Yoga

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

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

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.

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:  Multiple phases of care

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.

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

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.

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.

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

TYPE OF STUDY:  Systematic Review

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

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.

• 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: 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

• 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.

• 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.

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).

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.

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

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

PHASE OF CARE: Transition phase after active treatment

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

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

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

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

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

TYPE OF STUDY: Systematic review

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

TOTAL REFERENCES RETRIEVED: N = 135

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

• 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: Multiple phases of care

APPLICATIONS: Pediatrics

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.

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

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.

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

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

TYPE OF STUDY: Meta-analysis and systematic review

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

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

• 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.

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).

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.

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

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.

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.

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).

• 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.
   

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

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

The study was a randomized, controlled trial.

• 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)
   

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.

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.

• 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.

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.

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

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.

• 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.

The study was performed in outpatient clinics at Duke University.

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

The study was a randomized, controlled trial.

• 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.

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.

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

• 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.

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.  

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

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

Duke Pain Prevention Program and Treatment Program Office

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

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

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

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

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

To determine the effectiveness of pranayama yoga on fatigue during radiation therapy

Patients were randomized to receive only radiation therapy with routine care or to perform pranayama during radiation therapy. Those in the yoga group performed pranayama morning and evening five days per week for six weeks under supervision. Fatigue was assessed at the beginning and end of radiation therapy.

• N = 160   
• AGE = 57% were younger than 45 years
• FEMALES: 100%
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Patients were scheduled to receive 50 Gy. All had received chemotherapy and had undergong surgery. Most had stage II or III disease.
• OTHER KEY SAMPLE CHARACTERISTICS: Seventy percent had only mild fatigue at baseline.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: India

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

Cancer fatigue scale

Post-test fatigue scores in the intervention group were lower (p = 0.001), and the intervention group had a significant decline in fatigue score (p = 0.001); however, all scores continued to be in the range of mild fatigue only.

Pranayama may be helpful to prevent or reduce fatigue during treatment with radiation therapy.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Patients had only mild fatigue at all study time points.
• Although postintervention differences were significant with pranayama, clinical relevant is unclear, because fatigue was still only mild.

Participation in yoga during cancer treatment may be helpful to combat symptoms of fatigue. This is a low-risk intervention that nurses can suggest to patients to manage fatigue.

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

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.

• 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

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

• PHASE OF CARE: Active anti-tumor treatment

• RCT with active control

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

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.

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.

• 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

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.

There were two groups:

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

Randomization was performed using minimization.

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

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

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

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

The study was a randomized, clinical trial.

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

No significant differences were found in fatigue.

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

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.

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.

• 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.

• Single site
• Outpatient
• University medical center

Patients were undergoing the active treatment phase of care.

The study was a randomized, controlled trial.

• 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.

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).

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.

• 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.

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.

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

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.

• 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).

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

• PHASE OF CARE: Late effects and survivorship

Single-blinded, randomized, controlled trial

• 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

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).

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.

• 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.

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.

To test the effects of yoga on health-related quality of life, life satisfaction, cancer-related fatigue, mindfulness, and spirituality compared to conventional therapeutic exercises during (neo)adjuvant cytotoxic and endocrine therapy in women with stages I–III breast cancer

In a randomized controlled trial (N =119) (with data from 92 used for data analyses), women with breast cancer undergoing oncological treatment were randomly enrolled in a yoga intervention (YI) (n = 45) or a physical exercise intervention (PEI) (n = 47). Measurements were obtained before (t0) and after the intervention (t1), as well as three months after finishing the intervention (t2) using standardized questionnaires.

• N = 92   
• AGE = 40–62 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, radiation, combination radiation and chemotherapy, hormonal therapy
• KEY DISEASE CHARACTERISTICS: Breast cancer stage I–III 
• OTHER KEY SAMPLE CHARACTERISTICS: Exclusion criteria were (a) acute febrile or psychiatric diseases or (b) regular practice of yoga or experience practicing yoga

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Yoga at the center \"Yoga München GbR\" in Munich, physical exercise at the center \"Gesund. Reha rechts der IsarGmbH\" in Munich, and exercise at home

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial with active control

• Cancer-specific European Organization of Research and Treatment of Cancer Core Quality of life (QLQ-C30) questionnaire for health-related quality of life
• Brief Multidimensional Life Satisfaction Scale
• 15-item Cancer Fatigue Scale (CFS-D)
• 14-item Freiburg Mindfulness Inventory (FMI)
• 15-item version of SpREUK questionnaire for spiritual attitudes and coping with Illness

Statistically significant results were found on most functional scales of the EORTC, which indicated the spontaneous recovery of patients’ quality of life after chemotherapy and/or radiation. The global health, role, and social functioning of patients in both groups improved significantly, yet neither group significantly differed from the other in these variables. Fatigue, dyspnea, appetite loss, constipation, and diarrhea improved in both groups. For “nausea and vomiting” and “pain,” significant changes were observed over time. No difference existed in life satisfaction, cancer-related fatigue, spirituality, and mindfulness between the groups.

High drop out rate may be related to the number of measurements. One of the concerns was that patients in treatment were having difficulty with the exercise and yoga programs thought to be from the side effects of the treatment. Further study focusing on one or two areas would be beneficial.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Key sample group differences that could influence results
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Questionable protocol fidelity
• Subject withdrawals ≥ 10%
• The number of lessons varied from 5 to 12, and the time lapse varied from 6 weeks to 25 weeks, which was not considered in the evaluation of the program.

The authors felt that this study may have been accepted by patients post-treatment or by using other forms of yoga. Self-care is becoming more common today, and yoga something you can do for yourself. Further investigation should be conducted to see how effective yoga is for patients with cancer.

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

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.

• 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.

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

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

Single-group, prospective pilot study

• 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

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.

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.

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

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.

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

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

Patients were undergoing the active treatment phase of care.

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

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

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

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

To analyze the effects of a four-week yoga intervention on cancer-related fatigue and the burden of overall side effects in older cancer survivors

This report is a secondary analysis of a previously published multi-site, randomized, controlled trial to assess the effects of yoga on fatigue and sleep problems among patients with cancer who completed initial treatment. Participants aged 60 years or older who had completed fatigue measures were included in this analysis. Group yoga sessions were provided two days per week for four weeks. The program included breathing exercises, postures, and mindfulness exercises involving meditation, visualization, and affirmation. Random sessions were independently observed by study coordinators to verify the content.

• N = 97  
• MEAN AGE = 65.96 years
• MALES: 6%, FEMALES: 94%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types; breast cancer most prevalent (65%)

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: New York

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Elder care 

Single, blinded, randomized, controlled trial

• Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF)
• Clinical symptom inventory 11-point rating scale (Global symptom burden was calculated as the sum of all individual symptom scores ranging from 0–120.)

Participants attended an average of 6.2 of the eight yoga sessions. After the intervention, yoga participants reported a significantly lower level of fatigue compared to the standard care patients (p = 0.03) and a significantly lower global side effect burden (p < 0.01). Significant results were only in the physical and mental components of fatigue.

The findings of this study showed that yoga improved fatigue.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Other limitations/explanation: There was high variability among the sample in the time since initial treatment ended, this ranged from 2–24 months. The sample included very few men, and the majority of participants were white and well-educated. The duration of follow-up was only four weeks. Participants were aware of the study outcomes of interest, so there was an associated potential threat to the internal validity of the study

The findings of this study suggest that yoga may be beneficial to older cancer survivors for the reduction and management of cancer-related fatigue. Studies of yoga have tended to be done in women and individuals with relatively high formal education. Additional research is needed to examine the effectiveness and acceptance of this type of intervention in more diverse patient groups.

To examine the effectiveness of an eight-week yoga program on depression, anxiety, and fatigue in women undergoing adjuvant chemotherapy for breast cancer

Patients were randomized to yoga and control groups. Control group patients received usual care and maintained ordinary daily activity routines. The yoga group had 60-minute sessions including meditation and breathing exercise, yoga exercises, and a cool-down. The program was provided twice per week over eight weeks. Study measures were obtained at baseline, at week 4, at week 8, and at four weeks after the conclusion of the intervention. It is not clear if yoga sessions were provided in a group setting or what the timing was related to chemotherapy treatments.

• N = 60  
• MEAN AGE: Age and range not provided; about 50% were below or above 50 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All participants had breast cancer and were receiving adjuvant chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: 45% had a high school education and 33.3% had a university-and-above education 

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

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Brief Fatigue Inventory (BFI)
• Profile of Mood States (POMS)

Fatigue level and its influence on daily life were lower in the experimental group after eight weeks, which was maintained at three weeks postintervention (p < .001). In the control group, the fatigue level increased after eight weeks (p < .001). In the control group, the influence of fatigue on daily life initially declined but increased from baseline after eight weeks. In those participants with higher baseline fatigue levels, in the first four weeks, benefits were fewer in the experimental group. There were no differences between groups in anxiety or depression. Participation in the yoga sessions was 90% overall.

Yoga participation was associated with improvement in fatigue and the influence of fatigue on daily activities after four weeks. Yoga had no effect on measures of anxiety or depression.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)

Yoga can be beneficial for patients to reduce fatigue during active treatment as shown in this study. Findings that those with higher fatigue scores did not show fatigue reduction until after four weeks suggest that patients with greater fatigue may need a longer program than others to derive full benefits. There was no apparent effect of participation in yoga sessions on anxiety or depression.

Patients were randomized to a yoga plus exercise group or an exercise alone group. Both groups did aerobic exercises three days per week for six weeks. The yoga program involved postures, meditation, and relaxation with imagery. Yoga was provided in 60-minute group sessions three days per week on the same day as exercise was done. Yoga was supervised by a certified therapist.

• N = 40  
• MEAN AGE = 48.6 years
• MALES: Not written, but it seems to be 0%, FEMALES: Not written, but it seems to be 100%
• KEY DISEASE CHARACTERISTICS: Patients with unilateral breast cancer who were mentally intact and whose cancer treatment was completed at least three years prior
• OTHER KEY SAMPLE CHARACTERISTICS: A cardiologist performed the cardiologic examinations. Exclusion criteria included chronic systemic disease and metastasis, relative and absolute contraindications for exercise training, drug therapy with a risk for exercise, types I and II diabetes mellitus, uncontrolled hypertension, and cardiac disease.

• SITE: Single site    
• SETTING TYPE: Outpatient    
• LOCATION: Turkey

• PHASE OF CARE: Late effects and survivorship

Randomized, controlled trial

• European Organisation for Research and Treatment of Cancer Quality of Life Questionnarie (EORTC C30)
• Fatigue Severity Scale (FSS)
• Six-minute walk test
• Dynamometer for peripheral muscle strength
• Borg Fatigue Scale (BFS)
• Borg Dyspnea Scale (BDS)

• Dyspnea, fatigue, and leg fatigue perception were significantly decreased in both groups, and the improvement was similar in the two groups (P < 0.05).
• Peripheral muscle strength assessments improved in both groups (P < 0.05).
• Quality of life assessments improved in both groups (P < 0.05).
• Well-being, role function, and emotional and social functioning were statistically better in the group that included yoga compared with the aerobic exercise group (P < 0.05).
• FSS scores decreased more in the yoga and aerobic exercise groups compared to the group that received aerobic exercise alone (P < 0.05).

Aerobic exercise training and yoga improved functional capacity and QOL and reduced fatigue in patients with breast cancer. The addition of yoga to aerobic exercise was associated with greater improvements in fatigue perception and QOL measures.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: There were several limitations in this study. A group that practiced yoga alone was not included, therefore the effects of yoga alone could not be reported. The exercise training period was six weeks. Longer exercise interventions are needed to determine their effects on other outcomes. The power analysis was performed post-hoc according to the primary outcome (6MWT) but revealed that the study had sufficient power (85%) to support our conclusions. Yoga was provided in a group setting, and there was no similar group activity in the exercise alone group. Group support may be responsible for some of the differences seen in perceptions and overall QOL. Areas for future research include appropriate levels of intensity for exercise training, the application of the program during cancer treatment, and the application of the program with patients receiving bilateral mastectomies.

The findings of this study suggest that the addition of yoga to exercise interventions may cause improvements in perception of dyspnea and fatigue among breast cancer survivors that are greater than the effects of exercise alone. Mind–body approaches should be considered as adjuvant interventions for fatigue.

PHASE OF CARE: Late effects and survivorship

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

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

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

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