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

TYPE OF STUDY:  Meta analysis and systematic review

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

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

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

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

TOTAL REFERENCES RETRIEVED = 156

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

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

PHASE OF CARE: Multiple phases of care

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

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

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

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

STUDY PURPOSE: To assess effects of yoga on health-related quality of life, mental health, and cancer-related symptoms among women with a diagnosis of breast cancer who are receiving active treatment or have completed treatment.

TYPE OF STUDY: Systematic review

DATABASES USED: Cochrane Breast Cancer Specialised Register, MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials (2016, Issue 1), Indexing of Indian Medical Journals, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov 

YEARS INCLUDED: (Overall for all databases) did not give date range

INCLUSION CRITERIA: RCTs were eligible if they compared yoga interventions versus no therapy or versus any other active therapy in women with a diagnosis of non-metastatic or metastatic breast cancer, and if they assessed at least one of the primary outcomes on a patient-reported instrument, including depression, anxiety, fatigue, or sleep-disturbances.  

EXCLUSION CRITERIA: Duplicates, not including randomized control methodology, no assessment of relevant outcomes.

TOTAL REFERENCES RETRIEVED: 432

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers

FINAL NUMBER STUDIES INCLUDED: 23

TOTAL PATIENTS INCLUDED IN REVIEW: 2,166

SAMPLE RANGE ACROSS STUDIES: Only RCTs included.  

KEY SAMPLE CHARACTERISTICS: Sample sizes ranged from 18 to 309, with median of 74.5. Women's mean age ranged from 44 to 62.9 years, with a median of 54 years. All studies included women with non-metastatic breast cancer; one study included women with metastatic disease. Women included were at different stages in both their diagnosis and treatment. Cancer treatment type was varied.

PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified

APPLICATIONS: Elder care, palliative care

As relevant to these PEP topics, yoga primarily improved health-related quality of life, fatigue, and sleep disturbances. Evidence suggests short-term effects of yoga compared with psychosocial/education interventions on depression, anxiety, and fatigue. During active cancer treatment, yoga improved depression, anxiety, and fatigue compared with no therapy or psychosocial/educational interventions. After therapy, yoga showed effects on health-related quality of life, fatigue, and sleep disturbances. The studies were not robust enough to measure effects of yoga more than five years after diagnosis or in the metastatic breast cancer population.

Evidence supports that yoga can have benefits on health-related quality of life in patients with breast cancer, including a decrease in anxiety, depression, and fatigue. Additional research is needed to assess the effectiveness of yoga more than five years from diagnosis and in the metastatic population.

Yoga has been shown to be an evidence-based intervention which can improve health-related quality of life and symptoms, including depression, anxiety, and fatigue, in women with non-metastatic breast cancer at all stages of treatment, up to five years postdiagnosis.

STUDY PURPOSE: To review results of yoga trials conducted among patients during cancer treatment

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, CINAHL, and PsycINFO through October 2015

INCLUSION CRITERIA: Children or adults undergoing cancer treatment, intervention was yoga or a component of yoga, randomized or non-randomized study

EXCLUSION CRITERIA: Patients receiving only hormone therapy, interventions involving only meditation or yoga, delivered as part of an MBSR intervention

TOTAL REFERENCES RETRIEVED: Not reported

FINAL NUMBER OF STUDIES INCLUDED: 4 studies of children, 22 total studies–13 were RCTs

TOTAL PATIENTS INCLUDED IN REVIEW: 1,046

SAMPLE RANGE ACROSS STUDIES: 4 to 164

KEY SAMPLE CHARACTERISTICS: Varied tumor types–majority were done in women with breast cancer. Treatments include chemotherapy, radiation, surgery and combination of these

PHASE OF CARE: Active anti-tumor treatment     

APPLICATIONS: Pediatrics

Doses of yoga ranged from 1 to 18 sessions and frequency ranged from every three weeks to three times per week. Some were delivered as group classes and two included caregivers. Some interventions included psychoeducation and supportive interventions. Some provided instructions and recommendations for practice at home. Attrition rates ranged from 8%-56%. Adherence to planned sessions ranged from 59%-88% and where measured, adherence to home practice ranged from 50%-80%. In non-random studies, improvements in anxiety, depression, mood, cognition, sleep, and fatigue were reported. Several RCTs reported improvement in distress, depression, anxiety, and multiple treatment-related side effects and symptoms.

Evidence suggests that yoga can be helpful to adults undergoing cancer treatment. There is insufficient evidence to draw any conclusions regarding benefit for children.

• No quality evaluation
• Mostly low quality/high risk of bias studies
• Low sample sizes
• Varied type, frequency, and duration of interventions. Multiple limitations in study designs and high attrition rates

There is not a lot of strong evidence to show benefits of yoga for various symptoms for patients during cancer treatments due to individual study design limitations. Existing evidence suggests that yoga may be helpful for anxiety, depression, sleep, and cognitive impairment. Further well-designed research to explore these areas is needed. Yoga is a relatively low-risk intervention that may be helpful and could be suggested to patients who are interested and able to participate.

STUDY PURPOSE: To synthesize published research to assess if yoga improves physical and psychosocial quality of life in patients receiving treatment for breast cancer.

TYPE OF STUDY: Systematic review

DATABASES USED: Scopus, Medline, PubMed, Science Direct, Cochrane, ProQuest

YEARS INCLUDED: (Overall for all databases) January 2009 to July 2014

INCLUSION CRITERIA: Articles with a yoga or mindfulness-based stress reduction (MBSR) intervention that reported outcomes related to physical or psychosocial quality of life in patients with breast cancer; studies with 15 or more participants were included. 

EXCLUSION CRITERIA: Articles that were duplicate, inaccessible, or with irrelevant records.

TOTAL REFERENCES RETRIEVED: 395

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers

FINAL NUMBER STUDIES INCLUDED: 38

TOTAL PATIENTS INCLUDED IN REVIEW: Not reported

SAMPLE RANGE ACROSS STUDIES: RCTs: 18 to 410; NRTs: 15 to 286; otherwise not noted 

KEY SAMPLE CHARACTERISTICS: RCTs: average age was 58.3 years; NRTs: average age was 50.3 years; all participants in all studies were women except for nine men included in one study; all studies look at patients with breast cancer though further details were not specified (exact phase/type of treatment, etc.)

PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified

As relevant to this PEP topic: 60% (3 of 5) studies that examined anxiety supported decreased general anxiety among patients who participated in yoga therapy. The other two large studies also showed less anxiety in this population, although it was divided into state and trait anxiety. A decrease in depression and depressive symptoms was reported in all of the studies reviewed that looked at psychosocial benefits related to yoga, which supports other meta-analyses stating that adding yoga therapy to traditional breast cancer treatment can decrease depression in these patients.

Evidence supports that yoga can have benefits on both physical and psychosocial quality of life in patients with breast cancer, including a decrease in both anxiety and depression. Additional research should aim to assess long-term effects of yoga in this population.

• Low sample sizes
• No meta-analysis, no table of evidence; difficult to synthesize all data accurately independently on article review

Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Recommending yoga to patients with breast cancer undergoing active treatment may be beneficial, particularly for those with high levels of anxiety and/or depression.

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 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 evaluate differences in psychological states between breast cancer survivors who do practice yoga and those who do not

This case-control exploratory study consisted of two groups. The first was breast cancer survivors doing regular yoga (more than six months of regular yoga practice in the last year), and the second was women who had no prior yoga experience (or less than three yoga sessions in the last year). Yoga experience was self-reported by the participants, including their regular yoga schedule. No changes to their yoga practice or schedule were made by the researchers.

• N = 52   
• AGE: 30-65
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Female breast cancer survivors diagnosed with stage II or III ILC or IDC who received adjuvant chemotherapy and completed all treatment at least six months prior. 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with neutropenia, grade 3 or 4 thrombocytopenia, and other reported chronic illnesses (diabetes, arthritis, hypertension, thyroid abnormalities, obesity, or recent acute infections) were excluded. Patients who participated in other complementary or alternative treatments within the past six months were also excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Participants were screened at six-month follow-up appointment at three cancer centers in Bengaluru, India.

PHASE OF CARE: Late effects and survivorship

Case-control exploratory study

Perceived stress scale, Spielberg’s state and trait anxiety questionnaire, Beck’s depression inventory, General Health Questionnaire, WHO QOL Questionnaire-BREF

Analysis revealed significantly decreased anxiety, depression, and stress in the group that participated in yoga (p < 0.001). This group also reported better general health and overall quality of life (p < 0.001). Higher income predicted lower anxiety and depression scores, while better reported sleep quality predicted lower stress and depression scores as well.

This study supports yoga as an intervention to decrease anxiety, depression, and stress in breast cancer survivors.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Other limitations/explanation: Differences in regular yoga practices among the participants could have influenced the results as yoga schedules were not controlled for. In addition, this study only looks at yoga in breast cancer survivors and may not be generalizable to other patients with cancer.

Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Although this study only examined breast cancer survivors, discussing yoga as a method to decrease anxiety and depression may be an appropriate option for many patients with cancer.

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

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

Three centers in India

A randomized controlled trial design was used.

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

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

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

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

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

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

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

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

The study reported on 39 patients with lymphoma.

A randomized controlled trial design was used.

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

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

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

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

• 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

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

• PHASE OF CARE: Late effects and survivorship

• Randomized, controlled trial

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

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.

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

• 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.

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.

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 determine the long-term (nine months) effectiveness of three different group interventions compared to usual care for patients with breast cancer 

Participants were allowed to select one of three groups to receive either cognitive behavioral therapy, yoga, and self-hypnosis. People who declined to participate were in a control group. Measurements were taken T0 through T3 to include before and after the short-term interventions, at month 3, and at month 9 follow-up.

• N =123 total; 21 yoga, 67 self-hypnosis (after dropouts and one who died), 10 CBT, 24 control group 
• AGE: 27-73 across all groups 
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable; mixed numbers of patients who had surgery, chemotherapy, radiation therapy, and hormonal therapy
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer; 18 months postdiagnosis 
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria were at least 18 years old and can read, speak, and write French

• SITE: Not stated/unknown   
• SETTING TYPE: Not specified    
• LOCATION: Belgium

PHASE OF CARE: Multiple phases of care

Three group intervention self-selection; testing at T0, T1, T2 (month 3), T3 (month 9)

Demographics; medical history; Hospital Anxiety Depression Scale (anxiety and depression emotional distress); Quality of Life 30-item questionnaire (fatigue); Insomnia Severity Index (sleep quality)

Only results from baseline (T0) and the month 9 follow-up (T3) were reported using MANOVA with repeated analysis and post-hoc analysis. 

Post-hoc comparisons of time T0-T1: hypnosis group showed significant decreases in anxiety (p = 0.000), depression (p = 0.004), and fatigue (p = 0.045). Yoga group showed significant decrease in anxiety (p = 0.01). 

Post-hoc comparisons of time at T3: hypnosis group showed decreases in anxiety (p = 0.000), depression (p = 0.000), and fatigue (p = 0.002); yoga group showed decrease in anxiety (p = 0.024).

Self-hypnosis led to improvements in anxiety, depression, and fatigue. Anxiety improved in the yoga group. There were no improvements in the CBT or control groups.

• Small sample (< 100)
• Risk of bias (no random assignment)
• Other limitations/explanation: Control group included some of the non-consenters

Two of the three interventions may be helpful in reducing anxiety, depression, or fatigue when measured at nine months. Self-hypnosis may help patients improve emotional distress such as depression and anxiety, and may also reduce fatigue; yoga may also help improve anxiety. Larger samples and longer follow-up studies are needed.

To examine the long-term changes of anxiety, depression, and fatigue in patients with cancer six months after a yoga intervention

Gentle hatha yoga provided to the participants in small groups under supervision and guidance. 60 minutes once a week for 8 weeks total. Participants also received a CD and a printed manual to motivate training at home.

• N = 58   
• AVERAGE AGE: 58 years 
• MALES: 10%  
• FEMALES: 90% 
• KEY DISEASE CHARACTERISTICS: 55% breast cancer, remaining other cancers (lymphoma, leukemia, colorectal cancer, ovarian cancer, and endometrial cancer)

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

PHASE OF CARE: Active anti-tumor treatment

Prospective observational one group pre-/post-test design

Self-reported Generalized Anxiety Disorder Scale (GAD-7) to measure anxiety, Patient Health Questionnaire (PHQ-2) to measure depression, European Organization for Research and Treatment of Cancer QOL (EORTC) Questionnaire-Fatigue scale to measure fatigue

There was a statistically significant reduction in the anxiety, depression, and fatigue levels after six months from the baseline. A small time effect on anxiety (SES = 0.22, CI [-0.3, 0.47]) and fatigue (SES = 0.27, CI [-0.11, 0.13]) indicating slight nonsignificant increase of symptoms. No time effect found in terms of depression (SES = 0.01, CI = [-0.11, 0.13]).

Although the study shows reduction in outcomes, studies with larger sample sizes with better study designs (i.e., RCT) are needed to confirm the findings.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Questionable protocol fidelity

Yoga appears to have some benefit in reducing the symptoms of anxiety, depression, and fatigue, and the benefits may be lasting. Additional research with randomized studies will be important to confirm these results.

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.

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

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

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

• Single site
• Inpatient and outpatient setting
• India

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

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

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

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

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

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

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.

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

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

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

• Single site
• Outpatient setting
• Turkey

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

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

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

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

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

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

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

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

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

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

• Single site
• Outpatient setting
• India

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

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

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

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

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

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