Yoga

Yoga

PEP Topic 
Fatigue
Description 

Yoga is an ancient Eastern science that incorporates stress-reduction techniques such as regulated breathing, visual imagery, and meditation, as well as various postures. Hatha yoga is one type of yoga. Yoga has been examined as an intervention for anxiety, depression, chemotherapy-induced nausea and vomitimg, hot flashes, cognitive impairment, sleep-wake disturbances, pain, and fatigue in patients with cancer. It has also been examined as an intervention for caregiver strain and burden.

Likely to Be Effective

Research Evidence Summaries

Bower, J. E., Garet, D., Sternlieb, B., Ganz, P. A., Irwin, M. R., Olmstead, R., & Greendale, G. (2012). Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer, 118, 3766–3775.

doi: 10.1002/cncr.26702
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Study Purpose:

To examine, relative to a health education control, the feasibility and efficacy of an Iyengar yoga intervention for breast cancer survivors with persistent posttreatment fatigue.

Intervention Characteristics/Basic Study Process:

Outcome assessors of the performance tasks were blinded to group assignment. The intervention was briefly but fully described, and then participants were randomly assigned to a group that received a 12-week, Iyengar-based yoga intervention or a group that received 12 weeks of a health education (control group).

Sample Characteristics:

  • The sample was comprised of 31 women.
  • Mean age was 54.4 years (standard deviation [SD] = 5.7 years) in the intervention group and 53.3 years (SD = 4 years) in the control group.
  • All participants had stage 0 to II breast cancer.
  • Most participants were white.
  • The range of education was high school completion through graduate degree.
  • Twenty-four participants were completing radiotherapy, 17 were completing chemotherapy, and 22 were receiving hormone therapy.
  • In the intervention group, median time posttreatment was 1.7 years (range 0.7–4.1).
  • Breast cancer survivors with posttreatment fatigue were recruited through multiple mechanisms. Inclusion and exclusion criteria were applied.
  • The original enrollment target was 72 participants; researchers assumed a 20% loss to follow-up. Because of the stringent enrollment plan, the sample size was smaller than expected.
     

Setting:

  • Single site
  • Outpatient
  • University of California, Los Angeles
     

Phase of Care and Clinical Applications:

  • Patients were undergoing the posttreatment phase of care.
  • The study has clinical applicability for survivorship and late effects and survivorship.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Fatigue Symptom Inventory (FSI)
  • Multidimensional Fatigue Symptom Inventory (MFSI), to assess vigor
  • Beck Depression Inventory II (BDI-II)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Perceived Stress Scale (PSS)
  • Timed chair stands and functional reach test, to assess physical performance
  • Medical Outcomes Study (MOS)
     

Results:

Relative to the control group, fatigue severity in the intervention group declined significantly (p = 0.032) from baseline to posttreatment and over the three-month follow-up. In addition, relative to the control group, the yoga group had significant (p = 0.011) increases in vigor. Both groups had positive changes in symptoms of depression and perceived stress (p < 0.05). The authors noted no significant changes in sleep or physical performance. 

One adverse protocol-related event occurred:  a participant with a history of back problems experienced a back spasm in yoga class. After evaluation by her physician, she returned to class.

Conclusions:

A targeted yoga intervention led to a significant reduction in fatigue and improvement in vigor among breast cancer survivors with persistent fatigue symptoms. This conclusion should be understood in the context of the study:  participants were relatively healthy and without comorbid conditions found in the general population.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • Some participants had been living with cancer for more than five years, which was longer than most in the study had been living with cancer.
  • Because of the context of the study, researchers were unable to use a double-blind design.
  • The study included multiple conditions.
  • The results were not generalizable.

Nursing Implications:

This study offered minimal conclusive data in support of the intervention. Preliminary findings indicated that the yoga intervention is feasible and safe and has a positive effect on fatigue. A larger trial that includes participants with common comorbid conditions—a study more representative of the general population of women with breast cancer posttreatment—is warranted. Secondary outcomes included vigor, symptoms of depression, sleep, perceived stress, and physical performance.

Carson, J. W., Carson, K. M., Porter, L. S., Keefe, F. J., & Seewaldt, V. L. (2009). Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Supportive Care in Cancer, 17, 1301–1309.

doi: 10.1007/s00520-009-0587-5
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Study Purpose:

The study evaluated the effects of a yoga intervention on menopausal symptoms among breast cancer survivors.

Intervention Characteristics/Basic Study Process:

Patients were randomized to the yoga intervention or a wait-list control group. The intervention consisted of eight weekly, 120-minute, group classes led by a certified yoga instructor. Classes were videotaped and reviewed. Sessions involved 40 minutes of stretching poses, 10 minutes of breathing techniques, 25 minutes of meditation, 20 minutes of study of pertinent topics, and 25 minutes of group discussion. CD recordings were provided for home practice. Application of concepts to daily life were assigned weekly. Assessments were performed at baseline, posttreatment, and three months postintervention. Wait-list controls were reminded about the assessments they needed. Patients kept daily diaries to rate hot flashes and daily use of yoga.

Sample Characteristics:

  • The study was comprised of 37 women with a mean age of 54.4 years. 
  • Patients were an average of 4.9 years since diagnosis.
  • All patients had breast cancer, and 40.5% were stage IA.
  • Of the patients, 70.3% had prior chemotherapy, 13.5% were on tamoxifen during the study, 75.7% were married or partnered, 81.1% were Caucasian, and 80.3% had college or graduate level education.
  • Patients had no hormone therapy within three months.
  • Many patients were on antidepressants.
  • Of the patients, 50.5% were receiving aromatase inhibitors known to increase hot flashes.

Setting:

The study was performed in outpatient clinics at Duke University.

 

Phase of Care and Clinical Applications:

  • Patients were undergoing the late effects and survivorship phase of care.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Patients kept daily hot flash and yoga use diaries. Hot flashes were scored on a 0-to-9 numeric scale.
  • In addition, a questionnaire assessed the perceived credibility of the intervention.

Results:

Those in the yoga group had a significantly better decline in hot flash frequency, severity, joint pain, fatigue, and sleep disturbance (p < 0.002). Patients in the control group had significantly better decline in the degree to which they were bothered by symptoms (p < 0.0001). There was no difference in night sweats. Mean yoga practice time spent in use of techniques was associated with less fatigue (p = 0.032). Yoga daily participation ranged from 7.3 to 64.6 minutes. There was a 76% completion rate in the yoga group.

Conclusions:

The findings suggested a potential benefit of a group yoga and support intervention for some symptoms in breast cancer survivors.

Limitations:

  • The study had a small sample size.
  • The study had no blinding or attentional control.
  • It is unclear if the benefits were derived from the yoga activities or the group activities provided. 
  • There was a relatively high drop-out rate, raising the question of the practicality of the intervention as designed. 
  • The sample included patients with high education levels and current marriage or partnership support.
  • Measurement of symptoms was not clearly described, and scoring was unclear.

Nursing Implications:

The findings suggested that yoga and support activities provided in a group setting may help patients with symptoms of hot flashes, sleep deprivation, and fatigue. There was no apparent effect on night sweats.  

Carson, J. W., Carson, K. M., Porter, L. S., Keefe, F. J., Shaw, H., & Miller, J. M. (2007). Yoga for women with metastatic breast cancer: results from a pilot study. Journal of Pain and Symptom Management, 33, 331–341.

doi: 10.1016/j.jpainsymman.2006.08.009
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Intervention Characteristics/Basic Study Process:

The Yoga of Awareness Program included eight weekly, 120-minute, sessions, including gentle yoga postures, breathing exercises, meditation, didactic presentations, and group interchange. Patients were also encouraged to practice at home.

Sample Characteristics:

  • The sample was comprised of 13 women with metastatic breast cancer.
  • Mean age was 59 years (range 44–75).
  • Eleven of 13 patients were Caucasian.

Setting:

Duke Pain Prevention Program and Treatment Program Office

Study Design:

The study used an exploratory, pre-/post design; no control group was used.

Measurement Instruments/Methods:

  • Brief daily diary using a visual analog scale (VAS) during two pre- weeks and the last two intervention weeks
  • Focus group feedback

Results:

Those who withdrew had lower fatigue, which was interpreted as less motivation to participate. No significant change occurred in fatigue intercept (slope was not reported). There was a trend in which increased yoga practice was associated with decreased fatigue (p = 0.07). Lagged analysis showed that increased practice was predictive of decreased fatigue the next day. Participants reported that the program was successful to manage fatigue (mean = 7.6).

Limitations:

  • The study lacked a control group.
  • The study had a small sample size.
  • Single-item daily measures were used.
  • There was 28% attrition:  3 preintervention and 5 during the intervention.

Nursing Implications:

No adverse events were reported. The intervention was led by a certified yoga instructor.

Chandwani, K.D., Perkins, G., Nagendra, H.R., Raghuram, N.V., Spelman, A., Nagarathna, R., . . . Cohen, L. (2014). Randomized, controlled trial of yoga in women with breast cancer undergoing radiotherapy. Journal of Clinical Oncology, 32, 1058–1065. 

doi: 10.1200/JCO.2012.48.2752
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Study Purpose:

To test whether participation in yoga during radiation therapy would have long-term effects on fatigue, depression, and sleep disturbances

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to one of three groups: a yoga group, an exercise group, and a wait list control group. Yoga and exercise groups attended up to three 60-minute sessions per week during six weeks of radiation therapy. These were given one-on-one or in groups according to the patient’s convenience and schedule. Each received a CD and written program manual to encourage at-home practice. The yoga program included warm-up breathing, postures, deep relaxation, alternate nostril breathing, and meditation. The exercise program included exercises specifically recommended for women recovering from breast cancer treatment involving multiple positions and stretching. Study assessments were done at baseline, during the last week of treatment, and at one, three, and six months after treatment.

Sample Characteristics:

  • N = 132  
  • MEAN AGE = 52 (range = 26–79)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All had breast cancer, 64% also were on chemotherapy. Over 60% had breast-conserving surgery
  • OTHER KEY SAMPLE CHARACTERISTICS: 16.5% were African American, 44% had at least some college education

Setting:

  • SITE: Single site  
  • SETTING TYPE: Outpatient  
  • LOCATION:MD Anderson in Houston, TX

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active anti-tumor treatment

Study Design:

  • RCT with active control

Measurement Instruments/Methods:

  • SF-36®
  • Brief Fatigue Inventory
  • Pittsburgh Sleep Quality Index
  • Centers for Epidemiological Studies–Depression scale
  • Salivary cortisol levels

Results:

Greater increases in physical component scores of the SF-36 were seen in the yoga group compared to both other groups at one and three months (p = .01). The yoga group (p = .04) and exercise group (p = .02) had greater reduction in fatigue compared to wait list controls at the end of treatment. These differences were not significant at other time points. Fatigue consistently declined over time in all patient groups. Sleep quality improved in all groups over time with no significant differences between groups.

Conclusions:

Both yoga and exercise were associated with reduced fatigue by the end of radiation treatment; however, these effects were not maintained over the following six months.

Limitations:

  • Risk of bias (no blinding)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: Almost 30% were lost to follow-up despite payment of participants for completion of each study assessment. Other interventions that may have influenced outcomes were not described. No intent to treat analysis. Baseline fatigue was low on average across all groups

Nursing Implications:

Findings showed that both yoga and exercise programs during radiation therapy were beneficial in reducing fatigue. Fatigue declined over time in all patients, and effects seen by the end of treatment did not appear to last. The follow-up information here is limited by the high number lost to follow-up, showing the difficulty of conducting longitudinal examination of intervention effects. Nurses can recommend that patients participate in programs such as yoga and exercise during active cancer therapy.

Cohen, L., Warneke, C., Fouladi, R. T., Rodriguez, M. A., & Chaoul-Reich, A. (2004). Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer, 100, 2253–2260.

doi: 10.1002/cncr.20236
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Intervention Characteristics/Basic Study Process:

There were two groups:

  1. Yoga intervention group (n = 20) 
  2. Wait-list control group (n = 19). 

Randomization was performed using minimization.

Yoga sessions consisted of exercises in controlled breathing, visualization, and mindfulness with Tsa lung and Trul khor poses. Patients attended seven weekly sessions with a Tibetan yoga instructor. Written materials were provided.

Sample Characteristics:

  • The sample was comprised of eight patients with lymphoma receiving CHOP or similar chemotherapy within 12 months posttreatment.
  • Patients were predominantly female and posttreatment.
  • Mean age was 51 years.
  • Race and ethnicity were not reported.
  • Patients were excluded if they had a psychotic illness.

Setting:

  • Outpatient
  • Large specialized cancer center
  • Classes were conducted at a Wellness Center.

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment and long-term follow-up phases of care.

Study Design:

The study was a randomized, clinical trial.

Measurement Instruments/Methods:

  • Brief Fatigue Inventory (BFI)
  • Distress:  Impact of Events Scale (IES)
  • Anxiety:  State-Trait Anxiety Inventory (STAI) 
  • Depression:  Center for Epidemiologic Studies Depression scale (CESD)
  • Sleep disturbances:  Pittsburgh Sleep Quality Index (PSQI) 
  • Measures were taken at baseline and follow-up:  posttest and one week, one month, and three months later.

Results:

No significant differences were found in fatigue.

Limitations:

  • The study had a small sample size.
  • There was a possible floor effect because the scores were low.
  • The adherence rate was variable.
  • Timing of the measure may be a significant confounding factor because the study included patients both on and off treatment.
  • A trained Tibetan Yoga instructor was required for the delivery of the intervention.

Dhruva, A., Miaskowski, C., Abrams, D., Acree, M., Cooper, B., Goodman, S., & Hecht, F. M. (2012). Yoga breathing for cancer chemotherapy-associated symptoms and quality of life: results of a pilot randomized controlled trial. Journal of Alternative and Complementary Medicine, 18, 473–479.

doi: 10.1089/acm.2011.0555
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Study Purpose:

To assess the feasibility and effects of pranayama (regulation and expansion of breath) among patients receiving chemotherapy. To test the efficacy of pranayama in alleviating common chemotherapy-associated symptoms (fatigue, sleep disturbance, stress, anxiety, and depression) and improving quality of life (QOL). To evaluate patients' responses to the use of pranayama in alleviating common chemotherapy-associated symptoms affecting QOL.

Intervention Characteristics/Basic Study Process:

Participants were randomized 1:1 in blocks of four. The allocation sequence was generated by the study statistician and then transferred to sealed numbered envelopes. The study staff enrolled participants and implemented the allocation sequence, which was concealed from the study staff until study assignment. Blinding of participants was impossible due to the intervention, which consisted of a 60-minute class once per week taught by yoga instructors and twice daily home practice that totaled 20 to 30 minutes per day, along with usual care during two cycles of chemotherapy. The control group received only usual care during the initial cycle of chemotherapy, and the pranayama intervention along with usual care during the second cycle of chemotherapy.

Sample Characteristics:

  • The sample was comprised of 16 patients.
  • Mean age was 56 years (standard deviation [SD] = 11.9 years) in the control group and 52.4 years (SD = 14.6 years) in the treatment group.
  • The treatment group was 75% female and 25% male; the control group was 100% female.
  • Patients were receiving intravenous chemotherapy for cancer (50% of participants had breast cancer, 50% had some other type of cancer).
  • Patients were included in the study if they had a visual analog scale (VAS) score for fatigue of at least 4 out of 10 and a Karnofsky Performance Status (KPS) of 60 or higher.
  • Patients were excluded from the study if they participated in ongoing yoga practice; had severe chronic obstructive pulmonary disease (COPD), class III or IV heart failure, child class C cirrhosis, or end-stage renal disease; or had received more than three prior chemotherapy regimens.
  • The sample was 62.5% white, and 7 out of 16 were employed.

Setting:

  • Single site
  • Outpatient
  • University medical center

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Participants kept a daily diary in which they recorded the amount of time spent practicing pranayama.
  • At baseline, between the first and second cycle, and at the end of the study, the investigators took measures according to these instruments:
    • Piper Fatigue Scale (PFS)
    • General Sleep Disturbance Scale (GSDS)
    • Hospital Anxiety and Depression Scale (HADS)
    • Perceived Stress Scale (PSS)
    • Short Form 12 (SF-12 v1), to measure QOL.

Results:

Sixteen of 18 participants completed all study measures:  eight from the control group and eight from the treatment group. The study intervention had no adverse effects. Increased yoga practice was associated with statistically significant reductions in sleep disturbance (p = 0.04) and anxiety (p = 0.04). The mental component of QOL approached statistical significance (p = 0.05).

Conclusions:

This was the first study of a pure pranayama intervention for patients with cancer, and it demonstrated that yoga breathing is a feasible and safe intervention for this patient population. Any increase in the yoga breathing practice correlated with improvements of chemotherapy-associated symptoms and QOL. Researchers should confirm these findings by means of a larger study.

Limitations:

  • The study had a small sample size, with less than 30 participants.
  • The study had risks of bias due to lack of an attentional control and due to selection bias:  those who would elect to participate in a study of this kind may be more likely than others to benefit from it. In addition, the study included self-reported outcomes.

Nursing Implications:

Among patients with cancer who are undergoing chemotherapy, pranayama breathing techniques may help decrease sleep disturbance and anxiety and increase the mental component of QOL. Pranayama breathing, supplemented with reminders during and between treatments, seems to be an intervention that is feasible for this group of patients.

Moadel, A. B., Shah, C., Wylie-Rosett, J., Harris, M. S., Patel, S. R., Hall, C. B., . . . Sparano, J. A. (2007). Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life. Journal of Clinical Oncology, 25, 4387–4395.

doi: 10.1200/JCO.2006.06.6027
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Intervention Characteristics/Basic Study Process:

Random assignment occurred in a 2:1 ratio to the intervention group or control group after stratification by treatment (chemotherapy or antiestrogen therapy). The yoga intervention consisted of twelve 1.5-hour weekly classes held at three locations within the cancer center. Participants were permitted to attend more than one class per week, with such activity documented. The yoga intervention was developed for use with patients with breast cancer by one of the study authors who was an oncologist and a certified yoga instructor. The intervention was based on Hatha yoga stretches and poses, breathing exercises, and meditation. All exercises were performed in a seated or reclined position. Patients were asked to practice yoga at home daily and were given an audiotape/CD for guidance in their home practice.

Sample Characteristics:

  • Oncology outpatients were recruited from oncology clinics at a university medical center and from several private clinics between 2001 and 2005.
  • The sample was comprised of 128 patients with breast cancer.
  • Mean age was 54.81 years (range 28–75).
  • Of the patients, 42% were Black, 31% were Hispanic, 23% were White, 76% had high school education or less, 69% were not married, 45% had stage I, and 53% had undergone lumpectomy.
  • Of 164 women with breast cancer who consented, 128 (78%) completed the baseline and main follow-up (three-month) assessments.

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study used a randomized, wait-list control design.

Measurement Instruments/Methods:

Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F)

Results:

No significant difference was found in fatigue change scores from baseline to three-month follow-up between the intervention and wait-list control groups. Both groups were significantly fatigued compared with normative values for the FACIT-F. Subanalysis of the change scores only among the subgroup of patients not on chemotherapy (n = 71) also failed to demonstrate an effect of the yoga intervention on fatigue. However, adherence analysis suggested that participants in the intervention group who were highly adherent with the yoga intervention had significantly improved in fatigue compared with those in the intervention group who were less adherent with the yoga intervention. The primary reason for attrition was lost to follow-up (15%), with attrition similar between the intervention (22%) and control (21%) groups. Those who dropped out were significantly more likely to be younger.

Limitations:

  • The study had a small sample size (intervention group, n = 84).
  • One can speculate that the effects of the intervention may have been obscured by the relatively high level of fatigue of the participants. In support of this possibility is the fact that fatigue was a statistically significant predictor of yoga class attendance.
  • Yoga may be less feasible for patients who are on active treatment with radiation or chemotherapy or those who are already fatigued—adherence analysis revealed that greater fatigue, younger age, receiving radiotherapy, and not being on antiestrogen therapy together explained 40% of the variance in attendance at weekly yoga classes.

Guideline/Expert Opinion

Bower, J.E., Bak, K., Berger, A., Breitbart, W., Escalante, C.P., Ganz, P.A., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical Oncology clinical practice guideline adaptation. Journal of Clinical Oncology, 32, 1840–1850. 

PROFESSIONAL GROUP: American Society of Clinical Oncology (ASCO) expert panel

doi: 10.1200/JCO.2013.53.4495
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Purpose & Patient Population:

PURPOSE: To present screening, assessment, and treatment procedures for adult survivors of cancer who have completed treatment
 
TYPES OF PATIENTS ADDRESSED: Cancer survivors diagnosed at age 18 or older who completed curative treatment, are considered in remission, or are disease-free and on maintenance therapy.

Type of Resource/Evidence-Based Process:

RESOURCE TYPE: Consensus-based guideline  
 
PROCESS OF DEVELOPMENT: Two content experts reviewed and recommended use of pan-Canadian guideline; the ASCO panel suggested use of National Comprehensive Cancer Network (NCCN) articles. The Appraisal of Guidelines for Research and Evaluation (AGREE) II subscale was then used on three articles. Experts issued recommendations based on guidelines and modified based on local context and practice beliefs.
 
DATABASES USED: MEDLINE and Embase
 
KEYWORDS: Fatigue, cancer, survivor, post-treatment, late effects, long-term effects
 
INCLUSION CRITERIA: Cancer survivors diagnosed at age 18 or older who completed curative treatment, are considered in remission, or are disease-free and on maintenance therapy.
 
EXCLUSION CRITERIA: None

Phase of Care and Clinical Applications:

PHASE OF CARE: Late effects and survivorship

Results Provided in the Reference:

Adapted from three guidelines by multidisciplinary experts using supplementary evidence and clinical experience. Most recommendations listed verbatim but some modified to include updated evidence or current practice beliefs.

Guidelines & Recommendations:

Recommendations focused on patients who have completed active treatment or are considered in clinical remission. Treat underlying causes, moderate physical activity after cancer treatment with PT and lymphedema referrals as needed (meta-analysis, systematic review, [randomized controlled trial [RCT]; 10 cited), cognitive behavioral therapy (meta-analysis, RCT, systematic reviews; 6 cited), psychoeducational therapies (systematic, RCT; 3 cited), psychosocial services, mindfulness-based interventions (RCT; 3 cited), yoga (RCT; 2 cited), acupuncture (RCT; 2 cited), psychostimulants/wakefulness agents (limited evidence in patients who are post-treatment disease-free). Additional areas in which research needed include biofield therapies, massage, music therapy, relaxation, Reiki, Qigong, ginseng, and vitamin D.

Limitations:

Guidelines were tailored to survivors with current evidence as not all evidence done is survivors.

Nursing Implications:

Screening, assessment, and treatment guidelines summarized for use in cancer survivors.

Systematic Review/Meta-Analysis

Buffart, L. M., van Uffelen, J. G., Riphagen, I. I., Brug, J., van Mechelen, W., Brown, W. J., & Chinapaw, M. J. (2012). Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials. BMC Cancer, 12, 559.

doi: 10.1186/1471-2407-12-559
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Purpose:

STUDY PURPOSE: Evaluate effects of yoga on physical and psychosocial symptoms
TYPE OF STUDY:  Meta Analysis & Systematic Review

Search Strategy:

DATABASES USED: AMED, CINAHL, British Nursing Index, CENTRAL, EMBASE, PEDro, psycINFO, PubMed and SPORT-Discus
KEYWORDS:  States detailed search profiles available on request
INCLUSION CRITERIA:  RCT, adults with any cancer diagnosis, yoga intervention including physical postures, control group non exercise
EXCLUSION CRITERIA:  Yoga included as part of a larger intervention such as mindfulness based stress reduction were excluded

Literature Evaluated:

TOTAL REFERENCES RETRIEVED : N = 1909
EVALUATION METHOD AND COMMENTS ON LITERATURE USED Study method quality evaluated using a Delphi list previously developed and tested.  Low quality defined as <50% of possible total score.

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED; N(studies)  =  13
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW:  Range 18-128
KEY SAMPLE CHARACTERISTICS:  12 studies involved breast cancer patients, 1 was in lymphoma

Phase of Care and Clinical Applications:

PHASE OF CARE:  Mutliple phases of care

Results:

Physical outcomes: Pain was evaluated in 4 studies, meta analysis of 2 of these showed a large effect size (d=-0.63, 95% CI -0.98, -0.31)
Psychosocial outcomes: Reduced anxiety (d=-0.77; 095% CI -1.08, -0.46) fatigue (d=-.051, 95% CI -0.79,-0.22)  Effects on sleep disturbance were small and insignificant.
Dropout rates ranged from 0-38%
Interventions ranged from planned 6 -15 sessions.  Some studies involved supervised yoga classes, and some involved home practice only.  Studies involved patients in active treatment and others involved cancer survivors who had completed treatment.

Conclusions:

Findings suggest that yoga may be helpful to reduce anxiety and fatigue in patients with cancer.

Limitations:

States 3 studies included participant blinding or double blinding – it is unclear how a participant would not know they were receiving a yoga intervention.  Varied methods of measurement were used in the studies included – there is no description of how these were handled in meta analysis.  There is no report of heterogeneity findings.   Most studies were very small sample sizes.  There was a wide range of drop -out rates and no information about how this was handled in analysis.  Studies did not include attentional control conditions, so it is unclear how much effect was due to group support versus the actual yoga activity.  No differentiation was made between group session interventions versus patients who did home practice alone after instruction.

Nursing Implications:

Findings do not provide strong support for effectiveness of yoga for sleep.  Findings do suggest that yoga may be helpful for patients to reduce anxiety and fatigue.  Nurses can support involvement in this type of activity for patients who are interested in participating in yoga.

Harder, H., Parlour, L., & Jenkins, V. (2012). Randomised controlled trials of yoga interventions for women with breast cancer: A systematic literature review. Supportive Care in Cancer, 20, 3055-3064.

doi: 10.1007/s00520-012-1611-8
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Purpose:

STUDY PURPOSE: To examine physical and psychological benefits of yoga interventions in women with breast cancer

TYPE OF STUDY:  Systematic Review

Search Strategy:

DATABASES USED: MEDLINE, PsychINFO, the Cochrane Library, Embase, CINAHL, AMED, Web of Science, and Scopus

KEYWORDS: Yoga, breast cancer, and breast neoplasm

INCLUSION CRITERIA: Yoga intervention; women with breast cancer; a randomized controlled trial design (RCT); the studies were original full reports; and the studies were published in peer-reviewed journals.

EXCLUSION CRITERIA: Studies that investigated complementary and alternative medicines or exercise interventions; conference abstracts

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Eighteen RCTs met the inclusion criteria out of 274 initial data. The 274 initial articles returned were reduced to 132 after duplicates were removed. Further reductions occurred due to multiple publications of the same data or the same outcome measures; same studies or continuation of same studies also were removed from review.

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Physiotherapy Evidence Database (PEDro Scale) was used to rate methodological quality of RCTs. It is a 10-item scoring system that evaluates internal validity (random allocation; concealment of allocation; similarity of groups at baseline; blinding of participants, therapists, and assessors; adequate follow-up and undertaking an intention-to-treat analysis) and statistical information. A total score below 4 was considered to be of “poor” methodological quality; between 4 and 5 was considered to be of “fair” quality; 6 to 8 was considered to be of “good” quality; and 9 or 10 was considered to be of “excellent” quality. Two reviewers independently rated each study.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED: N = 18
  • SAMPLE RANGE ACROSS STUDIES: The sample size range was 18–164 at baseline to 14–75 at follow-up.
  • TOTAL PATIENTS INCLUDED IN REVIEW: N = 760
  • KEY SAMPLE CHARACTERISTICS: The mean age (based on 10 studies adequately reporting age) was 52.7 years (mean age range = 45–62.9 years). Most studies investigated women with early or advanced stage disease; three included women with noninvasive breast cancers. Seventeen studies conducted repeated measures at a minimum of two time points (pre- and post-intervention) using an adequate baseline assessment performed before or after randomization (though not all studies reported change scores). Follow-up occurred over a range of one to six months.

Phase of Care and Clinical Applications:

PHASE OF CARE: Active antitumor treatment and transition phase after active treatment. Twelve studies were conducted during treatment; six were conducted post-treatment (two months to six years); two were conducted during mixed time periods during and after treatment (mean time since diagnosis or treatment = 1.7–6.5 years).     

APPLICATIONS: Elder care and palliative care

Results:

  • The most common intervention was integrated yoga (consisting of postures, breathing, and meditation) and Iyengar and Hatha yoga (71 %) given via self-practice (83%) or in-class lessons. The duration was 4 to 12 weeks (median 8 weeks).
  • The primary outcome variables of the yoga intervention were (1) mood and psychosocial functioning (depression, anxiety, stress, and psychological symptom distress); (2) health-related quality of life; (3) fatigue; and (4) biological changes and physical measures (i.e., wound healing, hospital stay, TNF-alpha, immunoglobulin, nausea and vomiting, and overweight).
  • Overall, all 18 studies in the review reported positive effects from the yoga interventions, with the greatest impact on global QOL scores and emotional well-being. Few in the yoga program experienced improved cancer-related fatigue. Biological measures varied, and conclusions for this outcome cannot be drawn.
  • Total quality rating scores for the RCTs was a median of 6, indicating that overall the quality was “good” (range 1 to 8); one study was rated methodologically poor (score 1). Low quality was found in the description of the randomization process (i.e., concealed allocation), blinding (i.e., blinding of assessors), and reporting of adequate follow-up (i.e., > 85% of subjects).
  • Adherence was a major problem of the intervention.

Conclusions:

  • Qualities measures were used to evaluate studies. Overall study quality appears to be good, and the studies relatively consistently reported that yoga may be a useful practice.  
  • However, long-term and specific objective effects of yoga interventions need to be further examined. Outcome variables in this review varied across studies. Only seven studies used validated depression measures, and only two studies used a validated anxiety measure. Among them, six studies reported positive effects from the intervention on depression and/or anxiety, whereas two studies reported no effect.
  • The intervention program ranged from 6 to 26 weeks with up to three sessions of yoga per week and were generally well received and safe. Yet, more safety data are required to report that yoga is not harmful and is a credible intervention compared to conventional therapies. More economical and practical information also is needed to implement yoga.

Limitations:

This review does not specifically focus on depression and anxiety. Only studies with patients with breast cancer were included for this review. Thus, only several studies with depression or anxiety as outcome variables were included in the final review. None of the studies were found to have excellent design (e.g., small sample size and lack of long-term follow-up).

Nursing Implications:

The intervention may be beneficial, yet its specific effect on depression and anxiety should be further examined. Also, the intense, duration, and practical issues (e.g., who provided the intervention, who paid the cost) should be considered. Nurses can conduct large-sample, long-term studies of the efficacy of yoga using instruments that measure change scores and calculating sufficient power to detect group differences.

Sadja, J., & Mills, P.J. (2013). Effects of yoga interventions on fatigue in cancer patients and survivors: A systematic review of randomized controlled trials. Explore, 9, 232–243. 

doi: 10.1016/j.explore.2013.04.005
Print

Purpose:

STUDY PURPOSE: To evaluate the evidence of effects of yoga on fatigue among cancer survivors

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed, PsychINFO; in addition, reference lists of articles included in review
 
KEYWORDS: (yoga or yougis or asana or prana) and (fatigue or exhause or burnout or letharf or wary or weariness or drows or tired) and (cancer or metastatic or leukemia or lymphoma or tumor or oncology or oncologist or malignant or malignancy or chemotherapy or radiation)
 
INCLUSION CRITERIA: Articles published in English accepted into publication into a peer-reviewed journal; participants are cancer survivors participating in randomized, controlled yoga interventions
 
EXCLUSION CRITERIA: Adjunctive interventions such as psychotherapy, nutrition, or medications; case studies, conference abstracts, and nonexperimental studies

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 44
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Studies screened by the authors using standard data extraction form; risk of bias evaluated using Cochrane Collaboration tool

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 10
  • TOTAL PATIENTS INCLUDED IN REVIEW = 583
  • SAMPLE RANGE ACROSS STUDIES: 18–164
  • KEY SAMPLE CHARACTERISTICS: 564 women, 17 men; primarily breast cancer; 80%–100% Caucasian, with the exception of one study with 42% African-American, 31% Hispanic, 23% Caucasian, and 4% other 

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Transition phase after active treatment

Results:

Eight of 10 studies only had patients with breast cancer; various stages of cancer; no standard type of yoga intervention; little consistency in measuring fatigue; high risk of selection bias in included studies. In four studies the yoga group reported significant reduction in CRF; three studies reported that there were significant reductions in participants who attended a significant number of classes; four studies reported no differences in self-reported fatigue and no association with number of classes attended.

Conclusions:

The authors suggest that yoga may be beneficial for CRF but urge caution. Small sample sizes and lack of standardization affect ability to draw conclusions. None of the studies reported increase in fatigue, thus no evidence that yoga is detrimental. Evidence of significant reduction of fatigue with number of classes attended.

Limitations:

  • Small number of studies
  • Primarily women with breast cancer
  • Methodological bias in many studies

Nursing Implications:

There is suggestion that yoga may be beneficial; therefore, nurses can recommend this to appropriate individuals. Adherence impacts effect; therefore, it is important that the choice of activity fit with an individual’s lifestyle. More well-conducted studies are needed.

Sharma, M., Haider, T., & Knowlden, A.P. (2013). Yoga as an alternative and complementary treatment for cancer: A systematic review. Journal of Alternative and Complementary Medicine, 19, 870-875.

doi: 10.1089/acm.2012.0632
Print

Purpose:

STUDY PURPOSE: To determine the efficacy of yoga as a treatment option in cancer

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: CINAHL, MEDLINE, and Alt Healthwatch

KEYWORDS: Yoga and cancer and intervention or program

INCLUSION CRITERIA: Quantitative design; measured anxiety, depression, sleep disturbance, pain, quality of life, and/or stress as an outcome; published since 2010; English language; included any form of yoga as part of or the entire treatment of cancer

EXCLUSION CRITERIA: Not quantitative design

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 135

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No specific method of evaluating study quality is reported.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED: N = 13
  • SAMPLE RANGE ACROSS STUDIES: 536 total
  • TOTAL PATIENTS INCLUDED IN REVIEW: Range = 4-240
  • KEY SAMPLE CHARACTERISTICS: Six studies involved only patients with breast cancer; two involved parents of children or adolescents with cancer.

Phase of Care and Clinical Applications:

PHASE OF CARE: Mutliple phases of care

APPLICATIONS: Pediatrics

Results:

Of four studies examining effect on anxiety, two showed no effect and two showed a significant positive effect. One of these was a positive effect on parents. Two studies showed a positive effect for fatigue, and one showed no effect for fatigue. There were no effects seen for depression. One study showed a positive effect for sleep, and one showed no effect for sleep. One study of 18 breast cancer survivors showed a postitive effect for fatigue immediately after the intervention. Six of the studies used a randomized controlled trial (RCT) design. Duration and dosing of the yoga intervention varied substantially across studies. All of the studies used an instructor for the duration of the intervention. Methods of measurement used varied.

Conclusions:

Insufficient evidence exists to draw firm conclusions about yoga’s role and effect in cancer treatment.

Limitations:

There were few studies, and most had very small sample sizes. No information regarding the quality of the studies was included, other than general design, as this included both RCTs and quasiexperimental studies.

Nursing Implications:

There is limited evidence regarding the effects of yoga as a complementary approach in cancer treatment.

Zhang, J., Yang, K.H., Tian, J.H., & Wang, C.M. (2012). Effects of yoga on psychologic function and quality of life in women with breast cancer: A meta-analysis of randomized controlled trials. Journal of Alternative and Complementary Medicine, 18, 994-1002. 

doi: 10.1089/acm.2011.0514
Print

Purpose:

STUDY PURPOSE: To evaluate the effects of yoga in women with breast cancer

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: PubMed, EMBASE, Cochrane Library, Chinese Biomedical Literature Database, and Chinese Digital Journals Database

KEYWORDS: Yoga or asana and breast cancer, and additional breast cancer terms

INCLUSION CRITERIA: Randomized controlled trial (RCT) comparing yoga or yoga-based intervention with a control group

EXCLUSION CRITERIA: Studies that included yoga as part of a larger intervention

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 86

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane handbook was used for evaluation of methodological quality. Randomization was unclear in all but one study, and only one study blinded investigators. Three studies did not report complete outcome data, and dropouts were substantial percentages of the sample in all studies

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED: N = 6 included in meta-analysis  
  • SAMPLE RANGE ACROSS STUDIES: Range = 18-164
  • TOTAL PATIENTS INCLUDED IN REVIEW: N = 382
  • KEY SAMPLE CHARACTERISTICS: All were women with breast cancer aged ≥ 30 years.

Results:

Anxiety was measured in two studies, and meta-analysis showed no significant effect. Depression was measured in two studies, and meta-analysis showed no significant effect of yoga on depression. Fatigue was examined in five studies with no significant effect shown in meta-analysis. Sleep was measured in two studies with no significant effect shown in meta-analysis. Overall, quality of life was the only outcome measure in which a significant effect was seen from meta-analysis (SMD = 0.27, p = .03).

Conclusions:

Insufficient evidence exists to advocate for the use of yoga in patients with breast cancer. No significant effects were seen related to anxiety, depression, sleep disturbance, or fatigue in these patients.

Limitations:

A small number of studies were included, and all had methodological limitations. Yoga interventions differed and varied in frequency and duration.

Nursing Implications:

Insufficient evidence exists to show a benefit of yoga for women with breast cancer. High quality research is needed to evaluate the effects of yoga for symptom management.


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