Effectiveness Not Established

Yoga

for Sleep-Wake Disturbances

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, 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.

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.

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:  Multiple 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.

Print

Chiu, H.Y., Chiang, P.C., Miao, N.F., Lin, E.Y., & Tsai, P.S. (2014). The effects of mind-body interventions on sleep in cancer patients: A meta-analysis of randomized controlled trials. Journal of Clinical Psychiatry, 75, 1215–1223.

Purpose

STUDY PURPOSE: To examine the effect of mind-body interventions (MBIs) on sleep quality among patients with cancer, the moderating effects of the intervention components, subject characteristics, and methodologic features of the relationship between MBIs and sleep
 
TYPE OF STUDY: Meta-analysis

Search Strategy

DATABASES USED: PubMed, Cochrane Library, PsycINFO, and CINAHL
 
KEYWORDS: (mind-body intervention OR mindfulness-based stress reduction OR meditation OR yoga OR hypnosis OR breathing training OR exercise OR qigong OR tai chi OR music therapy OR biofeedback) AND (sleep OR sleep disturbance OR sleep quality OR insomnia) AND (cancer)
 
INCLUSION CRITERIA: Prospective, randomized clinical trials (RCTs) in which MBIs were tested to improve sleep; studies with ≥ 10 randomized participants (i.e., adults ≥ 18 years of age diagnosed with cancer); studies accepted or published in English in a peer-reviewed journal 
 
EXCLUSION CRITERIA: Studies without a control group; studies that did not report on a sleep parameter at baseline and after the intervention 

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 114
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two authors developed and used a data extraction sheet with study characteristics, participant characteristics, intervention details, and outcomes. Studies were independently screened. Disagreements were resolved by discussion, and consensuses were reached. The methodologic study quality was assessed by two authors using the Cochrane Handbook for Systematic Reviews of interventions in six key domains. Publication bias was examined using the fail-safe N and Egger tests; results indicated that publication bias was not present.

Sample Characteristics

FINAL NUMBER STUDIES INCLUDED = 15
 
TOTAL PATIENTS INCLUDED IN REVIEW = 1,405
 
SAMPLE RANGE ACROSS STUDIES: 16–410 patients
 
KEY SAMPLE CHARACTERISTICS: Participants were adults ≥ 18 years of age diagnosed with cancer. Ten studies were conducted in patients with breast cancer, and the remaining five studies were conducted in patients with other cancers. Eight RCTs tested yoga; two studies tested mindfulness-based stress reduction, mediation, and hypnosis; one study tested mind-body bridging and Qigong. 

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Results

The primary outcome was a change in a sleep parameters. The results of the meta-analysis indicated that MBIs had a medium effect size on the improvement of sleep quality, and this effect persisted up to three months after treatment. The weighted mean effect size was -0.43 (95% CI, -0.24 to -0.62), and the long-term effect size (up to three months) was -0.29 (95% CI, -0.52 to -0.06). The sensitivity analysis revealed that MBIs had a significant effect on sleep (g = -0.33, p < 0.001). The moderating effects of components of the intervention, methodologic features, subject characteristics, and the quality of the studies on the relationship between MBIs and sleep were not found (all p values > 0.05). The main interventions used in included studies in which yoga and mindfulness-based stress reduction were employed. Some studies involved the use of meditation, hypnosis, or sleep hygiene interventions. Yoga interventions yielded an effect size similar to that of other individual interventions (g = -0.40, p = 0.71).

Conclusions

This meta-analysis suggested that MBIs yield a medium effect size on sleep quality, and its effects are maintained for up to three months.

Limitations

Although there was a comprehensive review of the literature, the selection criteria may have limited the studies included in the review, and the search strategies may have influenced the articles obtained. Only RCTs with MBIs reporting improved sleep outcomes may have been published, and studies with negative results may have been missed, causing a publication bias. Analysis was only done across all studies, which had substantially different interventions, some of which included cognitive behavioral therapy, which is shown to be effective in sleep improvement. The validity of calculating results across studies with very different interventions is questionable. Different methods of measurement were used in some studies as well. The included studies all lacked attention control.

Nursing Implications

The findings of this meta-analysis support the implementation of MBIs into multimodal approaches to managing sleep quality in patients with cancer; however, it should be recognized that this pooled analysis was done across specific interventions that were very different from each other, and there are multiple limitations that affect the strength of these conclusions.

Print

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.

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: Multiple 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.

Print

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. 

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.

Print

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.

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.

Print

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.

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.  

Print

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. 

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.

Print

Chaoul, A., Milbury, K., Spelman, A., Basen-Engquist, K., Hall, M.H., Wei, Q., . . . Cohen, L. (2018). Randomized trial of Tibetan yoga in patients with breast cancer undergoing chemotherapy. Cancer, 124, 36–45.

Study Purpose

The purpose was to conduct a randomized control clinical trial examining the effects of a Tibetan yoga program compared to stretching and usual care group on sleep and fatigue among patients with breast cancer receiving chemotherapy.

Intervention Characteristics/Basic Study Process

Upon consent, patients completed a seven-day baseline assessment using actigraphy. At completion of baseline, patients were randomized to one of three treatment groups: Tibetan yoga, stretching, or usual care using adaptive randomization, minimization (age, stage of disease, time since diagnosis, baseline fatigue scores, menopausal status, surgical history, and chemotherapy regimen). Tibetan yoga and stretching groups attended four classes with trained instructors that ranged from 75 to 90 minutes each during chemotherapy. Patients then received three in-home booster sessions over six months. During the entire trial, patients were encouraged to practice at home. Long-term follow-up assessments were completed at 1 week and 3, 6, and 12 months postintervention. The usual care group was instructed not to perform yoga during the study period but given the opportunity to participate in yoga classes at the end of the study.

Sample Characteristics

  • N = 227
  • AGE: Mean 49.63 years
  • FEMALES: 100%
  • CURRENT TREATMENT: Chemotherapy
  • KEY DISEASE CHARACTERISTICS: Breast cancer stages 1-3
  • OTHER KEY SAMPLE CHARACTERISTICS: Newly diagnosed before starting treatment

Setting

  • SITE: Not stated or unknown   
  • SETTING TYPE: Multiple settings    
  • LOCATION: Large medical setting, MD Anderson Houston

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care

Study Design

Randomized controlled trial

Measurement Instruments/Methods

  • Primary outcomes: Sleep was measured using self-reported Pittsburgh Sleep Quality Index (PSQI); fatigue was measured using the Brief Fatigue Inventory.
  • Secondary outcomes included objective sleep using actigraphy.

Results

Of the 352 that completed baseline, 74 were randomized to yoga group, 68 to the stretching, and 85 to the wait-list. There were no group differences noted in demographics in the three sample groups. The dropout rate in each group was similar. PSQI global sleep scores were significantly lower in participants who completed the intervention (p = 0.04). The majority of patients in both intervention groups completed all sessions (73% yoga, 74% stretching). No group differences were noted on completeness and practice in both groups. For main outcomes, no significant differences in sleep or fatigue were noted between groups over time. Within-group differences were noted with PSQI sleep disturbances, where the yoga group had significantly lower disturbances after week 1 postintervention compared to stretching (p = 0.03) and usual care (p=0.02). Actigraphy data showed reduced wake after sleep onset (in minutes) for yoga compared to stretching (p = 0.0003) and usual care (p = 0.0002).

Conclusions

The completion of four sessions of Tibetian yoga provided short-term reduction in subjective and objective sleep outcomes compared to stretching but not to usual care. Practicing outside of the intervention setting showed better outcomes in sleep. There was also support to ensure that yoga instruction occurred in-person to maximize patient outcomes and benefit.

Limitations

  • Risk of bias (no blinding)
  • Findings not generalizable
  • Questionable protocol fidelity
  • Other limitations/explanation: Large number of participants were lost to follow-up.

Nursing Implications

Outcomes from this trial provide nurses with additional evidence that yoga could be beneficial for sleep-wake disturbances. However, the results are viewed with caution as the intervention did not show significant improvement compared to usual care.

Print

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.

Intervention Characteristics/Basic Study Process

The Tibetan yoga (TY) intervention involved seven weekly sessions with a yoga instructor who used imagery and exercise and included four aspects:  controlled breathing and visualization, mindfulness, two types of posture, and daily practice. Outcomes were psychological adjustment, sleep, and fatigue.

Sample Characteristics

  • The sample comprised 39 (final N = 38) patients with lymphoma.
  • Mean age was 51 years in both groups.

Setting

  • Community outpatient setting affiliated with a comprehensive cancer center
  • Southern United States

Phase of Care and Clinical Applications

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

Study Design

The study used a prospective, quasiexperimental design with two groups, including a wait-list control.

Measurement Instruments/Methods

Pittsburgh Sleep Quality Index (PSQI)

Results

The TY group reported significantly lower sleep disturbances scores (total PSQI) at follow-up (5.8 for TY versus 8.1 for the wait-list control). At follow-up, the TY group reported better subjective sleep quality, shorter latency, longer duration, and use of fewer sleep medications.

Limitations

  • The study had a small sample size.
  • The study did not control for time since diagnosis.
  • Methods of yoga taught may vary with instructor.
  • Training in yoga is required.
  • Costs are incurred for a space for the class and an instructor.
Print

Cramer, H., Pokhrel, B., Fester, C., Meier, B., Gass, F., Lauche, R., . . . Langhorst, J. (2015). A randomized controlled bicenter trial of yoga for patients with colorectal cancer. Psycho-Oncology, 25, 412–420.

Study Purpose

To evaluate the effects of yoga on quality of life, anxiety, depression, and sleep in patients with colorectal cancer.

Intervention Characteristics/Basic Study Process

Patients were randomized to the yoga or usual care group. The yoga group had weekly 90 minute hatha yoga classes for 10 weeks. Classes were done in a group setting. Patients were encouraged to practice yoga at home and keep a daily log of practice. Study measures were obtained at week 1, 10, and 22. After 22 weeks, patients in the control group were offered yoga participation.

Sample Characteristics

  • N = 44  
  • MEAN AGE = 68.26 years (range = 40-87)
  • MALES: 61.1%, FEMALES: 38.9%
  • KEY DISEASE CHARACTERISTICS: All had colorectal cancer and were an average of 23 months since surgery
  • OTHER KEY SAMPLE CHARACTERISTICS: The majority of patients were retired and were married

Setting

  • SITE: Multi-site  
  • SETTING TYPE: Outpatient    
  • LOCATION: Germany

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship

Study Design

  • Randomized, controlled trial

Measurement Instruments/Methods

  • Functional Assessment of Cancer Therapy (FACT) colorectal and fatigue scales
  • Hospital Anxiety and Depression Scale (HADS)
  • Pittsburgh Sleep Quality Index (PSQI)

Results

At week 10, the yoga group had greater decline in anxiety (p = 0.043) and depression (p = 0.038) scores, but, at week 22, there was no difference between groups. At week 10, there were no differences between groups in PSQI scores, however, at week 22, those in the yoga group had better sleep quality (p = 0.043). There was no relationship between home practice time and outcomes. Only about half attended yoga sessions, and average home practice was about one hour per week. There were no significant differences between groups in overall quality of life scores.

Conclusions

Yoga may be helpful to some patients to reduce sleep disturbances.

Limitations

  • Small sample (less than 100)
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Measurement validity/reliability questionable
  • Subject withdrawals of 10% or greater 
  • Other limitations/explanation: More than 20% were lost to follow up. Baseline anxiety and depression scores were very low, so it is not likely that reduction would be seen due to floor effects, and those reductions seen have questionable clinical relevance.

Nursing Implications

These results did not show meaningful impact of yoga on anxiety or depression. Yoga was beneficial in terms of improving sleep, although changes seen were small, and findings are limited due to study limitations. Further research in the potential role of yoga for sleep improvement is needed.

Print

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.

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.

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Janelsins, M.C., Peppone, L.J., Heckler, C.E., Kesler, S.R., Sprod, L.K., Atkins, J., . . . Mustian, K.M. (2015). YOCAS©® Yoga reduces self-reported memory difficulty in cancer survivors in a nationwide randomized clinical trial: Investigating relationships between memory and sleep. Integrative Cancer Therapies, 15, 263–271. 

Study Purpose

To investigate the effect of a combined hatha and restorative yoga intervention on memory in cancer survivors and to explore relationships between memory and sleep

Intervention Characteristics/Basic Study Process

YOCAS©® (Yoga for Cancer Survivors) is an instructor-guided standardized program that incorporates movement emphasizing restorative poses, breathing exercises, and mindfulness exercises. The intervention was offered twice a week in the late afternoon or evening over 75 minutes for a total of eight sessions. Although all the group trainers were Registered Yoga Alliance Teachers, they were also required to complete a training session, reviewing a detailed YOCAS©® manual to facilitate standardization across sites.

Sample Characteristics

  • N = 328   
  • MEAN AGE = 54.62 years
  • AGE RANGE = 26–72 years
  • MALES: 4%, FEMALES: 96%
  • CURRENT TREATMENT: Hormonal therapy in 53% of sample
  • KEY DISEASE CHARACTERISTICS: Various cancers but predominantly breast cancer (77%)
  • OTHER KEY SAMPLE CHARACTERISTICS: Of the sample, 82% had a partial college education or more. Seventy-four percent of women were postmenopausal.

Setting

  • SITE: Multi-site  
  • SETTING TYPE: Outpatient    
  • LOCATION: 12 cities within the United States

Phase of Care and Clinical Applications

PHASE OF CARE: Late effects and survivorship

Study Design

Secondary analysis of a randomized, clinical trial

Measurement Instruments/Methods

  • MD Anderson Symptom Inventory (MDASI)—primary outcome was one item regarding perceived memory.
  • Pittsburgh Sleep Quality Index (PSQI)—primary outcome was global sleep quality.

Results

At baseline, the average score on the MDASI indicated only a mild level of perceived memory problems overall. Although both groups continued to report memory problems as being mild, a significant decrease (p < 0.05) was observed in patients who completed the intervention. This difference continued to be significant when controlling for differences in age, gender, educational level, past treatment regimen, current hormonal therapy, baseline memory, and baseline sleep scores. Of note, those who received the intervention also had improved sleep (p < 0.05), which accounted for approximately 26% of the improvement in memory (p = 0.039).

Conclusions

Although yoga appeared to decrease perceived memory problems, this outcome was based on a single item of the MDASI. Further longitudinal studies designed specifically to measure the effect of yoga on cognitive function as measured by both objective and subjective measures are warranted.

Limitations

  • Risk of bias (no blinding)
  • Measurement validity/reliability questionable

 

Nursing Implications

Although this study suggested that yoga may improve patients’ perception of memory problems, some of the benefit was because of better sleep.

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Kiecolt-Glaser, J.K., Bennett, J.M., Andridge, R., Peng, J., Shapiro, C.L., Malarkey, W.B., . . . Glaser, R. (2014). Yoga’s impact on inflammation, mood, and fatigue in breast cancer survivors: A randomized controlled trial. Journal of Clinical Oncology. Advance online publication.

Study Purpose

To assess the effects of yoga on inflammation, mood, and fatigue and to test the hypothesis that yoga would decrease inflammation, depressive symptoms, and fatigue in breast cancer survivors

Intervention Characteristics/Basic Study Process

Women were randomly assigned to the intervention group or a wait-list control group. The intervention consisted of two 90-minute Hatha yoga sessions per week for 12 weeks delivered in a group setting. Sessions were audiotaped, and 50% were randomly assessed for differences from predetermined poses to assess fidelity of the intervention. Yoga teachers called anyone who missed a class. Home practice was encouraged, and all practice times were recorded by participants in weekly logs. Data were collected at baseline, immediately after the intervention, and after three months post-treatment.

Sample Characteristics

  • N = 186 (completed initial data), 181 (finally included)
  • MEAN AGE = 51.6 years (SD = 9.2 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors who had completed cancer treatment within the past three years and were at least two months post-treatment intervention (other than tamoxifen or aromatase inhibitors)
  • OTHER KEY SAMPLE CHARACTERISTICS: Those who already completed five hours or more of vigorous physical activity per week were excluded. Those with any prior yoga practice for more than three months were excluded. The majority of participants were college graduates, were employed full or part time, and were married. The average time since treatment was 10.9 months (SD = 7.9 months).

Setting

  • SITE: Single-site
  • SETTING TYPE: Outpatient
  • LOCATION: Ohio, United States

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship

Study Design

Single-blinded, randomized, controlled trial

Measurement Instruments/Methods

  • Multidimensional Fatigue Symptom Inventory Short Form (MFSI-SF)
  • Short Form (SF-36)
  • Center for Epidemiological Studies Depression Scale (CES-D)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Fasting blood samples for proinflammatory cytokines

Results

Patients attended a median of 79% of yoga classes and reported an average of 24.69 minutes of practice per day at home and in class over 12 weeks. Immediately after the intervention, there were no differences between the groups in fatigue; however, in the yoga group, fatigue was significantly lower at three months (Cohen’s d = -0.36, p = 0.002). Vitality in the yoga group was significantly higher immediately post-treatment and at three months (p = 0.01). There were no differences between the groups in depressive symptoms. Immediately postintervention, there were no differences between groups in cytokine levels; however, at three months, the yoga group had significantly lower cytokine levels compared to the control group (p < 0.05). Yoga participants reported improved sleep compared to patients in the control group (p = 0.03).

Conclusions

Yoga was associated with reduced fatigue, increased vitality, improved sleep, and reduced cytokine levels. Yoga did not appear to have an effect on depressive symptoms in this study.

Limitations

  • Baseline sample/group differences of import
  • Risk of bias (no appropriate attentional control condition)
  • Risk of bias (sample characteristics)
  • Other limitations/explanation: The sample included only women who were highly educated and had higher income levels.

Nursing Implications

The findings of this study demonstrated that yoga practice was effective in reducing fatigue and improving vitality and sleep in this patient population. Nurses can suggest that patients become involved in yoga practice as a way to manage fatigue and sleep disturbance. These findings also suggest that yoga can have an impact on subclinical inflammation, which may be a mechanism that fuels fatigue and the decline of physical function.

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Milbury, K., Chaoul, A., Engle, R., Liao, Z., Yang, C., Carmack, C., . . . Cohen, L. (2014). Couple-based Tibetan yoga program for lung cancer patients and their caregivers. Psycho-Oncology, 24, 117–120. 

Study Purpose

To examine the feasibility and preliminary efficacy of Tibetan yoga practice as a supportive approach for patients and caregiver dyads during radiation therapy for lung cancer

Intervention Characteristics/Basic Study Process

Participants had two to three weekly sessions of yoga for 45–60 minutes over five to six weeks. The program included deep breathing awareness and visualization, guided meditation, compassion-based meditation, and gentle movements coordinated with specific breathing patterns. Patients and caregivers completed study measures at baseline and at the end of the program.

Sample Characteristics

  • N = 10 dyads  
  • MEAN AGE = 71.22 years (patients, range = 61–82 years); 68.77 years (caregivers, range = 61–78 years)
  • MALES: Patients 50%; caregivers 10%, FEMALES: Patients 50%; caregivers 90%
  • KEY DISEASE CHARACTERISTICS: All patients had lung cancer and were receiving radiation therapy. 50% had stage IIIb disease. Average time since diagnosis was 2.88 months, range 1.13–5.97 months.
  • OTHER KEY SAMPLE CHARACTERISTICS: Slightly greater than 50% of participants had some college level or higher education, 80% were white, and 75% had incomes greater than $50,000 per year.

Setting

  • SITE: Single-site    
  • SETTING TYPE: Outpatient  
  • LOCATION: Texas

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS: Elder care  

Study Design

Single-group, prospective pilot study

Measurement Instruments/Methods

  • Center for Epidemiologic Studies Depression Scale (CES-D)
  • Anxiety dimension of the Brief Symptom Inventory (BSI)
  • Pittsburgh Sleep Quality Index (PSQI)
  • Brief Fatigue Inventory (BFI)
  • Medical Outcomes Study Short-Form Health Survey (SF 36)
  • Functional Assessment of Cancer Therapy Spiritual Well Being Scale (FACT-Sp)
  • Finding meaning in cancer scale

Results

Ten of 19 consenting dyads completed the study and attended a mean of 12 sessions (range = 6–15). For patients, there was a significant increase in spiritual well-being (d = 1.12, p = .03), improvement in sleep (d = .60), and depressive symptoms (d = .52). There were small effects for anxiety. For caregivers, there were significant decreases in fatigue (d = .89, p = .03) and anxiety (d = .81, p =.04) and some reduction in sleep disturbance (d = .71, p =.08). Class attendance and home practice frequency was not associated with differences seen in symptoms for either patients or caregivers.

Conclusions

A couple-based yoga program was seen as feasible for patients, including those with advanced disease. Medium effect sizes were seen for depressive symptoms and sleep disturbance.

Limitations

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Subject withdrawals ≥ 10%

Nursing Implications

Couple-based yoga sessions were shown to be feasible, and findings suggest that this type of supportive care during radiation therapy may be beneficial in some patients and caregivers for symptoms of fatigue, anxiety, depression, and sleep disturbances. The high drop-out rate suggests that many patients may not be interested or able to participate in such a program, but for those who are interested, it may be helpful. The fact, however, that the number of sessions attended and frequency of home practice were not related to the magnitude of results seen causes one to question whether it was the yoga practice or general support and attention provided that caused effects.

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Mustian, K.M., Sprod, L.K., Janelsins, M., Peppone, L.J., Palesh, O.G., Chandwani, K., . . . Morrow, G.R. (2013). Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. Journal of Clinical Oncology, 31, 3233–3241.

Study Purpose

To determine the effectiveness of a standardized yoga intervention compared to usual care for improving sleep quality among cancer survivors

Intervention Characteristics/Basic Study Process

Patients were stratified by sex and baseline sleep disturbance and randomized to yoga or usual care groups. Patients in the yoga group participated in a program of gentle Hatha yoga and restorative yoga for four weeks. Sessions were provided in community-based sites (e.g., community centers, yoga studios) in groups of 10–15 patients. Study measures were obtained at baseline and at the end of the four-week sessions.

Sample Characteristics

  • N = 221
  • MEAN AGE = 54.1 years
  • MALES: 4%, FEMALES: 96%
  • KEY DISEASE CHARACTERISTICS: 75% had breast cancer; 91% had previous surgery; 71% had chemotherapy; 66% had radiation therapy; 51% were on current hormone therapy; the average time since cancer treatment was 16.3 months.
  • OTHER KEY SAMPLE CHARACTERISTICS: 48% were not exercising at baseline; 72% were married or in a long-term relationship; all reported at least a level 3 of sleep disturbance on a 10-point numeric scale.

Setting

  • SITE: Multi-site  
  • SETTING TYPE: Outpatient  
  • LOCATION: United States

Phase of Care and Clinical Applications

  • PHASE OF CARE: Transition phase after active treatment

Study Design

  • RCT
    • Single-blind

Measurement Instruments/Methods

  • Pittsburgh Sleep Quality Index
  • Actigraphy

Results

Those assigned to the yoga intervention attended an average of 6.5 of 8 prescribed sessions. Compared to patients in the control group, participants in the yoga program showed greater improvement in global sleep quality (OR 10.79, p = .009), less daytime dysfunction (OR 0.381, p < .001), less sleep medication use (OR 0.561, p = .046), and improvement in subjective sleep quality (OR 0.631, p =.047). Global sleep quality, sleep disturbance, sleep efficiency, and subjective sleep quality also improved in patients in the control group. No significant differences were seen between groups in actigraphy findings.

Conclusions

Participation in group yoga sessions had a positive impact on self-reported sleep quality among cancer survivors.

Limitations

  • Baseline sample/group differences of import
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals of 10% or greater
  • Other limitations/explanation: At baseline, global sleep quality was higher in the intervention group; however, no analysis was provided of the significant of this difference. Use of other interventions for sleep are not discussed, other than sleep medication use, which is not defined. Sessions were done in groups, so to what extent effects seen were because of the yoga exercises versus the group activity and relationships is unclear. The dropout rate was almost 50% in both study groups.

Nursing Implications

Findings suggest that participation in group yoga sessions may be effective in improving self-reported sleep quality among cancer survivors. This type of activity may not be acceptable to all patients, given the dropout rates seen in this study. However, for those who are interested in this type of intervention, nurses can let patients know that it can be of benefit.

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Rao, R.M., Vadiraja, H.S., Nagaratna, R., Gopinath, K.S., Patil, S., Diwakar, R.B., . . . Nagendra, H.R. (2017). Effect of yoga on sleep quality and neuroendocrine immune response in metastatic breast cancer patients. Indian Journal of Palliative Care, 23, 253–260.

Study Purpose

The purpose of this study was to test the effects of a yoga program to determine impact on perceived stress, sleep, diurnal cortisol, and natural killer cell counts in patients with metastatic cancer compared to education and supportive therapy sessions.

Intervention Characteristics/Basic Study Process

Patients with advanced metastatic breast cancer were recruited from a comprehensive cancer center in the medical and radiation outpatient clinics. Consenting patients were randomized to yoga or supportive therapy groups. Providers of oncology care were blinded to group assignment. The yoga program intervention included two sessions a week for 12 weeks. Each session started with a lecture and yoga for 10 minutes followed by 20 minutes of low-impact yoga postures, breathing, and pranayama and relaxation. Then, subjects completed 30 minutes of guided yoga practice by one of two trained instructors. Practicing was encouraged between sessions with instructions and booklets documented in diary logs. The control group completed supportive care sessions, including education and reinforcing social support. Introductory sessions were 60 minutes before starting treatment and during each treatment visit for 15 minutes. Participants could contact counselors at any time with issues or questions. Diary logs were also completed.

Sample Characteristics

  • N = 91   
  • AGE: Mean 49.6 years
  • FEMALES: 100%
  • CURRENT TREATMENT: Combination radiation and chemotherapy
  • KEY DISEASE CHARACTERISTICS: Diagnosed with stage IV breast cancer within six months of enrollment with no brain involvement 
  • OTHER KEY SAMPLE CHARACTERISTICS: No active steroids, unable to perform exercise, psychiatric, neurological, autoimmune disorder. No pregnancy or lactating mothers.

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Comprehensive cancer center, India

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active antitumor treatment
  • APPLICATIONS:  Palliative care

Study Design

Two-arm, prospective randomized control trial

Measurement Instruments/Methods

The Pittsburgh Insomnia Rating Scale was used to measure distress related to sleep, sleep parameters, and sleep-related quality of life. Salivary cortisol was measured using oral swab on three consecutive days at three time points. Natural killer cells were collected at baseline and at the end of the study using serum samples to determine immune response. A daily diary was used to document yoga practice in the intervention group and control group.

Results

Of the 91 baseline participants, complete data were analyzed on 66. Reasons for high dropout were listed. No demographic group differences were noted at baseline. Within-group findings included significant decreased distress scores (p = 0.004), decreased sleep distress scores (p = 0.01), improved sleep quality-of-life scores (p = 0.006), improved sleep total distress scores (p = 0.002), decrease in cortisol (p = 0.03), and natural killer cells (p < 0.01) in the yoga group alone. Intervention adherence was 80% attending 24 supervised sessions. Attending more than 20 sessions showed the decreased 9 am cortisol level in the yoga intervention group.

Conclusions

There was evidence to support that yoga could be impacting sleep distress, sleep outcomes, and sleep quality of life, as well as neuroendocrine immune changes providing mechanistic information regarding the benefits of yoga on sleep. Additional research is needed to generalize findings to a wider cancer population.

Limitations

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: Inequality of intervention contact duration between groups

Nursing Implications

When recommending yoga as an intervention for sleep, there is a potential impact on subjective sleep outcomes, quality of life, and neuroendocrine responses such as immune function and cortisol levels.

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