Impaired sleep quality is a concerning problem for many patients with cancer, and pharmacologic treatments come with many negative effects. Several small studies indicate that yoga improves persistent fatigue, sleep disturbance, anxiety, and quality of life, in addition to reducing the need for sleep medication.1-5 A systematic review and meta-analyses found reductions in distress, anxiety, depression, and fatigue, but the effects on sleep were small and not significant.6 The recent study by Mustian and colleagues provides evidence for the use of a standardized multimodal yoga intervention to improve sleep quality.7
Mustian et al Study Design and Results
Of 410 patients randomized in this study, 321 completed baseline and postintervention assessments. As a randomized, multicenter nationwide trial, this is considerably larger than most phase II yoga studies, which typically enroll 20 to 40 patients. The Mustian et al intervention—the Yoga for Cancer Survivors (YOCAS) program—included a sequence of gentle hatha yoga postures (asanas), passively held restorative yoga poses, specific breathing practices (pranayama), and meditation, compared with standard care.
Intervention participants attended 75-minute sessions twice weekly for 4 weeks. Control participants received mainstream care to address sleep issues, and were offered the 4-week YOCAS program free of charge after study completion. Sleep quality for both groups was assessed using the Pittsburgh Sleep Quality Index and actigraphy (a validated, objective measure of sleep quality) pre- and postintervention.
Compared with control participants, those randomized to the YOCAS arm reported significantly greater improvement in the primary outcome of global sleep quality (P < .01), as well as secondary outcomes including daytime dysfunction (P < .01), subjective sleep quality, and use of sleep medication (P < .05 for both). Objective measures from actigraphy showed significantly greater improvements in wake after sleep onset and sleep efficiency (P < .01 for both).
For the 319 patients who completed the study, yoga participants reduced sleep medication use by 21% per week, while control participants increased usage by 5% per week. Investigators also found that patients across the symptom severity spectrum benefited, and that participants with very poor sleep efficiency benefited the most. These results were achieved even though the average “total dose” of yoga for the entire 4-week intervention was 80% of that prescribed.
Yoga Theory and Clinical Considerations
Asana, pranayama, and meditation are core components of classical hatha yoga, which is part of the Indian Systems of Philosophy and closely related to Ayurveda, the traditional medical system of India. Restorative poses that use props such as blocks, bolsters, and blankets to facilitate total relaxation into a pose have evolved since the 1970s, most notably by the Iyengar style of yoga (a form of hatha yoga with an emphasis on detail, precision, and alignment in posture and breath control).
The study authors note that the restorative component was selected on the basis of yoga theory that postulates its positive influence on sleep. Indeed, restorative postures allow for the experience of complete support and deep relaxation. It also has been noted that such restorative postures, breathing techniques, and meditation encourage what is traditionally known as “pratyahara,” a turning inward of the senses that can modulate nervous system activity and subsequently improve sleep.8 That the intervention was conducted in the late afternoon or evening after 4:00 PM also fosters the practice of good sleep hygiene, which encourages control over behavioral and environmental factors prior to sleep.
The objective use of actigraphy as a clinical endpoint as well as a standardized yoga intervention allow for more widespread generalization of trial results. While the authors identified posture, breath, and awareness as the unifying components in both hatha and restorative yoga, both the tempo of transitions and holding time also should be considered in future research.
That said, one might weigh author comments that additional phase III trials are needed against the limited financial resources available for research and the high cost of performing large-scale trials. The significant proportion of patients lost to follow-up or not fully evaluable (22%) is in line with the attrition rate of other clinical trials of yoga.
Lifestyle Interventions Gaining Traction
It may be unnecessary to wait for additional data to recommend yoga and other lifestyle interventions such as breathing practices, meditation, stress reduction, and physical exercise. These practices are well databased as effective treatments for disease-related symptoms including pain, dyspnea, digestion problems, skeletal issues, mobility and postural problems, depression, fatigue, anxiety, and sleep disturbance.9-15 Physical activity is well-documented as associated with survival benefits.16-19
Cancer patient engagement in symptom management and the recovery process is stronger than ever. Yoga, meditation, and exercise classes for cancer survivors are more routinely available throughout the country. Many of these modalities are self-selected by patients. But many patients require guidance on practices of self-care, especially with respect to nonpharmacologic interventions that help manage symptoms.
Comprehensive lifestyle interventions that extend beyond a single application can provide significant clinical benefits,20-23 especially in impaired sleep quality and other problems that have many contributing factors. The hallmarks of these techniques are that they are easily taught, inexpensive, safe, and beneficial.
Compound Benefits
As with other nonpharmacologic interventions, the YOCAS program engages participants in a lifestyle intervention. The risk of physical injury from participation in gentle supervised yoga sessions with experienced instructors is low, while the potential for clinical benefit is high. Adding an intervention such as YOCAS also may prove to be cost-effective in the long run, as some studies suggest that is the case for comparable modalities.24,25 It likely confers other benefits, as preliminary studies in other groups show that yoga reduces pain, improves cognition and cardiovascular function, and improves quality of life.26-28 Long-term practice may reduce inflammatory response to stress.29
Most yoga research in the oncology setting, including this study, tends to enroll women with breast cancer. Although data on other cancer patient subgroups may not yet be available, it is likely that they too can benefit. As is true of most fitness programs, yoga is readily adaptable to a broad range of clinical levels and goals.
Conclusion
In a busy practice, it can be tempting to prescribe medications for sleep disturbance, but these are not without side effects. The use of nonpharmacologic interventions for symptom control can considerably empower cancer survivors in their pursuit to self-manage symptoms, improve self-care, and speed recovery. ■
Dr. Wesa is an integrative medicine specialist with the Integrative Medicine Service; Ms. Benusis is a yoga therapist with the Integrative Medicine Service; and Dr. Cassileth is Chief of the Integrative Medicine Service and Laurance S. Rockefeller Chair in Integrative Medicine at Memorial Sloan-Kettering Cancer Center, New York.
Disclosure: Drs. Wesa and Cassileth, and Ms. Benusis reported no potential conflicts of interest.
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