Carney Institute (CI): Tell us a bit about yourself. 

Chloe Zimmerman (CZ): I came to Brown for undergrad and was a Program in Liberal Medical Education (PLME) student. It’s a unique eight-year continuum that allows pre-medical students to explore a diverse educational background by combining their undergraduate and medical school education at Brown. Because of this, I was able to create an Independent Concentration in Contemplative Psychosomatic Medicine that bridged my interests in healing approaches in non-allopathic medical traditions with traditional biomedical approaches to disease. 

I met my undergraduate advisor Cathy Kerr through Brown’s Contemplative Studies Initiative, which has now grown into its own undergraduate concentration. Cathy had a very interdisciplinary academic background, having received her Ph.D. at Johns Hopkins in American studies but, after being diagnosed with multiple myeloma, she became interested in the role of the brain in healing from physical illnesses and began investigating how mind body practices like mindfulness and Qigong can improve health outcomes. She received a career development award from the National Institutes of Health to support retraining in neuroscience and began integrating these ideas into her research. Carney associate director Chris Moore actually became her advisor and professor of neuroscience Stephanie Jones, a close colleague. 

I began working with Cathy on my undergrad thesis examining how mindfulness practice can improve chronic pain by altering regions of the brain associated with maladaptive body awareness. My senior year, Cathy received a generous gift from an interested donor to begin a clinical trial investigating whether cancer survivors suffering from fatigue receive benefit from Qigong, an ancient Chinese healing practice that combines controlled breathing, gentle movement, and meditation to balance energy flow, and promote good mental, physical and spiritual health. This was particularly interesting to me as I had studied traditional Chinese medicine during a PLME summer internship in China, so I decided to defer my entrance into medical school to work as her lab manager/study coordinator for this study. Fortunately for me, the medical school revitalized their M.D./Ph.D. program during that time. As I found that my interest in mind-body medicine research deepened throughout the Qigong study, I was able to pursue more rigorous research training by applying to the M.D./Ph.D. program.

CI: When you say energy flow in the context of Qigong or other forms of Eastern medicine, what does that mean? 

CZ: In Chinese medicine, optimal health is understood as this balance of yin and yang energies, and any health imbalance is considered to be basically an imbalance of the flow of those energies. All components of Chinese healing practices, including the movements of Qigong, the acupuncture needle placement, the choice of herbs used, etc. — fundamentally they’re trying to help bring those energies into alignment. From the outside, from the biomedical perspective, it's a lot harder to think through what measures are potentially changing.  

One of the effects Cathy was really interested in was how the brain changes the way it monitors the body state through the movement-based practice of Qigong specifically. One of her major interests was, when someone experiences subjective shifts in their energy flow or energy balance, what is changing in the brain? How much is “energy flow” related to shifting the sensory input from the body state, and how much does that influence improvements in, for instance, fatigue. A new paper that we’re about to publish in Integrative Cancer Therapies investigates and sheds light on these questions.

CI: Tell us more about the clinical trial exploring Qigong and cancer related fatigue? 

CZ: When it comes to cancer-related fatigue, there's no gold standard of treatment. The closest thing that seems to work the best in the literature is exercise. The problem is that it’s pretty tough to exercise when you're very fatigued. 

We did an initial qualitative interview study with women with breast cancer, asking them about how they experience fatigue. The tricky thing with talking about cancer related fatigue is that the word means something very different in the context of cancer survivorship compared to how we normally think about fatigue. I remember one woman saying that “the only way I can describe it is you sit down, you lie down, or you fall down.” It’s really a very extreme state. Cancer survivors actually rank fatigue as being worse than nausea and pain. 

We worked  with the Miriam Hospital to run the clinical trial, which has an excellent active lifestyle medicine center, and we were able to compare patient experiences by randomizing fatigued female cancer survivors to either a traditional moderate exercise/plant-based nutrition regimen vs. Qigong. We were specifically looking to see if there was a similar level of fatigue reduction with vastly different physical demands. 

CI: What were some of the findings from the trial that will be shown in the upcoming publication in Integrative Cancer Therapies? 

CZ: We ran the study for the first time in the fall of 2016. In the very last week of the class, Cathy sadly passed away. At that point, the study was transferred to professor Stephanie Jones who became the principal investigator and is currently my M.D./Ph.D. advisor. We decided to run a second year’s worth of the study to refine the Qigong class a bit more and to reframe the trial design a bit in 2017.

The study’s primary goal was to understand how much fatigue was reduced by 10 weeks of Qigong practice compared to 10 weeks of combined moderate intensity exercise and plant based nutrition. Surprisingly, given that Qigong is a much gentler form of movement than exercise and does not even involve increases in heart rate, we found that the magnitude of fatigue reduction was the same across both groups, and that the Qigong group additionally improved in measures of emotional health and stress.  

Fatigue is a complex experience that has many overlapping physical, psychological, and cognitive components, and our findings suggest that Qigong may reduce fatigue through different mechanisms than exercise. As a gentler alternative, Qigong may be especially useful for deconditioned cancer survivors or those particularly dealing with the psychological or emotional aspects of fatigue. 

We also collected EEG measures of attentional modulation, ECGs examining overall cardiac reactivity, and blood draws to look at inflammatory changes in addition to a variety of self-report questionnaires and exit interviews. This data analysis is ongoing but showing some initial promising findings and will be the focus of follow up publications. We are really interested in physiological mechanisms that underlie changes in emotional health, fatigue, and life stress. 

In an initial review of the exit interviews from both groups — traditional exercise regimen vs. Qigong — we asked participants how they understood their energy levels and their fatigue. Uniformly, the Qigong group said, “I really learned to listen to myself, and I learned to honor where my body is. To sleep when I need to sleep. Eat when I need to eat.” And the exercise group noted something more akin to, “I learned how to push through. To tell myself that in a week I'll feel better because I did this exercise now.” Essentially, to not listen to my body. What’s really interesting is just how different these strategies are, despite the questionnaires showing a similar magnitude of fatigue reduction across groups. I think different people respond better to different strategies. The more options and regimens like Qiqong that are available to people experiencing post cancer fatigue, the better the efficacy in care. 

CI: As an M.D./Ph.D. candidate, combining and balancing all these different modalities — research, clinical care, integrative medicine — seem to make a lot of sense. What’s next for you? 

CZ: I'm in the fifth year right now of the overall M.D./Ph.D. program, in the middle of my Ph.D. with Stephanie Jones and Carney assistant professor Frederike Petzschner as my co-advisors in a project that specifically explores neural measures of maladaptive bodily signal processing in chronic pain patients. I have recently received an F30 training grant from the National Center for Complementary and Integrative Health for this project. We are working with my clinical mentor, Dr. Alexios Carayannopoulos, D.O., at the Norman Prince Spine Institute to study how baseline brain measures of bodily processing might predict who will respond better to a mind-body intervention or to an invasive spine treatment for their pain. With this training grant, it's exciting to bring my interests in pain, neuroscience, and mind-body medicine full circle, and to build on the work that Cathy started and that continues in her memory. 

My long-term goal is to go to residency, most likely in Physical Medicine & Rehabilitation  (PM&R) because I love that, in a sense, it’s applied neurology. PM&R focuses on restoring function in both the peripheral and the central nervous system to improve people’s recovery, and is very open to the use of mind-body practices in healing trajectories.

I learned pretty quickly in medicine that diagnosing things is pretty algorithmic and it's not what I necessarily love as much. I really find it gratifying to follow people after an initial injury or after the initial change and ask, “How do you actually change and adapt the illness journey to provide the best outcomes for each individual patient”? I think we still have a lot to learn about which mind-body practices are best for which patient. The Qigong study has shown me how much healing potential there is from practices that have been historically dismissed by the biomedical clinical and research communities, and I think we have a responsibility to keep investigating how they may exert their healing effects in rigorously designed studies.