participant, starting with two digits for Forwards and two digits for Backwards then
progressing the degree of difficulty by adding one digit for each level. The participant repeats the
numbers in the correct forward or backwards order (depending on which test she is
completing).43 The participant gets two tries at each level regardless of whether she gets the first
attempt correct or not.43 The participant’s score is based on the total number of correct attempts
achieved.43 This takes approximately 5-7 minutes. The COWAT is a test that measures executive
function. During the COWAT, participants are given three trials, each using a different letter
(e.g., FAS, CFL) to list as many words beginning with that letter in one minute.44 Participants
cannot use proper nouns, numbers (e.g., nine for “N”) or the same word using a different ending
(e.g., cancel, cancelled).44 The total number of acceptable words are added together for all three
trials and measured for performance.44 This test takes approximately 4-5 minutes to complete.
These tests are used often within the literature of cognition but there are countless more that are
used. Throughout this literature review, many studies that will be discussed have used other tests
than the ones described above, but details will be given on the ones above as they pertain to the
current study.

Aging Effects on Cognition in Healthy Adults

Cognitive domains are associated with various regions of the brain. It has been found that
executive function depends on both the anterior and posterior regions of the brain, while episodic
memory is associated primarily with the temporal and internal capsule white matter. Working
memory seems to be related through all regions; however, largely associated with anterior white
matter. Lastly, processing speed is associated with mainly the anterior portion of the brain,
specifically the superior frontal gyrus.45
The most observed declines and improvements in cognition have been found in executive
function. Research suggests that declines can be prevented and even reversed, but the exact
factors that determine this are still unknown. Although age-related changes in white matter vary
by region,46 it is hypothesized that degeneration of white45,47 and grey matter47 and loss of
neuroplasticity47 within the brain contribute to declines in cognition. Raz et al. found in a 5-year
longitudinal study that the brain shrinks with age even in healthy older adults, but individual
differences contribute to the magnitude and variability of that change in brain volume.48 The

11
previous study found that age-related declines in brain volume were greater than originally
predicted using cross-sectional data, warranting research aimed towards attenuating these
declines.
As previously mentioned, TMTA, TMTB, Digit Span Forward and Backward, and the
COWAT are all commonly used to assess domains of cognition. The average time for TMTA for
healthy adults aged 45-54 years is about 31.8s (±9.9), while TMTB time is 63.8s (±14.4s). With
0-12 years of education, adults aged 55-59 years on average take 35.1s (±10.9s) to complete
TMTA and 78.8s (±19.1s) to complete TMTB. Those aged 60-64 years average 33.2s (±9.1s)
for TMTA and 74.6s (±19.6s) for TMTB, while healthy adults aged 65-69 years average 39.1s
(±11.8s) for TMTA and 91.3s (±28.9s) for TMTB.42 For healthy adults completing the COWAT
(FAS), total acceptable words for those aged 40-49 years average 43.5 (±12.2), while 50-59
years average 42.2 (±11.1), 60-69 years averaged 38.5 (±13.7), and 70-79 years average 34.8
(±12.8) words.49 These averages for healthy adults show that scores on these tests generally
decline with healthy aging.

Cancer Effects on Cognition

Studies regarding cancer and cancer treatment effects on cognition vary between the
different domains measured. Cognitive changes with treatment have been found with all types of
cancer treatment50 and specifically with breast cancer treatment.35,51 Data show that BCS
experience a deficit in cognitive functioning when compared to healthy older women.5,9 The
mechanisms behind these impairments are unknown but hypothesized to include neurotoxic
effects, oxidative damage, and blood clotting in the central nervous system vessels from cancer
treatments. Self-reported measures often show more cognitive decline than when objective
measures are used.52 This could be due to the cancer experience causing depression and anxiety.
Positive correlations have been seen in those with greater signs of depression often subjectively
report greater cognitive deficits without objective decline. One theme that seems consistent
among most studies is that only a few domains are affected, most often including executive
function assessed using TMT (AB together)53, TMTB7,10, or COWAT10 and processing speed
using TMTA.7,10 For reference of average scores, a study looked at BCS following one year after
completion of treatment. The average age of the women was 57 years and education was 14.6

12
years. The researchers found that BCS who received chemotherapy completed TMTA in 25.4s
(±6.1s) and TMTB in 62.5s (±23.0s) while those who only received hormonal therapy
completed the TMTA in 25.0s (±6.8s) and TMTB in 67.9s (±23.3s).7 These same women
averaged Digit Span (as a whole) scores of 17.2 (±3.9) and 18.1 (±4.1) respectively and
COWAT (FAS) scores of 43.3 (±14.0) and 40.9 (±10.5) words, respectively. These data
collected for the BCS are better than what has been reported for the healthy adult population for
some of these tests and could be due to the BCS having a higher average education level than the
healthy adults’ scores previously mentioned.
Although some studies do not show significant cognitive decline, others show that BCS
have significant declines in executive function and memory during and after treatment in
comparison to healthy older women5 and in comparison to before treatment.10 Bender et al.
looked at cognitive differences before and after treatment between breast cancer patients who
received only chemotherapy, those who received chemotherapy and tamoxifen, and patients that
had ductal carcinoma in situ (DCIS) that received neither treatment.54 This study compared
objective measures of attention, executive function, and general intelligence as well as subjective
measures of overall cognition. Researchers measured depression, anxiety, fatigue, and
concomitant medications because these are often associated with cognitive decline. The study
found that objective cognitive declines in the two groups that received treatments were domain
specific to memory. They also found no correlation between objective and subjective cognitive
decline, leading researchers to believe that perception of cognitive decline may be due to factors
such as anxiety or depression.
Along with subjective cognitive decline, Schagen et al. studied the effect of informing
versus not informing cancer patients about chemotherapy-related cognitive decline.55
Researchers recruited cancer patients who had received chemotherapy and those who had no
history of chemotherapy and further divided each group into one of two subgroups: one that
received an introduction to the study that “some patients treated with chemotherapy experience
cognitive problems” or the other group that received a neutral introduction (control). Self-
reported cognition was assessed, objective cognitive performance was measured to assess the
learning and memory domain, and mood affect was measured. The study found that those who
were informed of chemotherapy-related cognitive decline, especially participants with
chemotherapy experience, showed significant subjective and objective declines in comparison to

13
those who were not informed. Subjective complaints of cognitive decline can be influential on a
cancer patient’s QOL, anxiety, depression, and overall lifestyle.52 Furthermore, even without
chemotherapy or radiation, women simply diagnosed with breast cancer tend to experience
depression; however, cognitive decline has been observed mostly in BCS who have received
chemotherapy.10,53 Chemotherapy is typically thought to be the largest contributor to decrements
in cognition and this decline is typically referred to as “chemo-brain” but may actually be due to
a combination of all cancer treatments received by BCS.6
In a recent meta-analysis by Jim et al., researchers found that BCS treated with
chemotherapy performed worse on verbal ability tasks compared to non-cancer controls and
worse on visuospatial ability tasks (tasks that require the ability to copy or reconstruct a two-
dimensional figure or pattern) than patients treated without chemotherapy.5 This meta-analysis
looked at 17 studies that examined attention, executive function, information processing, motor
speed, verbal ability, visual memory, and visuospatial ability. Significant differences were only
found in verbal ability and visuospatial ability when comparing those treated with chemotherapy
to patients treated without chemotherapy. This contradicts studies previously described that saw
significant decrements in executive function, memory, and processing speed. Wefel et al.
conducted a study assessing cognitive function using TMTA, TMTB, COWAT, and Digit Span
at 2.9 months, 7 months, and 13.1 months after baseline, where baseline was prior to treatment.10
Researchers found that 65% of participants experienced acute onset (2.9 months or 7 months)
cognitive decline in learning and memory, executive function, and processing speed domains.
Additionally, 61% of patients experienced late onset (7 months) decline in learning and memory,
with 30% of those patients demonstrating new onset of decline that had not previously been
observed. This suggests that some individuals may not experience cognitive decline until a year
after their cancer treatment has been completed.
In contrast, Hermelink et al. found cognitive deficits in participants prior to treatment but
stable cognition during treatment which then argues that perhaps the decrements are not from
chemotherapy.37 The Digit Span Forward scores improved from 8.1 (±2.1) to 8.4 (±1.9)
however this was not statistically significant, while the Digit Span Backward scores did
significantly improve from 6.8 (±2.2) to 7.3 (±2.4) after treatment. TMTA scores before
treatment averaged 34.0s (±13.8s) and 32.0s (±12.7s) after, while TMTB scores averaged 79.9s
(±36.9s) before and 78.5s (±50.7s) after. Both TMTA and TMTB scores were not statistically

14
significant. Furthermore, it has also been suggested that cognitive functioning after
chemotherapy may return to baseline after about 6 months5; however, longer lasting effects have
also been observed.10
The exact causes of cognitive decline (if there is any decline) are still unknown, and the
discrepancies between which domains decline and when patients see these declines highlights the
fact that more research is needed in this area. As before, one’s own perception of declining
cognition or depression and anxiety could play a role in how one may perform on objective
measures of cognition. Because cognition and QOL may be associated, the following section will
discuss cancer effects on QOL.

Cancer Effects on QOL

The World Health Organization defines QOL as individual perceptions of positions in life
in relation to goals, expectations, standards, and concerns in the context of an individual’s
culture and value systems. It may encompass physical health, psychological states, levels of
independence, social relationships, and personal beliefs. Thus, having a good QOL would mean
that an individual perceives his or her life as fulfilling and joyful. Cancer treatments, however,
can either cause or intensify mood alterations such as depression or anxiety. Because of this,
BCS have an increased risk for depression, anxiety, fatigue, and poor QOL.4,11
There are many questionnaires used to assess QOL including ones specific to cancer
patients (Functional Assessment of Cancer Therapy-General) and even more specifically breast
cancer patients (FACT-Breast). The Medical Outcomes 36-item Short Form Health Survey, more
commonly referred to as the SF-36, is a 36-item, patient-reported survey of health status in 8
domains.56 The 8 domains include vitality, physical functioning, bodily pain, general health
perceptions, physical role functioning, emotional role functioning, social role functioning, and
mental health.56 The higher the score an individual receives, the less disability he or she may
have, with a score of 100 being the highest possible.56 It is commonly used in research to
measure health-related QOL (HRQOL).
Leung et al. recently looked at data from the Australian Longitudinal Study on Women’s
Health (ALSWH), which collected data on women aged 18-75 years from 1996-2010.57 In this
sample 345 women were identified who had recently been diagnosed with breast cancer and had

15
completed the SF-36. Researchers found a significant decrease in HRQOL after diagnosis within
the bodily pain, general health, physical functioning, physical role, and vitality domains between
pre-diagnosis and recently after breast cancer diagnosis. The bodily pain mean decreased from
68.1 to 65.1, general health decreased from 69.7 to 63.7, physical functioning decreased from
80.8 to 77.8, physical role decreased from 73.9 to 65.2, and vitality decreased from 57.9 to 55.9.
However, compared to when they were recently diagnosed, these women experienced significant
improvements in the general health, physical role, emotional role, social functioning, and vitality
domains at the 3-year follow-up. General health increased from 63.7 to 67.2, physical role
increased from 65.2 to 72.7, emotional role increased from 73.8 to 80.0, social functioning
increased from 77.0 to 82.1, and vitality increased from 55.9 to 58.6. Frazetto et al. used the
Geriatric Depression Scale (GDS) to assess QOL in 173 women aged 65-75 years. These women
were divided into four categories: 1) 46 BCS; 2) 62 women diagnosed with breast cancer; 3) 32
women with recurrent breast cancer after 10 years; and 4) 30 women in good health status.11 The
GDS is an assessment consisting of 100 questions answered with a “yes” or “no”. Researchers
found that there was a correlation between depression and cancer experience, with a significant
difference in grade of depression between those with cancer experience and healthy participants.
Although it is unknown, which comes first, there seems to be a synergistic relationship,
or combined effect, among QOL, depression, and anxiety where each individually affects the
other. There have been many studies that focus on improving QOL for BCS using exercise
training (aerobic and resistance training) or yoga, thus the following sections will discuss the
studies regarding the effects of exercise and yoga interventions on cognitive measures conducted
within a healthy population as well as BCS.

Exercise Interventions and Cognition in Healthy Older Adults

A number of domains of cognitive function have been studied after exercise interventions
(aerobic, or resistance training) such as attention, motor speed, executive function, information
processing, and memory.58–60 Aerobic and resistance exercise training have been studied in older
healthy adults and both modalities have been shown to improve cognitive function. Etnier et al.
noted that moderate to high intensities of aerobic exercise have been associated with large
increases in cerebral blood flow and proposed that this increased volume of nutrients and oxygen

16
to the brain might contribute to the positive relationship between exercise and cognition.61 It has
also been proposed that because resistance training reduces homocysteine levels it may prevent
cognitive decline because high levels of homocysteine have been associated with impaired
cognition, Alzheimer’s disease and cerebral white matter lesions.62
Much of the research on exercise and its effects on cognition have used aerobic exercise
programs over resistance training. Many associations have been found between individuals with
higher physical activity levels or aerobic capacity and higher cognitive functioning.47,63 It is
unclear whether higher cognitive function is due to aerobic exercise; however, it is suggested
that aerobic activity does benefit executive function including tasks such as multi-tasking,
planning, and inhibition.64 Nagamatsu et al. conducted a study evaluating the changes in verbal
memory and learning and spatial memory after 26 weeks of resistance training, aerobic training,
or balance and tone training (control).65 The resistance training program intensity began within
the work range of six to eight repetitions for two sets and stayed within that range for the
duration of the study. The resistance training protocol consisted of biceps curls, triceps
extension, seated row, latissimus dorsi pull-downs, leg press, hamstrings curls, minisquats, lunge
walks, mini lunges, and calf raises. The aerobic training program intensity started at 40% of the
individual’s heart rate reserve (HRR) and progressed to 70-80% over the course of the study.
Researchers screened for mild cognitive impairment or cognitive decline that is greater than
expected for an individual’s age and education level but does not significantly interfere with
everyday function. It was found that older adults with probable mild cognitive impairment
showed positive effects on verbal and spatial memory, measured by the Rey Auditory Verbal
Learning Test (RAVLT) and a computerized in-house task, respectively, with both aerobic and
resistance programs. In a study by Best et al., healthy women between the ages of 65 and 75
years participated in either once-weekly or twice-weekly resistance training sessions, or a twice-
weekly balance and tone training sessions for 52 weeks and were then invited to take part in a 2-
year follow-up.66 Both resistance training programs had long-term positive impacts when using
TMTA and TMTB, and Digit Span Backward to assess executive function, with the once-weekly
group showing a significant change from baseline at post-intervention and the 2-year follow up
and twice-weekly showing significant change from baseline at the 2-year follow up.
Additionally, in a 12-month study, resistance training improved cognitive impairments in elderly
women by enhancing executive functioning or selective attention and conflict resolution.67 Even

17
simply walking 1.5 hours per week at a 21-30 min/mile pace has been associated with less
working memory and attention decline (measured through the Digit Span Backward) and higher
functioning in healthy older women.68
Brown et al. showed that group-based exercise programs have also demonstrated greater
improvements in fluid intelligence than exercising alone.69 Participants were screened for
cognitive impairments prior to the programs. Fluid intelligence (the ability for abstract thought
and problem-solving) was assessed using 4 subtests of the Wechsler Adult Intelligence Scale-
Revised (WAIS-R): similarities, arithmetic, picture complete, and digit symbol. Executive
function was measured through the TMTB and the COWAT. WAIS-R Digit Span Forward was
used to assess learning and sequential processing, while Backward was used to assess working
memory. One-hundred and fifty-four participants aged 62-95 years old (87.7% female) were
divided into a group-based exercise program (GE), a group program consisting of flexibility and
relaxation (FR), or a group with no exercise to control for benefits of social interaction (NEC).
The GE was composed of a warm up followed by resistance training exercises, balance training,
and activities for challenging hand-eye and foot-eye coordination, ending with a cool-down
totaling around 55-65 minutes. The FR involved minimal-intensity exercise comprised of gentle
bending and rotations and controlled rhythmical breathing. After the 6-month programs, the GE
average COWAT score increased from 32.8 (±11.1) to 36.4 (±11.4) while the FR average also
increased from 33.3 (±10.2) to 36.4 (±9.3), however, both of these increases were not
statistically significant. The GE average score for TMTB improved from 58.0s (±33.2s) to 55.2s
(±38.2s) while the FR average score increased from 78.6s (±55.0s) to 80.4s (±66.4s), and again
these changes were not statistically significant. All of these changes in the GE group were not
significant from baseline to 6-months and not significant in comparison to either FR or NEC.
Similar non-significant results were seen for working memory, whereas the GE group’s Digit
Span (together) slightly improved from 35.0 (±10.2) to 35.9 (±10.8) and Digit Span Forward
decreased from 7.3 (±2.2) to 7.2 (±2.1). Digit Span Backward did significantly increase from
5.7 (±1.8) to 6.2 (±2.1). All these changes were not statistically significant in comparison to
either FR or NEC. Although participants did not significantly improve in executive function or
working memory, fluid intelligence showed significant improvements with the GE in comparison
to FR and NEC with increases in similarities and arithmetic subtests of the WAIS-R previously

18
described. Similarities, with respect to GE, significantly improved from 13.1 (±5.1) to 18.9
(±5.1) while arithmetic significantly improved from 9.3 (±3.7) to 10.0 (±3.9).
Although, some studies show improvement within executive function, processing speed,
and working memory, data surrounding which domains improve are not consistent, which
warrants more research. While aerobic and resistance training programs have been shown to
slow down the cognitive decline in the general older adult population,70 the research is still
conflicting and there is debate as to whether or not improvements in cognitive function are
exercise-induced.

Exercise Interventions and Cognition in BCS

Most studies with BCS, cognition, and exercise have evaluated physical activity levels
with cognition rather than aerobic or resistance training interventions. A study by Marinac et al.
assessed the effects of aerobic light-intensity activity (1.5-2.9 metabolic equivalents (METs))
and moderate-vigorous physical activity (3.3-7.0 METs) measured through accelerometers on
cognitive domains such as executive function, information processing, and memory assessed
using a 45-minute computerized test.16 Researchers reported no significant association between
light-intensity activity and any domains of cognition but a positive association between
moderate-vigorous activity and information processing speed. Ten minutes of moderate-vigorous
activity was associated with a 1.35-point higher score (out of 100) on the information processing
test when adjusted for sedentary time, total accelerometer wear time, and primary language
spoken. Pradhan et al. found that self-reported attention function was positively associated with
higher levels of physical activity in young BCS when adjusting for anxiety, depression, and
fatigue.71 Although physical activity and cognition were assessed through questionnaires and not
objectively measured, young BCS reported worse attention function, more depressive symptoms,
and more fatigue when compared to acquaintance controls. Furthermore, Hartman et al. reported
that higher levels of physical activity were associated with better performance on computerized
tests measuring executive function and attention domains.17
Although the evidence thus far has been cross-sectional and has shown that greater
physical activity is associated with greater cognitive functioning, there has not been a study that
looks at cognition in BCS after an exercise intervention. It would be beneficial to study how

19
cognition may or may not change after an exercise intervention within this population. Because
poor QOL is sometimes associated with decreased cognition, the following section will discuss
some of the studies that examine the changes in QOL after exercise in both healthy older adults
and BCS.

Exercise Interventions and QOL in Healthy Older Adults

Declines in cognitive function are also associated with psychological factors such as poor
QOL, depression, and anxiety.12 A review of 9 studies by Bicego et al.72 suggested that exercise
improved mood and QOL through socialization, goal setting, and decreased body weight.
Because decrements in cognitive function are associated with poor QOL and depression,
improvements in these measures would greatly benefit cognition.
Although some exercise programs have had no effect on cognitive function in older
adults, they have however found improved QOL. Kimura et al. designed a twice-weekly, 3-
month resistance training program targeting large muscle groups to improve balance.73 They also
assessed health-related QOL (HRQOL) using the SF-36 and executive function using
computerized task-switch reaction time trials. Researchers found that although there was no
training effect on executive function, overall HRQOL improved after the intervention.
Specifically within the SF-36, mental health significantly improved from 53.5 (±8.5) to 56.2
(±8.8).
In a cross-sectional study, Acree et al. administered the SF-36 to 112 participants (63
females and 49 males) between the ages of 60 and 89 years to assess HRQOL.74 Participants
were divided into higher and lower physical activity groups and no exercise, with higher defined
as participating in more than one hour per week of regularly performed moderate physical
activities while lower was defined as moderate physical activities done regularly for less than
one hour per week. The higher physical activity group had significantly higher values in all 8
domains of the SF-36 in comparison to the lower physical activity group. After adjusting for
gender and hypertension, the higher physical activity group still had higher values in 5 of the
domains than the lower physical activity group, with a mental health domain value of 77 (±16)
in the lower physical activity group and 84 (±12) in the higher physical activity group. The

20
association between higher physical activity levels with higher SF-36 scores supports that
exercise improves QOL.
Within the healthy older adult population, exercise has been associated with better QOL.
Intervention studies show that higher physical activity levels likely cause improvements in QOL.
There are many proposed mechanisms for this improvement, but one that might play a role
within the current study is the increase in socialization.

Exercise Interventions and QOL in BCS

Resistance training, with respect to BCS and reducing the side effects of cancer
treatment, has become of particular interest to researchers within the last several years.
Resistance training programs have demonstrated improved bone density75, strength14,15,76,
physical function76, and body composition15, which are all crucially important for performing
activities of daily living (ADL) for BCS. After treatment is completed, BCS can have a myriad
of complications including problems with body composition.77 This effect combined with the
aging process and reductions in physical activity can lead to decreases in strength and the ability
to do ADL from the loss of muscle mass.
Ohira et al. looked at the effect of a 6-month, twice-weekly resistance training program
on QOL in BCS15. Researchers measured strength via 1-repetition maximum (1-RM) tests, body
composition via dual-energy X-ray absorptiometry (DXA) scans, and QOL via the Cancer
Rehabilitation Evaluation System Short Form (CARES-SF). This study found that improvements
in QOL were significantly associated with increases in lean muscle mass and body strength. A
sedentary lifestyle and declining body composition are associated with decreases in mental
health including QOL, body image issues, anxiety, depression, fatigue, fear, and cognitive
function. Because of this, it is important that BCS improve their physical activity levels. Milne et
al. studied the effects of a combined aerobic and resistance training program on BCS within two
years of completing their adjuvant treatment.14 The exercise program consisted of a 20-minute
cardiovascular portion and a resistance training component with 12 different exercises completed
3 times a week. Quality of life was assessed using the FACT-B scale and showed significant
improvement with all participants. This study found that QOL improvements were observed after

21
week 6 and continued through week 12 of the program, providing evidence for exercise as a
viable treatment method for improving QOL.
Although, most recent research shows that exercise improves QOL measures in BCS,13 a
study by Simonavice et al. showed that after 6 months of resistance training, BCS achieved
strength and functional gains similar to those of healthy post-menopausal women, but did not
have significant increases in QOL.76 Research regarding BCS and QOL has become very popular
and many studies show great improvements. Similar to the healthy adult population, although
some studies do not show increases in QOL, there are other improvements from the exercise
interventions, which benefit BCS in their daily lives.
As previously mentioned, yoga has also become a subject of interest when discussing
other types of exercise interventions for individuals going through or recovering from cancer
treatments. The remaining sections will examine the effects of yoga on cognition and QOL for
both the healthy older adults and BCS.

Yoga Interventions and Cognition in Healthy Older Adults

Yoga is typically used for spiritual meditation and relaxation; however, research with
yoga is growing in evaluating the effects of yoga practice on improving joint or muscular pain,
decreasing anxiety and depression, and improving cognition and QOL.78 Various types of yoga
are being used in research including Iyengar, Hatha, yin yoga, as well as non-specified or light
yoga.21,39,78,79 Although the names of the yoga interventions vary, the styles are very similar and
the aim is to improve flexibility, circulatory health, pain from injuries, and depression.
A recent meta-analysis by Gothe et al. reviewed studies using tests such as TMTA,
TMTB, Digit Span Forward and Backwards and COWAT and found that yoga demonstrated
modest effects on specific cognitive domains in healthy adults.38 Attention, processing speed,
and executive function demonstrated the largest benefits from yoga interventions in comparison
to memory; however, memory still had significant improvements. Six out of the 7 acute studies
showed that a single yoga session was associated with moderate improvements in attention and
processing speed, while 11 of the 15 randomized-controlled trials (RCTs) showed similar results.
One acute study and 13 RCTs examined executive function changes after yoga and found
significant effects. Those studies that did show a positive relationship between yoga and

22
cognition suggested that this might be due to yoga’s down-regulating effect on the sympathetic
nervous system during stress. This effect ultimately improves anxiety and depression, which as
previously stated, can affect cognition.
Gothe et al. conducted an 8-week study where healthy older men and women participated
3 times a week in either a Hatha yoga or stretching-strengthening program.80 The Attention
Network Test (ANT), which is similar to the Eriksen flanker test using a combination of reaction
tasks, was used to assess attention. TMTA, TMTB, and Pattern Comparison Tests were used to
assess processing speed. Participants in the Hatha yoga group experienced improvements in all
three tests compared to the stretching-strengthening group. Analysis showed a significant time x
group interaction for TMT and specifically a significant group effect for TMTB time at follow-
up, while a significant group by time interaction was observed for attention. In contrast, a study
by Oken et al. found that older adults who participated in a yoga intervention for 6 months
showed no significant improvements in cognition.81 Participants were randomized into a yoga,
exercise, or control group for 6 months and tested for attention and alertness. A 10-word list-
learning task measuring delayed memory and WAIS-III Letter-Numbering Sequencing
measuring working memory were used as secondary assessments. This discrepancy that an 8-
week study can show significant improvements and a 6-month study cannot warrants more
research on yoga’s effect on cognition.
Although some studies show no improvements, most studies that research yoga effects on
cognition within healthy older adults show improvements in cognition. From acute to
longitudinal, data are not consistent in regards to how much cognition improves by, if at all. This
warrants more research on the effects that yoga may have on cognition.

Yoga Interventions and Cognition in BCS

Although there have been cognitive improvements in the general healthy population with
yoga, there has not been such improvement in objective measures for BCS. Few studies have
been done evaluating cognitive changes after a yoga intervention in the BCS population to date.
However, most of these studies that have been completed have utilized self-reported measures,
observing subjective improvements in cognitive deficits.71,79 Self-reported assessments have
included the Breast Cancer Prevention Trial (BCPT), Cognitive Problems Scale,79 and the

23
Attention Function Index71 which measures attention through perceived changes in attention,
working memory, and executive function. Any self-reported improvement could be due to better
QOL since better QOL is associated with higher cognitive functioning and often observed after
yoga interventions. Derry et al. found that the BCPT showed significantly less self-reported
cognitive problems after 3-months of yoga compared to the control group.79 Only one study was
found looking at objective measures for cognitive changes during or after a yoga intervention,
however this population only contained four early stage BCS currently receiving
chemotherapy.82 Objective cognitive function was measured using CogState, which contains
customizable computerized tests. Researchers did not specify which tests were used but stated
that speed, accuracy, and number of errors were assessed for each test measuring processing
speed, attention, working memory, and problem solving. Subjective cognitive changes were
assessed via the Perceived Cognition Questionnaire (PCQ). This case series reported a trend in
improvement in speed and reduction of errors with yoga however there were no significant
differences in the variables measured.
Although many studies have found yoga to improve cognition in the healthy adult
population, it is unclear whether yoga can improve cognition in the BCS population. Objective
tests for measuring cognitive function are needed in larger sample sizes to evaluate if changes
can occur in cognition with yoga in BCS. The following two sections will discuss research
regarding the effects of yoga on QOL in both healthy older adults and BCS.

Yoga Interventions and QOL in Healthy Older Adults

As mentioned in the previous section, yoga has served many purposes in the research
world, from alleviating lower back pain to enhancing walking, balance, muscular strength, and
blood pressure to improving mood, affect, and QOL. A study by Halpern et al. observed changes
in the SF-36 questionnaire measuring HRQOL in participants after 12 weeks of twice-weekly
hatha yoga classes.83 The yoga classes consisted of meditation exercises, standing, sitting, prone
and supine postures as well as balance and flexibility components. The control and yoga groups
contained 84% and 81% women, respectively, with the total average ages being around 74 years.
Compared to the control, the yoga group saw significant improvements in the physical role,
vitality, and social functioning domains of the SF-36. Physical role increased from 54.3 (±38.0)

24
to 64.2 (±35.6), vitality increased from 59.3 (±17.4) to 63.7 (±17.8), and social functioning
increased from 77.5 (±21.9) to 83.7 (±21.6). Additionally, as discussed in the previous section,
Oken et al. did not show improvements in cognition after 6 months of yoga or exercise, however,
researchers did find that the SF-36 showed significant group effects on vitality/energy and
fatigue, role physical, social functioning, and the physical composite scale.81
Despite many studies showing beneficial effects of yoga on QOL, a meta-analysis
recently looked at 18 studies observing yoga effects on various measurements and found that
although there seemed to be beneficial improvements from yoga on depression, household
functioning, and sleep for the older adult population, these benefits were still unclear because the
methods varied among studies and each had small sample sizes.84

Yoga Interventions and QOL in BCS

Because of the emotional toll that comes with being diagnosed with cancer, BCS are at a
high risk for decreased QOL. Similar to the general healthy population, yoga interventions have
helped improve QOL in BCS and breast cancer patients.78,85–87 Improvements in QOL from yoga
could be due to a number of factors including decreased anxiety and stress, increased
mindfulness, and perhaps an added spiritual component to the person’s lifestyle.
A study by Derry et al. found that yoga helped significantly reduce self-reported
cognitive decline, as well as fatigue and anxiety and depressive symptoms that often plague BCS
post-treatment.79 Similarly, a study by Culos-Reed et al. showed that 7 weeks of 75 minute-yoga
sessions including gentle breathing, laying supine, and stretching and strengthening exercises
improved overall mood and stress in BCS when compared to the control group.23 In contrast, a
study by Chandwani et al. looked at QOL in breast cancer patients currently undergoing
radiotherapy.21 Participants were randomized into a yoga, stretching, or waitlist group. During
their radiotherapy treatment, participants in the yoga and stretching groups attended up to three
60-minute yoga classes each week. Even though there were no significant improvements in QOL
after the 6 weeks, participants still benefited from yoga through improvements in posture and
body position as well as physical functioning (measured by the SF-36 physical function
component).

25
 Comparable to the healthy adult population, yoga more often than not improves QOL
within the BCS population. Even when data show no significant improvements in QOL after a
yoga intervention, BCS may still benefit from yoga through other improvements in anxiety,
posture, and physical functioning.

Conclusions

Due to the side effects from their breast cancer treatments, BCS are susceptible to
decreased cognitive performance and QOL along with increased depression and anxiety. Studies
have found that the cognitive domains that generally seem to decline with cancer treatment are
executive function, attention, working memory, and processing speed. Exercise has recently been
researched as a means to improve cognition in older adults. Most aerobic interventions used to
test cognitive changes show significant improvements or at least maintenance of cognition.
There have not been many resistance training interventions used to evaluate changes in
cognition, however, a combination intervention may show greater improvements than either
resistance training or aerobic alone. Decreased QOL has also been observed with cancer
treatment and may be correlated with cognitive declines. Studies have shown that the effects of
the diagnosis of cancer in combination with side effects from treatment results in BCS having
significantly lower QOL than healthy adult women. Exercise and yoga interventions have shown
some improvements or at least maintenance of QOL in BCS. Therefore, more research is needed
to determine if an exercise program that combines resistance and aerobic training may be
effective in improving cognition and QOL in BCS. While yoga, especially gentle forms such as
restorative and yin yoga, may not be optimal for the improvement in cognition, more research is
needed to identify if this mode of exercise may produce positive effects on QOL in BCS.

26
 CHAPTER 3

METHODS

Study Design

Participant Recruitment

Forty-five BCS (stages 0-III) were recruited from a larger 6-month BCS study at Florida
State University (FSU) within the Clinical Exercise Physiology Laboratory to participate in the
current study. Participants were between the ages of 45 and 75 years with stages 0-III breast
cancer. BCS who had completed primary breast cancer treatment (chemotherapy, radiation,
and/or surgery) for a minimum of 3 months were eligible to participate. Participants who were
taking aromatase inhibitors were also eligible to participate. Participants who had been
diagnosed with stage IV breast cancer or women who had been identified with current active
cancer were not eligible to participate in the study. In addition, women who were undergoing
primary breast cancer treatment or receiving medication that is known to affect muscle or fat
metabolism were excluded. Women with other chronic conditions including hypo or
hyperthyroidism, uncontrolled hypertension (>160/100 mmHg), uncontrolled diabetes, and
uncontrolled heart disease were also excluded. Those who were participating in a regular
exercise program (resistance training ≥ one time per week, aerobic training ≥ two times per
week, or yoga ≥ two times per week) were ineligible to participate in the study. This study was
approved by the Institutional Review Board at FSU (Appendix A).

Orientation Visit

Eligible participants met with the researchers at the Clinical Exercise Physiology
Laboratory at FSU for an orientation visit. During this visit, participants were provided with a
full review of the study details and were given the opportunity to ask questions. If they wanted to

27
participate, they completed the informed consent (Appendix B). Following the informed consent,
participants completed a medical history questionnaire (Appendix C). Each participant was also
given a physician’s consent form to take to her oncologist or primary care physician to inform
the physician about her participation in the study and to ensure that the physician did not have
any concerns (Appendix D). Once physicians’ consents were received, participants were called
to schedule their first visit to the laboratory.

Laboratory Visit 1

Baseline blood pressure, heart rate, height, and weight measurements were taken. Blood
pressure was measured at the brachial artery using a blood pressure cuff (Adcuff, American
Diagnostic Corporation, Hauppauge, NY) and stethoscope (3M™ Littmann Classic III, Littmann
Stethoscopes, St. Paul, MN). The particpants sat quietly for 5 minutes with their arm supported
near heart level, back supported, and feet flat on the ground. The cuff was wrapped around the
upper portion of the unaffected arm (if lymph nodes were removed) and aligned with the brachial
artery. The cuff was inflated to about 200 mmHg and released slowly (about 2-4 mmHg/second)
during which time the researchers listened for blood pressure sounds and recorded their findings.
Resting heart rate was measured at the radial artery for 30 seconds using a stopwatch (Survivor
Accusplit, Pleasanton, CA). Researchers used two fingers to feel for the radial pulse near the
wrist and, starting with zero, counted the nuber of heart beats felt in 30 seconds. Two
measurements of each were completed and averaged. Weight and height were measured with a
physician’s scale (Seca Corporation, Mexico) and wall mounted stadiometer measure (Seca
Corporation, Mexico), respectively. Body composition was measured via the use of an iDXA
scanner (General Electric Healthcare, Madison, WI). Very low doses of radiation were used;
however, this test is non-invasive. Participants rested in a supine position on a padded table for
approximately 20 minutes while the scan was completed for body composition (body fat
percentage and lean body mass). Testing was completed according to the manufacturer’s
instructions and specifications by a certified X-ray technician. Following the body composition
measures, participants completed a one-repetition maximum (1RM) test on the chest press
machine (MedX, Ocala, FL) and knee extension and flexion strength on the Biodex™ isokinetic
machine (System 3 Pro, Shirley, NY). For these tests, participants warmed-up by completing

28
several submaximal repetitions with light weight or light force. For the chest press, participants
were progressed from submaximal to maximum weight that they could lift one time through a
full range of motion. For the Biodex™ knee extension, participants extended and flexed their leg
as hard as possible against a shin pad. Strength was assessed at 180º per second on the dominant
leg, evaulating peak torque. Participants performed 5 repetitions of knee extension and flexion
each. This first visit took approximately two hours to complete.

Laboratory Visit 2

During the second baseline visit, particpants first completed questionnaires assessing
cognitive functioning and QOL (Appendix E). The specific questionnaires were the Short
Portable Mental Status Questionnaire (SPMSQ)88, the Trail Making Test Part A (TMTA)42 and B
(TMTB)42, the Digit Span Forwards (DSF) and Backwards (DSB)43, the Controlled Oral Word
Association Test (COWAT)89, the Patient Health Questionnaire (PHQ-9)90, and the 36-item
Short Form Survey (SF-36).56 The SPMSQ is a questionnaire used for screening cognitive
deficits. The SPMSQ was administered verbally to the participant, it consisted of 10 questions
and took approximately one minute to complete. A test with 0-2 errors indicates intact
intellectual functioning, 3-4 errors indicates mild intellectual impairment, 5-7 indicates moderate
intellectual impairment, and 8-10 indicates severe intellectual impairment. TMTA is a test used
to assess processing speed and was administered on paper. Circles on the paper were numbered 1
– 25, and the participant was instructed to draw a line to connect the numbers in ascending order,
without lifting the pen, as quickly as possible. The time was recorded and measured for
performance. TMTB is a test used to assess executive function. Similar to TMTA, there are 25
circles, however, the circles include both numbers (1 – 13) and letters (A – L); as in Part A, the
participant drew lines to connect the circles in an ascending pattern as quickly as possible
without lifting the pen, but with the added task of alternating between the numbers and letters
(i.e., 1-A-2-B-3-C, etc.). The time was recorded and measured for performance. DSF is a test
used to measure attention. Researchers recited a series of numbers in a specific order to the
participant, starting with two digits and progressing the degree of difficulty by adding one digit
for each level. The participant was instructed to repeat the numbers in the correct forward order.
The participant was given two tries at each level regardless of whether the first attempt was

29
correct or not. The test ended when the participant failed at both trials of the same length. The
total number of correct trials was added and measured for performance. DSB is a test used to
measure working memory. Similar to DSF, researchers recited a series of numbers in a specific
order to the participant, starting with two digits and progressing the degree of difficulty by
adding one digit for each level. The participant was instructed to repeat the numbers in the
correct backwards order. The participant was given two tries at each level regardless of whether
the first attempt was correct or not. The test ended when the participant failed at both trials of the
same length. The total number of correct trials were added and measured for performance.
COWAT is a test used to assess executive function. Participants were given three trials, each
using a different letter (e.g., F, A, S) to list as many words beginning with that letter in one
minute. Participants could not use proper nouns, numbers (e.g., nine for “N”) or words that differ
from a previous response by tense, plurality, or grammar usage. Changing a word ending to
produce a new word that refers to a noun (e.g., “teach” and “teacher”) was considered acceptable
and such instances were scored as two separate words. Homonyms of previous responses were
accepted if the participant makes the meanings clear. Slang and commonly used foreign words
were also scored as acceptable responses. The total number of acceptable words were added
together for all 3 trials and measured for performance. The PHQ-9 is a nine-question
questionnaire used to assess depression. It was administered on paper and took approximately
one minute to complete. Scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe,
and severe depression respectively. Finally, the SF-36, is a 36- item, patient-reported survey of
health status in 8 domains. The 8 domains include physical functioning, role limitations/physical,
role limitations/emotional, energy/fatigue, emotional well-being, social functioning, pain, and
general health. The higher the score the participant received, the less disability she had, with a
score of 100 being the highest possible. It is commonly used in research to measure health-
related QOL (HRQOL). This questionnaire was administered on paper and took approximately 5
minutes to complete.
After the cognitive tests, participants repeated the 1-RM test and the highest values of the
two baseline visits was recorded as the criterion value. Participants then completed the 6-minute
walk (6MW) test to assess aerobic capacity. Participants walked indoors around an oval hallway
45m in length for 6 minutes. Their distance was recorded using a trundle wheel (Invicta,
Bicester, OX).

30
Intervention

Once the two baseline visits were completed, participants were randomized to one of two
groups, FIT or yin yoga stratified by breast cancer stage, type of cancer treatment, age, weight,
and lean mass. Participants assigned to the FIT group completed 3 months of supervised exercise
training sessions consisting of exercises that were performed using body weight, dumbbells, step
benches (The Step, Marietta, GA), step risers (The Step, Marietta, GA), stability balls, and mats
(Yoga Direct, Richmond, VA). These exercises were high impact and included jumping and
hopping. Each exercise session lasted approximately 45 minutes and was completed twice per
week. The intensity of the exercise program started out low to prevent injury and to introduce
participants to the exercises and then intensity was gradually increased over the course of the 3
months. Exercises performed included squat jumps, jump lunges, push-ups, dumbbell rows,
shoulder presses, biceps curls, triceps extensions, and planks. The participants progressed to
more high impact versions of these exercises throughout the duration of the exercise program.
See Appendix F for pictures and the description of the FIT protocol. All sessions were monitored
and led by a certified fitness professional and all exercise sets and repetitions were recorded.
Participants assigned to the yin yoga group completed 3 months of supervised yin yoga training
sessions, which consisted of exercises that focused on stretching and relaxation. Exercises were
lying or seated and were performed on a yoga mat (Yoga Direct, Richmond, VA) using
equipment such as yoga blocks (3”x6”x9”) (Yoga Direct, Richmond, VA), straps (Yoga Direct,
Richmond, VA), and bolsters (Yoga Direct, Richmond, VA). Each yin yoga session lasted
approximately 45 minutes and was completed twice per week. See Appendix G for pictures and
the description of the yin yoga protocol. The yin yoga sessions were led by a Yoga Alliance
registered yoga teacher (RYT 200). There was no third group that abstained from physical
activity. Researchers felt that having a third group that did not participate in physical activity was
unethical because participants might miss out on the benefits of either FIT or yin yoga. Thus, yin
yoga served as an active control group.

31
Post Testing

All procedures from the two baseline visits were repeated during two post-testing visits at
the end of the 3-month intervention.

Statistical Analysis

Descriptive statistics were calculated for all variables and included means and standard
deviations for normally distributed continuous variables and medians, minima and maxima for
non-normally distributed continuous variables. Independent t-test was used to determine if there
were differences in baseline variables between groups. Changes in dependent variables over time
were analyzed using repeated measures analysis of variance (ANOVA) (group by time). When
interactions and time effects were significant independent and paired t-tests were used to
determine if there were differences within groups and over time. Intent to treat analysis was used
to evaluate all partiipcants whether they completed the study or not. For those who dropped out
their initial measurements were carried over to their post testing measurements. A secondary
analysis was completed on the participants who completed all training and testing. Significance
was accepted at p≤0.05. All analyses were performed using the SPSS (version 23.0) statistical
package.

32
 CHAPTER 4

RESULTS AND DISCUSSION

Results

For the larger 6-month study, ninety-eight women were recruited by posted flyers or from
lists from previous studies. Forty-one women declined participation after hearing about the study
and nine did not meet the criteria for the study. Forty-eight women came to an orientation
meeting. After the orientation two did not provide consent to the study and one did not receive
her physician’s consent to participate in the study. Forty-five women completed baseline testing
and three did not. The forty-five participants who competed baseline testing were stratified into
either the FIT or yin yoga group by breast cancer stage, type of cancer treatment, age, weight,
and lean mass. There were 21 participants in FIT and 24 in yin yoga. Thirty-two women
completed the 3-month training program, with 5 dropping out of FIT and 8 dropping out of yin
yoga. Of the 5 women who discontinued participation in FIT, two women dropped out due to
health issues, two opted out due to time constraints, and one dropped out because the intensity
was too high for her. Of the 8 women who discontinued in yin yoga, three women opted out due
to time constraints, three women dropped out due to health issues, one discontinued participation
because her work was offering exercise classes which, were more convenient for her, and one
received physician consent for baseline testing but not for the intervention. Figure 1 outlines the
progression of participants through the study. With intent-to-treat, all participants (N=45) had a
mean adherence of 69.2% (±30.2%) for the 24 sessions over the 12-week period. There was no
significant difference between the two groups for adherence, where FIT (n=21) averaged 74.0%
(±26.5%) and yin yoga averaged 64.9% (±33.1%) of the visits. For those who completed
treatment (N=32), mean adherence for the whole group was 84.9% (±11.8%), while FIT (n=16)
and yin yoga (n=16) averaged 85.2% (±11.6%) and 84.6% (±12.4%) respectively. There was no
significant difference between the groups for adherence to their respective interventions.

33
34
 The 45 women were approximately sixty years of age (60.5 years (±8.3 years)),
overweight, (BMI of 29.2 kg/m2 (±7.1 kg/m2)) and were on average 7 years post-treatment (87.1
(±85.3 years)). Four women had stage 0 cancer, 17 had stage 1, 14 had stage 2, 9 had stage 3,
while one woman was not sure of her diagnosis. For cancer treatment, all 45 women had surgery,
27 women had chemotherapy, 23 women received radiation, and 22 completed hormone therapy.
All of the participants were screened for cognitive impairments using the SPMSQ, where a score
of 0-2 errors indicates intact intellectual functioning and a score of 3-4 indicates mild intellectual
impairment. In the current study, using this questionnaire, all of the women had intact
intellectual functioning.

Baseline Demographics

Table 1 presents the baseline characteristics of both the FIT (n=21) and yin yoga (n=24)
groups. Table 2 presents the baseline participant frequencies for race, cancer stage, and type of
treatment. For the FIT group the participants included one African American woman and 20
White women. Three women had stage 0 cancer, 9 women had stage 1, 6 women had stage 2,
and 3 women had stage 3. All 21 women had surgery, 11 had chemotherapy, 11 received
radiation, and 10 completed hormone therapy. In yin yoga, there was 1 Asian/Hispanic woman, 2
African American women, and 21 White women. One woman had stage 0 cancer, 8 women had
stage 1, 8 women had stage 2, 6 women had stage 3, and 1 woman was not sure of diagnosis. All
24 women had surgery, 16 had chemotherapy, 12 received radiotherapy, and 12 completed
hormone therapy. There were no significant differences between either group in the baseline
characteristics except for time since treatment (p=0.02) with FIT having a greater amount of time
since treatment.

Differences Between Participants Who Dropped Out and Participants Who Did Not

There were no significant differences between those who dropped out (n=13) and those
who completed the study (n=32) on any of the baseline demographic or cognitive measures.
There was a significant difference (p=0.02) between the two groups in the pain domain of SF-36.
Seven of the 13 dropout participants scored lower than a 60 in the pain domain while 7 of the 32

35
Table 1. Baseline Participant Demographics (N=45)
FIT Yin Yoga
(n=21) (n=24)
Mean ± SD min-max Mean ± SD min-max
Age 60.3 ± 7.4 44-77 60.7 ± 9.2 41-74
Height (cm) 164.5 ± 8.1 142.9-175.3 162.4 ± 4.8 154.9-174.0
Weight (kg) 78.4 ± 16.0 38.3-110.3 77.3 ± 22.2 52.2-152.6
2
BMI (kg/m ) 29.1 ± 6.0 12.5-36.7 29.3 ± 8.0 19.5-58.7
Time since treatment (months) 120.3 ± 103.5 2-363 60.6 ± 52.2* 1-220
Lean mass (kg) 42.7 ± 5.7 32.8-57.4 40.3 ± 8.2 30.5-66.5
Body fat (%) 44.1 ± 7.6 17.5-51.2 44.6 ± 6.2 32.1-54.6
Data are presented as means ± standard deviation
* p≤0.05; significantly different between baseline measures
FIT: Functional Impact Training; BMI: Body Mass Index.

Table 2. Baseline Participant Frequencies for Race,

Cancer Stage, and Type of Treatment (N=45)
FIT Yin Yoga
(n=21) (n=24)
Race
Asian/Hispanic 0 1
African American 1 2
White 20 21
Cancer stage
0 3 1
1 9 8
2 6 8
3 3 6
Unknown 0 1
Treatment type
Surgery 21 24
Chemotherapy 11 16
Radiation 11 12
Hormone Therapy 10 12
FIT: Functional Impact Training

36
who completed the study also scored below 60 in the pain domain. Those who stayed in the
study had a mean score of 76.6 (±22.9) while those who dropped out had a mean score of 56.5
(±28.2). The baseline PHQ-9 depression screening questionnaire was approaching significance
(p=0.06), where those who dropped out had a mean score of 5.3 (±4.7) and those who completed
had a mean score of 2.9 (±3.3). Scores for PHQ-9 questionnaire below 5 indicate no symptoms
of depression, 5-9 indicate minimal symptoms, 10-14 indicate minor depression, 15-19 indicate
moderately severe depression, while scores of 20 or above indicate severe major depression.
Two participants with scores between 10-17 dropped out, while one (with a score of 15) stayed
in the study. In total, 7 of the 13 participants who dropped out scored at least a 5 on the PHQ-9,
showing minimal to moderately severe depression symptoms, while 8 of the 32 participants who
stayed scored at least 5 on the PHQ-9 showing the same symptoms. Over half of the drop outs
showed some sort of symptoms of depression.

Fitness Measures

In the intent-to-treat analysis (N=45), the 6-minute walk (p≤0.05), isokinetic (ISK)
180º/second peak torque extension (p=0.03), ISK 180º/sec peak torque flexion (p=0.01), and
1RM chest press (p=0.01) were all significantly different between the two groups at baseline,
where FIT had higher values than yin yoga. There was a group by time interaction for the 1RM
chest press (p≤0.05, F(1,43)=14.90, effect size (ES)= 0.257) with FIT significantly improving
more than yin yoga in upper body strength. All of the fitness measures showed significant time
effects [6MW (p≤0.05, F(1,43)=4.66, ES= 0.098); ISK peak torque extension (p≤0.05,
F(1,43)=11.65, ES= 0.213), ISK peak torque flexion (p≤0.05, F(1,43)=6.55, ES= 0.132); 1RM
(p≤0.05, F(1,43)=5.36, ES= 0.111)]. For FIT (n=21), there was a significant difference from
baseline to post test for the ISK 180º/sec peak torque extension (p=0.03) and the 1RM chest
press (p≤0.05), while the ISK 180º/sec peak torque flexion was approaching significance
(p=0.08). For yin yoga (n=24), there was a significant difference from baseline to post test for
ISK 180º/sec peak torque extension (p=0.02). Table 3 presents the means and standard
deviations of the fitness changes for everyone who participated in the study.

37
 Table 3. Intent-To-Treat Fitness Changes for Participants in Fitness Measures (N=45)
FIT Yin Yoga
(n=21) (n=24)
Baseline Post Baseline Post
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
6-Minute Walk (m)t 611.5 ± 69.8 622.5 ± 85.7 530.7 ± 89.4* 545.0 ± 101.7
ISK Peak Torque 180°/s
Extension (nm)t 69.7 ± 16.7 75.2 ± 20.2x 57.6 ±18.6* 61.7 ± 17.8x
t
Flexion (nm) 44.1 ± 12.4 48.1 ±15.4 33.4 ± 12.4* 36.9 ± 14.2
t x
1RM chest press (kg)^ 73.2 ± 18.1 80.2 ± 19.7 59.8 ± 14.4* 58.0 ± 15.3
Data are presented as means ± standard deviation
*p≤0.05: significantly different between groups at baseline
^p≤0.05: significant group by time interaction
t
p≤0.05: significant time effect
x
p≤0.05: significantly different from baseline to post-test
FIT: Functional Impact Training; ISK: Isokinetic; 1RM: One Repetition Maximum

Table 4 presents the means and standard deviations of fitness changes for those who
completed the study. For those who completed the study (N=32), the 6-minute walk (p=0.01) and
ISK 180º/sec peak torque flexion (p=0.01) were both significantly different between the two
groups at baseline, where FIT had higher values than yin yoga. Isokinetic 180º/sec peak torque
extension was approaching significance (p=0.06). There was a group by time interaction for the
1RM (p≤0.05, F(1,30)=15.82, ES= 0.345) with FIT significantly improving more than yin yoga.
There was a significant time effect for all of the fitness measures effects [6MW (p≤0.05,
F(1,30)=4.91, ES= 0.141); ISK peak torque extension (p≤0.05, F(1,30)=12.59, ES= 0.296), ISK peak
torque flexion (p≤0.05, F(1,30)=6.80, ES= 0.185); 1RM (p≤0.05, F(1,30)=4.88, ES= 0.140)]. For
FIT (n=16), there was a significant difference from baseline to post test for the ISK 180º/sec
peak torque extension (p=0.03) and the 1RM chest press (p=0.00), while the ISK 180º/sec peak
torque flexion was approaching significance (p=0.08). For yin yoga (n=16), there was a
significant difference from baseline to post test for ISK 180º/sec peak torque extension (p=0.02).

38
 Table 4. Fitness Measures for Participants Who Completed the Study (N=32)
FIT Yin Yoga
(n=16) (n=16)
Baseline Post Baseline Post
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
6-Minute Walk (m)t 613.0 ± 71.6 627.5 ± 91.2 536.2 ± 80.0* 557.7 ± 97.9
ISK Peak Torque 180°/s
Extension (nm)t 69.7 ± 18.1 77.0 ± 22.2x 56.6 ± 19.9 62.8 ± 18.7x
Flexion (nm)t 43.4 ± 12.2 48.8 ± 16.2 32.3 ± 11.4* 37.6 ± 14.4
t x
1RM chest press (kg)^ 73.3 ± 18.4 82.4 ± 19.8 63.3 ± 15.5 60.7 ± 17.2
Data are presented as means ± standard deviation
*p≤0.05: significantly different between groups at baseline
^p≤0.05: significant group by time interaction
t
p≤0.05: significant time effect
x
p≤0.05: significantly different from baseline to post test
FIT: Functional Impact Training; ISK: Isokinetic; 1RM: One Repetition Maximum

Intent-To-Treat Analysis for Cognitive and QOL Means

Baseline and post-intervention cognitive and QOL means for all 45 participants are
displayed in Table 5. There were no significant differences in cognitive measures between the
two groups at baseline. For the QOL measures, the SF-36 scores were divided up into 8 domains:
physical functioning (PF), role limitations/physical (RLP), role limitations/emotional (RLE),
energy/fatigue (EF), emotional well-being (EWB), social functioning (SF), pain (PN), and
general health (GH) (based on the RAND SF-36 scoring where a higher score is associated with
better QOL). At baseline, the SF domain was approaching significance (p=0.052), but none of
the other domains for the SF-36 or the PHQ-9 means were significantly different between the
two groups. There were no group by time interactions for any of the cognitive or QOL measures.
The COWAT Total was the only cognitive measure with a significant time effect (p≤0.05,
F(1,43)=6.34, ES= 0.129). While most measures for both groups seemed to improve, only yin yoga
saw a significant difference from baseline in the COWAT Total (p=0.03) score. For QOL
measures, the SF and PN domains are the only two subcategory tests that did not see a significant
time effect [PF (p≤0.05, F(1,43)=7.27, ES= 0.145); RLP (p≤0.05, F(1,43)=7.67, ES= 0.151), RLE
(p≤0.05, F(1,43)=6.15, ES= 0.125); EF (p≤0.05, F(1,43)=6.89, ES= 0.138); EWB (p≤0.05,
F(1,43)=14.66, ES= 0.254); GH (p≤0.05, F(1,43)=12.01, ES= 0.218)]. FIT had significant
39
improvements from baseline to post test in RLP (p=0.04), EWB (p=0.01), and GH (p=0.01). The
EF domain had a significant time effect but when evaluating individual difference FIT was only
approaching significance (p=0.052). Yin yoga had significant improvements from baseline to
post test in PF (p=0.03), RLE (p=0.05), EWB (p=0.03), and GH (p=0.02).

Table 5. Intent-To-Treat Cognitive and QOL Measures (N=45)

FIT Yin Yoga
(n=21) (n=24)
Baseline Post Baseline Post
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Cognitive:
TMTA (s) 22.7 ± 6.5 21.8 ± 6.2 25.2 ± 8.0 25.3 ± 7.8
TMTB (s) 52.3 ± 18.5 53.3 ± 21.5 64.3 ± 39.3 64.8 ± 39.1
DSF 9.8 ± 2.1 10.0 ± 2.0 9.7 ± 2.5 9.6 ± 2.3
DSB 6.1 ± 2.1 6.1 ± 1.8 6.4 ± 1.9 6.5 ± 2.1
DS Total 15.8 ± 3.6 16.1 ± 3.3 16.1 ± 4.2 16.1 ± 4.1
COWAT F 13.9 ± 4.5 15.2 ± 6.1 13.9 ± 4.9 14.2 ± 5.0
COWAT A 13.2 ± 3.9 13.3 ± 4.2 11.3 ± 4.4 12.5 ± 3.6
COWAT S 15.2 ± 5.3 15.3 ± 5.0 15.0 ± 5.2 15.3 ± 5.0
t
COWAT Total 42.3 ± 12.0 43.8 ± 12.5 39.3 ± 13.2 41.9 ± 11.9x
SF36:
Physical Functioningt 77.9 ± 21.1 82.1 ± 22.2 74.0 ± 23.4 77.7 ± 22.4x
t
Role limitations/physical 63.1 ± 41.5 78.6 ± 38.1x 71.9 ± 37.1 78.1 ± 34.8
t
Role limitations/emotional 65.1 ± 44.1 71.4 ± 43.8 83.3 ± 31.1 93.1 ± 24.0x
Energy/fatiguet 56.9 ± 23.9 66.0 ± 19.7 55.6 ± 22.7 60.8 ± 24.4
Emotional well-beingt 72.6 ± 18.8 79.6 ± 18.2x 77.8 ± 13.4 82.7 ± 11.4x
Social Functioning 75.0 ± 23.7 82.7 ± 24.2 88.0 ± 20.0b 86.5 ± 20.8
Pain 71.2 ± 24.0 73.1 ± 21.9 70.4 ± 27.9 68.9 ± 28.3
General Healtht 68.1 ± 15.7 72.6 ± 14.2x 63.1 ± 18.8 70.6 ± 18.3x
PHQ-9 3.5 ± 3.8 3.7 ± 4.1 3.7 ± 3.9 3.7 ± 3.3
Data are presented as means ± standard deviation
b
p=0.052; approaching significantly different at baseline between the two groups
t
p≤0.05: significant time effect
x
p≤0.05: significantly different from baseline to post-test
FIT: Functional Impact Training; SPMSQ: Short Portable Mental Status Questionnaire;
TMTA: Trail Making Test A; TMTB: Trail Making Test B; DSF: Digit Span Forward;
DSB: Digit Span Backward; DS Total: Digit Span Total; COWAT: Controlled Oral Word
Association Test; SF36: Short Form Health Survey (36); PHQ-9: Patient Health
Questionnaire

40
Secondary Analysis of Cognitive and QOL Means

Table 6 presents the means and standard deviations for cognitive and QOL measures in
the secondary analysis. Since 13 women dropped out of the program, a secondary analysis was
run including only those participants who completed the program. There were no significant

Table 6. Cognitive and QOL Measures of Participants Who Completed the Study (N=32)
FIT Yin Yoga
(n=16) (n=16)
Baseline Post Baseline Post
Mean ± SD Mean ± SD Mean ± SD Mean ± SD
Cognitive:
TMTA (s) 22.2 ± 7.1 21.0 ± 6.6 26.3 ± 8.2 26.5 ± 8.0
TMTB (s) 53.1 ± 19.9 54.4 ± 23.5 71.0 ± 45.7 71.8 ± 45.4
DSF 9.4 ± 2.2 9.7 ± 2.1 9.7 ± 2.6 9.6 ± 2.3
DSB 6.2 ± 2.3 6.3 ± 1.9 6.2 ± 2.0 6.3 ± 2.4
DS Total 15.6 ± 3.9 15.9 ± 3.6 15.9 ± 4.4 15.9 ± 4.2
COWAT F 13.8 ± 4.9 15.5 ± 6.8 13.7 ± 5.1 14.1 ± 5.3
COWAT A 13.3 ± 4.3 13.4 ± 4.7 10.7 ± 4.9 12.4 ± 3.8
COWAT S 16.1 ± 5.6 16.3 ± 5.1 13.7 ± 5.0 14.1 ± 4.8
COWAT Totalt 43.2 ± 13.3 45.2 ± 13.8 36.8 ± 13.4 40.6 ± 12.1x
SF36:
Physical Functioningt 78.4 ± 22.0 84.1 ± 23.0 76.6 ± 22.0 82.2 ± 19.3x
Role limitations/physicalt 65.6 ± 41.7 85.9 ± 34.1x 75.0 ± 35.4 84.4 ± 30.1
t
Role limitations/emotional 66.7 ± 42.1 75.0 ± 41.3 79.2 ± 34.2 93.8 ± 25.0x
t
Energy/fatigue 59.7 ± 23.4 67.2 ± 16.9 60.0 ± 20.9 67.8 ± 21.5
Emotional well-beingt 74.8 ± 16.2 81.5 ± 13.5x 78.3 ± 14.8 85.5 ± 10.8x
Social Functioning 79.7 ± 20.3 86.7 ± 20.1 89.8 ± 17.2 87.5 ± 18.8
Pain 75.6 ± 25.0 74.2 ± 23.1 77.5 ± 21.4 75.2 ± 22.8
General Healtht 68.8 ± 14.0 74.4 ± 10.5x 63.1 ± 20.2 74.4 ±18.2x
PHQ-9 2.5 ± 2.1 2.8 ± 2.8 3.4 ± 4.1 3.4 ± 3.2
Data are presented as means ± standard deviation.
t
p≤0.05: significant time effect
x
p≤0.05: significantly different from baseline to post test
FIT: Functional Impact Training; SPMSQ: Short Portable Mental Status Questionnaire;
TMTA: Trail Making Test A; TMTB: Trail Making Test B; DSF: Digit Span Forward;
DSB: Digit Span Backward; DS Total: Digit Span Total; COWAT: Controlled Oral Word
Association Test; SF36: Short Form Health Survey (36); PHQ-9: Patient Health
Questionnaire

41
differences between the groups for baseline scores. There were no group by time interactions for
any of the measured variables. For cognitive measures, there was a significant time effect for
COWAT Total (p≤0.05, F(1,30)=6.98, ES= 0.189). Most cognitive measures did tend to improve
for both groups, however, only yin yoga saw a significant difference from baseline to post test
for the COWAT total score (p=0.03). For QOL measures, the SF and PN domains were the only
two that did not see a significant time effect [PF (p≤0.05, F(1,30)=7.62, ES= 0.203); RLP (p≤0.05,
F(1,30)=7.66, ES= 0.203), RLE (p≤0.05, F(1,30)=6.70, ES= 0.183); EF (p≤0.05, F(1,30)=5.74, ES=
0.161); EWB (p≤0.05, F(1,30)=15.32, ES= 0.338); GH (p≤0.05, F(1,30)=13.62, ES= 0.312)].
Although most SF-36 measures slightly improved for both groups, FIT had significant
differences from baseline to post test in RLP (p=0.04), EWB (p=0.01), and GH (p=0.01), and yin
yoga group had significant differences from baseline to post test in PF (p=0.03), RLE (p=0.05),
EWB (p=0.03), and GH (p=0.02). While the EF domain had a significant time effect, FIT was
only approaching significance (p=0.08). There was no group by time interaction or time effect
for PHQ-9.

Discussion

During the aging process many older adults experience cognitive decline. Cancer patients
or survivors, however, may experience this decline sooner and faster in comparison to healthy
aging older adults.5,9 It is hypothesized that cancer treatments may contribute, but factors
including anxiety and depression may also play a role in this process. Exercise has demonstrated
modest effects on improving cognition within the healthy adult population;47,63,66,67 however,
research regarding BCS, exercise, and cognitive function has been cross-sectional or has
evaluated subjective measures of either cognitive function or exercise.16,17,71 In addition, past
literature has evaluated physical activity levels as opposed to specifically evaluating aerobic or
anaerobic exercise interventions. In terms of QOL, the literature has shown that exercise
interventions can improve QOL in BCS.14,15 To the researchers’ knowledge, this is the first study
to look at the effects of an exercise intervention while measuring cognitive function objectively
in BCS.
For the current study, a sample of BCS completed objective cognitive function tests and
answered questionnaires on QOL before and after 3 months of either FIT or yin yoga. It was

42
hypothesized that FIT would experience greater cognitive function improvements compared to
yin yoga. The first hypothesis of the study was rejected since there were no group differences in
cognitive function measures. There was one significant time effect for yin yoga that was not
expected. Yin yoga improved from baseline to post testing on the COWAT Total for both the
intent-to-treat analysis and the secondary analysis of participants who completed the study.
The second hypothesis was that FIT and yin yoga would both have improvements in
QOL after their respective interventions with no difference between the two groups. This
hypothesis was not rejected since both groups responded similarly in improvements in QOL
measures. Both groups had significant improvements from baseline to 3 months using the SF-36
for QOL measurement with no significant differences between groups. With intent-to-treat, FIT
had significant improvements in the role limitations/physical, emotional well-being, and general
health domains while yin yoga had significant improvements in the physical functioning, role
limitations/emotional, emotional well-being, and general health domains. For those who
completed the study, FIT experienced improvements in the role limitations/physical, emotional
well-being, and general health domains while yin yoga experienced improvements in the
physical functioning, role limitations/emotional, emotional well-being, and general health
domains.
While examining differences between those who dropped out and those who completed
the study, it was found that there was a significant difference in baseline pain scores (p=0.02) of
the SF-36 between the two groups. As previously mentioned, in scoring the SF-36, a higher score
is associated with better QOL. Those who dropped out seemed to have more pain with a mean
score of 56.5 (±28.2) than those who stayed in the study who had a mean score of 76.6 (±22.9).
Seven of the 13 dropout participants scored lower than a 60 in the pain domain while this was
also true for 7 of the 32 who completed the study. According to a follow-up study on QOL in
BCS (N=763), the mean score for the pain domain was 76.6.91 This is closer to the mean score
of those who completed the study while the mean of those who dropped out was well below this.
Scores for PHQ-9, the depression screening questionnaire, range from 0 to 27, where scores
below 5 indicate no symptoms of depression, 5-9 indicate minimal symptoms, 10-14 indicate
minor depression, 15-19 indicate moderately severe depression, while scores of 20 or above
indicate severe major depression. At baseline, those who dropped out had a mean score of 5.3
(±4.7) and those who completed the study had a mean score of 2.9 (±3.3). This difference was

43
approaching significance (p=0.06). Over half of the drop outs reported some range of depressive
symptoms. These questionnaires may be useful for future studies in helping to predict individuals
who may be at a greater risk for dropping out of intervention studies and may be used for a
screening tool.

Cancer and Cognition

According to normative data for healthy older adults the participants in the current study
(N=45) had faster average means for TMTA and TMTB,42 as well as better DSF and DSB
scores69, while the COWAT Total scores were similar to those of healthy older adults49
(normative data for individual letters of COWAT not found). Better mean scores on TMTA and
TMTB were observed in another study where researchers compared breast cancer patients who
received chemotherapy to breast cancer patients who only received hormonal therapy prior to,
during, and 1 year after treatment.7 In this study 1 year after treatment, participants who received
chemotherapy completed TMTA in 25.4 s (±6.1) and TMTB in 62.5 s (±23.0) while those who
only received hormonal therapy completed the TMTA in 25.0 s (±6.8) and TMTB in 67.9 s
(±23.3). These same women averaged Digit Span Total scores of 17.2 (±3.9) and 18.1 (±4.1)
respectively and COWAT (FAS) Total scores of 43.3 (±14.0) and 40.9 (±10.5) words,
respectively. This study suggested that any cognitive impact that chemotherapy might have had
on BCS might be attenuated after 1 year since there were no differences between the two groups
at that time. Upon examination, in the current study there were 6 participants within 1 year of
completing treatment, 5 of which had surgery and received chemotherapy, radiation, and
hormone therapy. There were no significant baseline differences in cognitive measures between
those within 1 year of completing treatment and those who were more than 1 year past treatment.
There were also no group by time interactions or time effects for cognitive measures with the
exception of the COWAT Total which already demonstrated a time effect in the primary
analysis. It is likely that cognition returns to normal shortly after treatment considering the BCS
in the study previously mentioned and the BCS in the current study both had similar scores
compared to healthy older adults. It might be beneficial to continue studying cognitive changes
before, during, and after cancer treatment to determine when cognition might return to baseline
for BCS and what affects its return

44
 Another thing to consider is education level. Although education level was not recorded
in the current study, the women had better average scores at baseline than their educated, healthy
adult counterparts so it is possible that these sedentary women were more educated than other
studies examining cognition and BCS. Additionally, anxiety and depression from cancer
diagnosis or experience has been linked to decrements in cognition, however, BCS in the current
study improved in QOL and did not improve in cognition. It is possible that these may only play
a role in cognitive function shortly after diagnosis or treatment. Since the BCS in the current
study were on average 7 years post treatment, their anxiety and depression may no longer affect
cognition.

Exercise and Cognition

In the healthy adult population, higher physical activity has been associated with better
cognitive function,47,63 and aerobic and resistance exercise have been shown to improve
cognition.65–67 This is seen in executive function measures,66,67 but often observed in processing
speed, attention, or working memory.47,63,65,68 For BCS, researchers have observed correlations
between higher levels of physical activity and higher cognitive functioning, but no research to
date has examined the effects of exercise interventions on cognition in BCS. It was hypothesized
that after 3 months, BCS participating in FIT would improve cognition more than BCS
participating in yin yoga based on the literature from the healthy adult population. This
hypothesis was rejected, however, as mentioned before, the participants in the current study had
greater average scores at baseline than healthy older adults. Exercise may be more of a viable
option for maintaining rather than improving cognitive function in this population since they had
high scores to being with.
At baseline, FIT performed better on all of the fitness measures compared to yin yoga in
the intent-to-treat analysis. Over time, both groups saw some strength improvement, but FIT
improved to a greater degree than yin yoga in the intent-to-treat and secondary analyses. A meta-
analysis by Colcombe et al. showed that exercise had the greatest effect on executive processes
(g=0.68, SE=0.052, N=37, p<0.05) in older adults who were cancer free. In this review, it was
also found that those who participated in a combined exercise program (resistance and aerobic)
improved to a greater degree than those in aerobic training alone (0.59 vs. 0.41, SE=0.043,

45
N=101, p<0.05).63 However, in terms of length of program, brief training programs of 1-3
months provided at least as much benefit as moderate training programs for 4-6 months, but not
as much benefit as long-term programs of greater than 6 months. Additionally, in a study by Best
et al., healthy women between the ages of 65-75 years participated in a 52-week program of
either once-weekly or twice-weekly resistance training sessions, with cognitive assessments at
baseline, post-intervention and a follow-up at year 2 (one year after the intervention).66 The
resistance training program included a progressive, high-intensity protocol with free weights and
two sets of each exercise, similar to the FIT protocol in the current study. Both resistance
training programs had long-term positive impacts when using TMTA and TMTB (the difference
in time to complete TMTA and TMTB used as the score) and Digit Span Backward to assess
executive function. The once-weekly group showed a significant improvement in executive
function from baseline at post-intervention (d=0.35; p=0.002) and the 2-year follow up (d=0.48;
p=0.002). The twice-weekly group showed significant improvement in executive function from
baseline at the 2-year follow up (d=0.31; p=0.005). With essentially no significant difference in
cognition but significant improvements in fitness, it is likely that the training program should be
longer to exhibit cognitive benefits. Since the protocols were similar, perhaps this is why
cognitive function did not show statistically significant improvements in the current study. It is
also possible that some participants did not maintain a high-intensity during the study.

Exercise and QOL

The majority of the literature on BCS and exercise interventions examines the changes in
QOL, with QOL improving in most studies.13–15 It was hypothesized that BCS participating in
FIT would experience similar improvements in QOL measures compared to BCS participating in
yin yoga. Similar to previous studies, this hypothesis was not rejected. In the intent-to-treat
analysis, FIT and yin yoga each significantly improved in 3 domains of the SF-36 (both
improving in emotional well-being and general health). In the analysis only including those who
completed the study, FIT and yin yoga both significantly improved in the same 3 domains, while
yin yoga improved additionally in role limitations/emotional. The current study found results
similar to a study by Milne et al. who examined the effects of a combined aerobic and resistance
exercise program on QOL in BCS. Participants in this program attended 3 sessions a week for 12

46
weeks, and researchers found that QOL significantly improved for BCS within 2 years of
completing their adjuvant therapy. The current study contributes to the continually growing
literature in support of exercise as a method for improving QOL in BCS.
According to a follow-up study (N=763) looking at long-term QOL in BCS, the yin
yoga’s mean for social functioning (88.0±20.0) was close to the mean score for women in that
study (87.9) while FIT (75.0±23.7) was below this mean.91 Interestingly, social functioning of
the SF-36 did not significantly improve for either FIT or yin yoga despite both interventions
being in group settings. A study by Brown et al. showed that 6 months of group-based exercise
significantly improved the cognitive domain fluid intelligence (the ability for abstract thought
and problem-solving) and not executive function or working memory.69 The sessions were 1
hour long and twice per week. Since the women in FIT did not improve in cognition or social
functioning, it is possible that they were not socialized enough. Socialization is another factor
that may play a role in cognition. The below average socialization score for FIT with no
significant improvement might be a reason why there was not a significant improvement in
cognition. Perhaps the sessions or the study need to be longer. It is also possible that
socialization improvement in cognitive function may be specific to the fluid intelligence domain
but more research is needed to examine the role of socialization on cognition.

Yoga and Cognition

The effects of yoga on cognition have been studied and research has only shown modest
improvements in cognitive domains within the healthy adult population. No research has
objectively evaluated the effects of yoga on cognition in a sample of BCS. Self-reported
measures of cognition show improvements in BCS,71,79 but this may be due to improvements in
QOL, as anxiety and depression are associated with declines in cognitive function. To the
researchers’ knowledge, this is the first study (with more than four participants82) to examine
objective measures of cognition in BCS after a yoga intervention. In the current study, although
yin yoga did see a significant improvement from baseline to post testing in the COWAT Total
score, this improvement does not seem meaningful as yin yoga did not improve in the other
cognitive measures. While there are no studies that use objective measures within a large sample
of BCS, Gothe et al. reviewed studies within healthy older adults examining the effects of yoga

47
on cognition using TMTA, TMTB, DSF, DSB, and COWAT (along with other cognitive tests) in
a meta-analysis.38 This revealed that, within the randomized-controlled trials, attention and
processing speed (g=0.299, p=0.001) and executive function (g=0.27, p=0.001) demonstrated
modest benefits from yoga interventions. In contrast, a study by Oken et al. found that older
adults who participated in a yoga intervention for 6 months showed no significant improvements
in cognition.81 Even though some studies have shown that yoga interventions may improve
cognition in healthy adults, more research is needed to see if these results translate to BCS.
The PHQ-9 was a questionnaire used for screening depression. The mean scores for this
test in FIT and yin yoga did not change significantly from baseline to 3 months or between
groups for either the intent-to-treat analysis or the secondary analysis. At baseline, the maximum
score for FIT on the PHQ-9 was 17 while yin yoga was 15, which are both in the range for major
depression. However, the PHQ-9 mean score was below 5 before and after the interventions for
both FIT and yin yoga, showing no signs or symptoms of depression. This population was
healthy except for their previous cancer diagnosis and therefore it is possible that cognition and
QOL returned to their baseline after treatment. More research is needed to determine when
changes in QOL and cognition occur with diagnosis, treatment, and recovery in BCS.

Yoga and QOL

In the healthy,83 and BCS populations78,85,86 yoga has demonstrated its beneficial effects
on QOL through decreased anxiety and stress and increased mindfulness. In the healthy adult
population, Halpern et al. found that after 12 weeks of twice-weekly yoga sessions, participants
in the yoga group experienced improvements in the SF-36 vitality (energy/fatigue), physical
functioning and social functioning domains.83 Physical function increased from 54.3 (±38.0) to
64.2 (±35.6), vitality increased from 59.3 (±17.4) to 63.7 (±17.8), and social functioning
increased from 77.5 (±21.9) to 83.7 (±21.6). The BCS in the current study saw similar
improvements but within different domains of the SF-36. A pilot study by Levine et al. found
that twice-weekly, 60-minute hatha yoga sessions were beneficial for QOL in BCS that reported
poor QOL prior to the intervention.86 Despite having QOL means similar to those of healthy
adults, the BCS in the current study still saw improvements in QOL. Similar to previous
literature, the current study supports yoga as an effective method for improving QOL in BCS.

48
Conclusions

In conclusion, our findings indicate that a FIT, combination of resistance and aerobic
training, or a yin yoga program did not have significant improvements in cognition over 3
months. Both FIT and yin yoga may be viable options for maintenance of cognition during
aging, since both saw neither a significant increase or decrease in scores. FIT and yin yoga did,
however, demonstrate significant improvements in QOL over the course of the study. Along with
recent literature, it seems that exercise and yoga may both be non-pharmaceutical options for
improving QOL in BCS. Further research is needed to examine the effects of exercise training
interventions on cognition in terms of intensity, duration, frequency and mode of training
programs in BCS. Future research should focus on longer FIT (or similar combination aerobic
and anaerobic program) and yin yoga intervention effects on cognition within the BCS
community. Future studies could potentially examine a program that combines a FIT or similar
program with yin yoga since both had beneficial effects on different subcategories of QOL.

49
 APPENDIX A

IRB APPROVAL

50
 APPENDIX B

APPROVED INFORMED CONSENT

51
52
53
54
55
 APPENDIX C

MEDICAL HISTORY QUESTIONNAIRE

CONTACT INFORMATION

Name:
Home phone
Office phone or cell phone

PERSONAL INFORMATION

Age ________ Date of birth _____/_____/_____

Month Day Year

Race ____ White

____ Black
____ Asian
____ Hispanic
____ Other: _______________

Are you currently involved in an exercise program? N____ Y____ If yes, please describe (Include
days/week, intensity, types of exercise)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

EMERGENCY INFORMATION

Individual to be contacted in the event of an emergency:

Name:

Relationship to you:

Home phone

56
 MEDICAL HISTORY FORM

Primary oncologist: Name:

Address and City:

Phone:

Primary Care Physician: Name:

Address and City:

Phone:

Do you: Smoke? __________ Packs per day __________ # Years smoked ____________

Drink Alcohol? __________ Drinks per day __________

List any allergies you have to drugs, food or other items:

_____________________________________________________________________________________
________

_____________________________________________________________________________________
________

List medications and/or vitamins or supplements you are taking:

Name of drug/supplement Dosage Times/day Duration of drug/supplement use

Cancer History

57
• Diagnosis (stage, affected side):
______________________________________________________________________-
__________________________________________________________________________________
______________
__________________________________________________________________________________
______________
• Date of
diagnoses:_________________________________________________________________________________
• Types of TX: (surgery, radiation, chemotherapy, hormone therapy)
__________________________________________________________________________________
______________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
______________________________________________________________________
• Beginning and ending dates of each treatment:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________
_________________________________________________________________________________________
_______
_________________________________________________________________________________________
_______
_________________________________________________________________________________________
_______
• Menopausal Age: (Natural or Treatment induced)
_________________________________________________________
• Additional Concerns/Information:
_________________________________________________________________________________________
_________________________________________________________________________________________
______________
_________________________________________________________________________________________
_______

_____________________________________________________________________________________
___________

58
OTHER MEDICAL PROBLEMS: Indicate if you have had any of the following medical problems:

Past Now
____ ____ Alcoholism
____ ____ Anemia
____ ____ Arthritis
____ ____ Asthma
____ ____ Back injury or problem
____ ____ Blood clots
____ ____ Bronchitis
____ ____ Chest pain
____ ____ Cirrhosis
____ ____ Claudication
____ ____ Diabetes
____ ____ Elbow or shoulder problems
____ ____ Emotional disorder
____ ____ Eye problems
____ ____ Gall bladder disease
____ ____ Glaucoma
____ ____ Gout
____ ____ Headaches
____ ____ Heart Attack
____ ____ Heart Disease
____ ____ Hemorrhoids
____ ____ Hernia
____ ____ Hip, knee, or ankle problems
____ ____ Hypertension
____ ____ Intestinal disorders
____ ____ Kidney disease
____ ____ Liver disease
____ ____ Lung disease
____ ____ Mental illness
____ ____ Neck injury or problem
____ ____ Neuralgic disorder
____ ____ OB/GYN problems
____ ____ Obesity/overweight
____ ____ Osteoporosis
____ ____ Parkinson's disease
____ ____ Phlebitis
____ ____ Prostate trouble
____ ____ Rheumatic fever
____ ____ Seizure disorder
____ ____ Stomach disease
____ ____ Stroke
____ ____ Thyroid disease
____ ____ Ulcers
____ ____ Other - specify: ________________
59
Research Project Availability

Please mark your availability for Functional Impact or Yoga exercise training. Choose all dates/times that
accommodate you.
Preferably, choose a combination of Monday/Thursday or Tuesday/Friday at your ideal times.
Training sessions will last approximately 45-60 minutes.

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

(make-up day) (make-up day)
<8:00 am*
8:00 am
9:00 am
10:00 am
11:00 am
Noon
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
>6:00 pm*
*Please indicate what time specifically would best accommodate you

Potential Start Date

Please circle two dates indicating an ideal range in which you would like to begin the study.

Please indicate any dates that you will not be available for exercise
training:______________________________
60
1. Have you ever belonged to a fitness center?

If yes, how long?

What activities did you do when you went to the fitness center?

How many days a week did you go? How long did you stay for each session?

2. Why did you join the fitness center?

Did you achieve your goals? Why or why not?

3. What areas of the fitness center did you feel most comfortable using?

4. What areas of the fitness center did you enjoy using the most?

4. What areas did you feel least comfortable using?

5. Why did you discontinue your membership?

6. What could have made your experience better?

61
 APPENDIX D

PHYSICIAN CONSENT FORM

Florida State University

Dept. of Nutrition, Food & Exercise Sciences
Tallahassee, FL 32306
(850) 644-4685
A patient of yours,______________________, has expressed an interest in taking part in a
research project sponsored by the Department of Nutrition, Food and Exercise Sciences at
Florida State University. The purpose of this form is to make you, the physician, aware that the
above individual wishes to participate in a study that will entail some physical exertion. Please
see attached informed consent. We would like your input as to whether the patient may have an
underlying condition that would be contraindicated for participation in this study.

1. Does this individual have any physical limitations/conditions which you feel warrants the
complete exclusion of testing (yes/no)?

2. Does this individual have any physical limitations/conditions which you feel warrants limiting
or modifying the testing session (yes/no)? If so, please explain:

3. Additional Comments:

If you have any questions or concerns pertaining to this form and/or your patient's participation
in the research project please feel free to contact me at 644-4685.

Thank you for your assistance.

Physician's Signature: __________________________________ Date: __________________

Please mail the completed form or fax: Lynn B. Panton, Ph.D.

Lynn B. Panton, Ph.D.

436 Sandels Building
Florida State University
Tallahassee, FL 32306
Fax: (850) 645-5000

62
 APPENDIX E

QUESTIONNAIRES/TESTS

63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
 APPENDIX F

FUNCTIONAL IMPACT TRAINING PROTOCOL

81
 APPENDIX G

YIN YOGA PROTOCOL

82
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