Yoga

Yoga

PEP Topic 
Anxiety
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 vomiting, hot flashes, 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

Banerjee, B., Vadiraj, H.S., Ram, A., Rao, R., Jayapal, M., Gopinath, K.S., . . . Hande, M.P. (2007). Effects of an integrated yoga program in modulating psychosocial stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy. Integrative Cancer Therapies, 6, 242–250.

doi: 10.1177/1534735407306214
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Intervention Characteristics/Basic Study Process:

The yoga intervention was a 90-minute, six-week course taught by expert yoga trainers. The course included meditative practices, various postures, guided imagery of cancer cells, positive thought provocation, chanting of various sounds according to the respective patient’s religious beliefs, awareness practices, deep relaxation, and soothing sound vibrations. Control group patients were given supportive counseling and advised to take light exercise.

Sample Characteristics:

  • The study reported on a sample of 68 women with breast cancer receiving radiotherapy and/or chemotherapy.
  • Of these, 58 completed the study: 35 in the yoga intervention group, and 23 in the supportive counseling group.

Setting:

Three centers in India

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Perceived Stress Scale
  • Alkaline single-cell gel electrophoresis (comet) assay to study cellular DNA damage from peripheral blood

Results:

There was significant decrease in anxiety levels in the yoga intervention group (repeated measures ANCOVA, p < 0.001). Yoga intervention decreased anxiety in women with breast cancer receiving radiation therapy.

Limitations:

  • The study had a small sample size.
  • The study used a convenience sample: Patients may self-select to participate in a study they believe to be effective.
  • Start of intervention was not linked to time into radiation treatment and/or administration of chemotherapy.
  • Expert yoga trainers were required to administer the yoga courses.

Cohen, L., Warneke, C., Foulacli, 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:

Yoga intervention was a seven-week Tibetan yoga (TY) program provided to patients with lymphoma who were undergoing active treatment or who had concluded treatments within the past 12 months. The TY intervention consisted of stress-reduction techniques, including:

  • Regulated breathing
  • Visual imagery
  • Meditation and mindfulness techniques
  • Various low-impact postures.

TY classes were conducted by an experienced TY instructor. After each class, participants were given an audiotape that walked them through all of the techniques. They were encouraged to practice the techniques at least once per day.

Patient characteristics used for group assignment were the type of cancer (Hodgkin or non-Hodgkin lymphoma), the status of treatment (active treatment or completed), gender, age, and baseline state anxiety scores. The allocation process was concealed from investigators. Patients were randomized and notified of their group assignment by telephone. Three separate cohorts of patients were assigned to either the TY group (n = 20) or the wait group (n = 19). The wait group was offered the program three months after the last follow-up assessment was completed. (One participant dropped out of study before attending any classes; therefore, 19 were evaluated.)

Measures were taken at baseline, one week, one month, and three months after the last session.

Sample Characteristics:

The study reported on 39 patients with lymphoma.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Impact of Event Scale (IES)
  • State-Trait Anxiety Inventor (STAI)
  • Center for Epidemiologic Studies Depression Scale (CESD)
  • Brief Fatigue Inventory (BFI)
  • Pittsburgh Sleep Quality Index (PSQI)

Results:

There were no statistical differences between groups on the measures of psychological adjustment (intrusion or avoidance, state anxiety and depression) and fatigue. However, the TY program reduced patients’ sleep disturbances (p < 0.004).

Limitations:

  • The study had a small sample size.
  • The study used a mixed sample of patients with cancer undergoing active treatment as well as cancer survivors 12 months after treatment.
  • The study had special costs associated with training (TY instructor and audiotapes).

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.

Rao, M.R., Raghuram, N., Nagendra, H.R., Gopinath, K.S., Srinath, B.S., Diwakar, R.B., . . . Varambally, S. (2009). Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: A randomized controlled trial. Complementary Therapies in Medicine, 17(1), 1–8.

doi: 10.10Rao_anxiety_yoga16/j.ctim.2008.05.005
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Study Purpose:

To compare effects of a 24-week yoga program with those of a supportive therapy control intervention in patients with early breast cancer

Intervention Characteristics/Basic Study Process:

Prior to surgery, patients were assessed and randomly assigned to the yoga program intervention or control condition. All patients received 50 cGy of radiation therapy over six weeks and were prescribed six cycles of standard chemotherapy with the same schedule. Patients in both groups received alpraxolam 0.5 mg once daily for one week following chemotherapy for the first one to two chemotherapy cycles. Patients in the yoga group had four in-person sessions during the perioperative period and were to undergo three in-person sessions per week for six weeks during radiotherapy treatment, with self-practice on the remaining days. During chemotherapy, patients had in-person sessions during visits (one per 21 days) and in-person sessions with a trainer every 10 days. The instructor monitored self-practice through telephone calls and house visits. The control intervention was brief supportive therapy with education, including 15-minute counseling sessions every 10 days during treatment by a social worker. All patients were asked to maintain daily diaries of symptoms, medication, and diet intake, and for those in the yoga group, their frequency and duration of yoga practice.

Sample Characteristics:

  • The study reported on a sample of 38 female patients.
  • Age information was not reported.
  • All patients had early-stage breast cancer, and 51% were postmenopausal.
  • Of the total sample, 28% reported having other stressful life events in the past two years.

Setting:

  • Single site
  • Inpatient and outpatient setting
  • India

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • State-Trait Anxiety Inventory: symptom grading on 0–4 Likert-type scale
  • Patient diary

Results:

Sixty-one percent of patients initially randomized dropped out of the study. Approximately half of these patients decided to leave the study after initial surgery, and the rest of the dropouts were removed from the study because they did not end up receiving the same expected adjuvant treatment sequence. Anxiety declined over time in all patients, and overall ANOVA did not show a significant group and time effect. Post hoc analysis showed that the yoga group had significantly lower anxiety immediately postsurgery and midway through radiation therapy (p < 0.05) and midway through chemotherapy (p < 0.001). Analysis of overall symptom distress showed a significant effect of the yoga group over time for reduction in symptom distress (p = 0.001). Post hoc testing showed a significant decrease in trait anxiety in the yoga group compared to controls at several time points in the study (p < 0.01). The effect size for state anxiety was 0.33. Anxiety and symptom distress were strongly correlated at all phases of treatment, with r ranging from 0.49 to 0.73 (p < 0.05).

Conclusions:

Anxiety decreased over time in all patients. The yoga intervention was associated with a significantly greater reduction in anxiety at several time points in the treatment schedule, immediately following surgery, midway through radiation therapy, and midway through chemotherapy.

Limitations:

  • The study had a small sample size, with less than 100 participants. Although small, the sample size was based on power analysis, but assumed a larger anxiety effect size than found in this study.
  • The study had a very high drop-out rate. Intention to treat analysis was done using baseline measures for dropouts, resulting in much less change in outcomes seen, which was not particularly helpful in attempting to evaluate the effects of participation in the intervention. The control condition did provide some patient attention, but it was much less than that received by the intervention group.
  • The study did not include information regarding actual patient adherence to self-directed yoga practice.
  • Potential risk of bias exists due to no blinding.

Nursing Implications:

Yoga as provided in this study, with individual instructor-directed sessions and patient self-guided practice expectations, had a mild effect in reducing anxiety over time during various phases of cancer treatment. Guided sessions were done at scheduled visits for treatment, suggesting that this can be a practical way to facilitate patient participation. Patients may find yoga helpful to reduce stress and anxiety.

Ülger, O., & Yagli, N.V. (2010). Effects of yoga on the quality of life in cancer patients. Complementary Therapies in Clinical Practice, 16, 60–63.

doi: 10.1016/j.ctcp.2009.10.007
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Study Purpose:

To investigate the effects of yoga on patients with breast cancer to help them cope with the treatment process and reduce social isolation

Intervention Characteristics/Basic Study Process:

Patients were given eight sessions of classical yoga twice a week in a physical therapy department. Each session lasted one hour, including warm up and breathing exercises, asanas, relaxation, and medication. Study data were collected before and after treatment. All sessions were taught by one yoga physiotherapist, and all assessments were done by another yoga teacher.

Sample Characteristics:

  • The study reported on a sample of 20 female patients.
  • Mean patient age was 41.6 years (SD = 6.17 years).
  • All patients had breast cancer and had received chemotherapy. At least six months had passed since completion of chemotherapy.

Setting:

  • Single site
  • Outpatient setting
  • Turkey

Phase of Care and Clinical Applications:

Patients were undergoing the transition phase of care after initial treatment.

Study Design:

A prospective trial with a pre/post-test design was used.

Measurement Instruments/Methods:

  • State-Trait Anxiety Inventory
  • Visual analog scale for satisfaction
  • Nottingham Health Profile (NHP): for quality-of-life measure

Results:

State and trait anxiety significantly declined from baseline after the yoga intervention (p = 0.001). All NHP parameters improved after the yoga sessions, including energy level, pain, sleep, emotional level, social adaptation, and physical skills.

Conclusions:

Participation in yoga sessions was associated with reduced anxiety and improved quality-of-life scores after initial cancer treatment in these patients with breast cancer.

Limitations:

  • The study had a small sample size, with less than 30 participants.
  • No demographic information to describe the sample other than age was provided, so relevant sample characteristics are not known.
  • It is not clear if yoga sessions were done in groups or individually.
  • There was no comparison or control group, and it has been shown that anxiety and other symptoms tend to decline over time, so it is not known if changes seen here were due to time or the intervention as well.
  • The measure used for quality of life is somewhat questionable, as the instrument is not generally used to measure quality of life, and application in cancer survivors was not discussed.

Nursing Implications:

Findings suggest that yoga may be helpful for patients with cancer to reduce stress and improve overall fitness and ability to relax.

Vadiraja, H.S., Raghavendra, R.M., Nagarathna, R., Nagendra, H.R., Rekha, M., Vanitha, N., . . . Kumar, V. (2009). Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: A randomized controlled trial. Integrative Cancer Therapies, 8, 37–46.

doi: 10.1177/1534735409331456
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Study Purpose:

To compare effects of an integrated yoga intervention with those of a brief supportive intervention on salivary cortisol levels and mood in patients with early breast cancer undergoing adjuvant radiotherapy

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to a six-week yoga intervention or a control group. The yoga intervention included a set of asanas (postures), breathing exercises, meditation, and yogic relaxation techniques with imagery. Individual hour-long sessions were to be attended at least three times per week for six weeks during radiation treatments. These were administered by a trained yoga therapist. The control intervention was brief supportive therapy with education that was routinely offered to all patients. Control patients and caretakers underwent counseling sessions for 15 minutes every 10 days with a social worker as well. Study data were collected at baseline and at the end of the study period. Patients were asked to provide saliva samples three times per day for three consecutive days before and after radiotherapy. Specific procedures for saliva collection, storage, and immunoassay were followed.

Sample Characteristics:

  • The study reported on a sample of 75 female patients.
  • Mean patient age was 46 years (SD = 9.13 years) in the yoga group and 48.5 years (SD = 10.2 years) in the control group.
  • All patients had breast cancer, with 73.9% having stage III disease and all having undergone mastectomy.
  • Most patients (77.3%) also received three cycles of adjuvant chemotherapy, 97.8% were married, and 54.5% were premenopausal.

Setting:

  • Single site
  • Outpatient setting
  • India

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Perceived Stress Scale
  • Mean cortisol levels and diurnal cortisol response

Results:

There were no significant effects of the yoga intervention on cortisol results overall; however, the mean pooled diurnal cortisol and 6 am cortisol levels were lower in the yoga group (p < 0.05). There were significant declines in anxiety levels in both groups. ANCOVA showed a significant decrease in reported anxiety in the yoga group compared to controls (p < 0.001). Depression declined in both groups over time. ANCOVA showed a significant decrease in reported depression in the yoga group compared to controls (p = 0.002). There was a significant decrease in perceived stress in the yoga group (p < 0.001), but not in the control group. Effect sizes seen were 0.31 for anxiety and depression scores and 0.36 for perceived stress.

Conclusions:

Results suggest decreases in anxiety, depression, perceived stress, and 6 am and pooled mean cortisol levels with the yoga intervention used here.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • It is not clear that the control condition provided the same amount of attention to patients as that provided with the yoga intervention.
  • There was no blinding, with associated risk of bias.
  • Demographics show that the vast majority of patients were married, which may not be typical of other patient populations. Potential partner/family supports may have contributed to results seen.
  • Cultural aspects may have impacted results seen.
  • No information regarding the extent of mastectomy was provided, and there is no subgroup analysis based on surgery type, between those who did and did not have chemotherapy as well, or in association with other patient symptoms that contribute to symptoms measured here.

Nursing Implications:

Findings show that anxiety and depressive symptoms decline over time among patients in active treatment with adjuvant radiation therapy in women with breast cancer. Participation in stress reduction interventions, such as yoga, may augment this decline. Changes in cortisol findings seen here with yoga suggest that effects may be attributed to stress reduction, rather than attention, social support, and education alone. Further research in this area is warranted to determine efficacy of yoga in other patient groups, and association with other patient symptoms and problems associated with anxiety and depression.

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.

Cramer, H., Lange, S., Klose, P., Paul, A., & Dobos, G. (2012). Yoga for breast cancer patients and survivors: A systematic review and meta-analysis. BMC Cancer, 12, 412.

doi: 10.1186/1471-2407-12-412
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Purpose:

STUDY PURPOSE: To assess the evidence for effects of yoga on quality of life and psychological health in patients with breast cancer and survivors

TYPE OF STUDY:  Meta analysis and systematic review

Search Strategy:

DATABASES USED: Medline, PsycINFO, EMBASE, CAMBASE, and Cochrane Library through 2/2012

KEYWORDS: Yoga, quality of life, mental health, psychological health, anxiety, depressive disorder, stress, distress, and terms for breast cancer

INCLUSION CRITERIA: Randomized controlled trial (RCT) of patients older than 18 with history of breast cancer; assess health-related quality of life (QOL) or well-being; mental, physical, function, social, or spiritual well-being; and/or psychological health

EXCLUSION CRITERIA: Studies that included yoga as part of a larger intervention, such as mindfulness-based stress-reduction, were excluded.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED = 156

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used, and study quality was evaluated using Cochrane risk of bias criteria.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED: N = 12
  • TOTAL PATIENTS INCLUDED IN REVIEW: N = 742

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care

Results:

Program length and intensity varied from daily interventions for one week to interventions weekly for six months. Four studies included an attention-control condition. Risk of bias was generally high. Meta-analysis showed moderate short-term effects of yoga on global health-related QOL (SMD = 0.62, p = .04). Large short-term effects were found for anxiety (SMD = -1.51, p < .01), depression (SMD = -1.59, p < .01), and distress (SMD = -0.86, p < .01). None of these effects were maintained at long-term follow-up. There was significant heterogeneity in analysis of all outcomes except for overall mental, social, and spiritual well-being. Analysis showed that significant overall effects were only seen among studies involving yoga during active anticancer treatment.

Conclusions:

Yoga may have short-term benefit for patients for overall QOL, anxiety, depression, and general distress; however, these effects do not appear to be maintained. It appears that benefit may be mainly seen during the active treatment phase of care.

Limitations:

  • Small overall number of studies that could be included in various meta-analyses
  • High risk of bias in studies
  • High heterogeneity
  • Highly varied interventions
  • Samples limited to patients with breast cancer

Nursing Implications:

Participation in activities such as yoga during treatment may help patients with anxiety, distress, and depression and overall quality of life during active treatment. The optimum frequency and duration of this type of intervention is unclear, and variability and study limitations make showing strong support of this intervention difficult. Yoga has been shown to be safe for patients with cancer; thus, for those patients who are interested in participating in yoga, there does not appear to be any reason to avoid it. Further well-designed research in this area is warranted to continue to explore the most effective timing, duration, and approaches for yoga interventions.

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.

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
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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
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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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