Health Care Professional Information

Clinical Summary

Yoga was first described in the Vedic texts of India and has been practiced over several centuries. It is an integral part of Ayurveda, the traditional healing system that originated in India. Major components of yoga include regulated breathing (pranayama), moving through various postures (asansas), meditation (dhyana), and optimal coping principles (swadhyaya) (1) to cultivate physical and emotional health, and spiritual growth,  with self-realization as a core intention. Many styles of yoga encompass some or all of these components. In the United States, most practices focus on postures, meditation, and breath control (2).

Yoga is effective in reducing symptoms of carpal tunnel syndrome (3), irritable bowel syndrome (4), asthma (5), and drug-resistant epilepsy (6). It is also helpful for weight maintenance (7), diabetes (8), migraines (9), low back pain (10), depression (11) (12) and anxiety (4) (11) (13) (14) (15) (16). Preliminary evaluations suggest yoga is feasible and beneficial in populations with post-traumatic stress disorder (14) (17) (18). Yoga may improve symptoms and quality of life in patients with paroxysmal atrial fibrillation (16) and as an adjunct to pulmonary rehabilitation, contribute to improvements in dyspnea for COPD patients (1). For adolescents and young adults with difficult disease states, clinicians have also noted that yoga can return a sense of control to one’s experience (4) (19).

With the introduction of yoga in many cancer centers across the country, patients now use this modality at all disease stages to relieve various symptoms (20) (21) (22). The ability of yoga to reduce stress, increase sense of well-being, improve quality of life, and impart more restful sleep in both newly diagnosed and long-term cancer survivors is well documented (2) (23) (24) (25) (26) (27) (28) with the potential for reduced need for sleep medications (28) (29). Studies in breast cancer survivors indicate that yoga improves social functioning and mood, reduces stress levels (30) (31), and can help to address a range of psychological symptoms (32). In survivors with persistent fatigue and induced or exacerbated menopausal symptoms, yoga has also reduced fatigue, joint pain and the number of hot flashes while increasing vigor, with benefits persisting at 3-month follow-up (22) (33). Yoga can improve quality of life in breast cancer patients undergoing radiation therapy (34). Preliminary studies in other cancers have also shown that yoga can increase forced expiratory volume in non-small cell lung cancer patients (35) and improve sleep quality for lymphoma survivors (29).

Adverse effects associated with improper yoga practices have been reported. However, appropriate and long-term yoga practices to relieve symptoms can have additional downstream benefits, such as genetic and physiologic changes (35), as well as the ability to adhere to exercise programs or make other lifestyle changes (1). Cancer patients interested in beginning yoga should first consult their physicians. In addition, it is advisable to learn proper technique from certified instructors who have experience working with cancer patients, because survivors may have special limitations due to surgery, chemotherapy, and radiotherapy.

Purported Uses
  • Anxiety
  • Depression
  • Dyspnea
  • Fatigue
  • Hot flashes
  • Improve sleep quality
  • Increase flexibility and strength
  • Pain
  • Post-traumatic stress disorder
  • Reduce need for sleep medications
  • Stress
Mechanism of Action

Because components of yoga practice include postural alignment and engagement of the extremities, yoga raises somatic self-awareness, educating the user of states in which the body experiences balance and calm, and identifying symptoms that may be problematic (3). The engagement of the mind, attention to comfort, and deep relaxed abdominal breathing reduces gastrointestinal symptoms by disrupting chronic patterns of functional disability and maladaptive coping strategies often experienced with irritable bowel syndrome (4).

Some studies have shown that the meditation component of yoga increases blood flow to the brain, releases endogenous dopamine, and reduces respiratory rate (6). The changes in breathing patterns that accompany various yoga practices may also alter airway hyper-responsiveness (5). Yoga postures and controlled breathing interact with both the somatic nervous system and endocrine mechanisms, thereby affecting insulin kinetics (8). Neuroplastic mechanisms for its antidepressant effects include elevated serum brain-derived neurotrophic factor (BDNF) levels (36). Yoga relieves stress and anxiety by increasing levels of the neurotransmitter gamma amino-butyric acid (GABA) (13) and improving hypothalamic-pituitary-adrenal (HPA) axis functioning (25). Improvements in fatigue, sleep disturbance, anxiety, and quality of life are also attributed to increased parasympathetic and decreased sympathetic activities, stimulation of the vagus nerve, and reduction in allostatic load which optimizes homeostasis in stress response systems (14), thereby replacing the flight-or-fight response with the relaxation response (19). By eliciting the relaxation response, long-term practice has been shown to promote mitochondrial resiliency via ATPase and insulin function upregulation and downregulation of NF-kB-dependent pathways (35).

Contraindications

Pregnant women and individuals with hypertension or glaucoma should use caution when practicing certain yoga postures.

Adverse Reactions

Rare, due to improper practice: hematoma (12) (37) , nerve damage (38), aggravation of glaucoma (39) (40), embolism (41), ligament rupture (42), and spontaneous pneumothorax (43) (44).

Literature Summary and Critique

Mustian KM, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol. 2013;31:3233-41.
This large RCT evaluated the efficacy of a standardized Iyengar-based yoga intervention vs standard care to improve global sleep quality among post-treatment cancer survivors. A total of 410 survivors with moderate or greater sleep disruption for 2– 24 months after surgery, chemotherapy, and/or radiation therapy were randomized to either standard care or standard care plus the Yoga for Cancer Survivors (YOCAS) intervention, which comprises breathing exercises, 16 gentle Hatha and restorative yoga postures, and meditation. Participants attended two 75-minute sessions weekly for 4 weeks. Sleep quality was assessed using the Pittsburgh Sleep Quality Index and pre-/post-intervention actigraphy, a validated, non-invasive objective measure that assesses sleep and its components using a watch/sensor to collect activity data. Participants in the YOCAS program demonstrated greater improvements in global sleep quality, subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and use of medication postintervention compared with those receiving standard care only. The investigators concluded that this particular yoga regimen was a useful therapy to improve sleep quality and reduce the need for sleep medications.

Bower JE, et al. Yoga for persistent fatigue in breast cancer survivors: A randomized controlled trial. Cancer. 2012;118:3766-75.
This RCT evaluated the effects of Iyengar yoga in breast cancer survivors with persistent fatigue. A total of 31 women were randomly assigned to practice yoga for 12 weeks or to health education. The severity of fatigue declined significantly in the yoga group compared with controls, and the yoga group also had significant increases in vigor. However, there were no improvements in depressive symptoms, stress, sleep, and physical performance.

Carson JW, et al. Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. J Sex MedSupport Care Cancer. 2009;17:1301-9.
This preliminary trial evaluated a yoga intervention for menopausal symptoms in a sample of early-stage (IA-IIB) breast cancer survivors. A total of 37 women who were disease-free and experiencing hot flashes were randomized to an 8-week Yoga of Awareness program that used gentle yoga poses, meditation, and breathing exercises, or to a wait-list control. Daily reports of hot flashes were collected at baseline, posttreatment, and 3 months posttreatment through an interactive phone system. Intent-to-treat analysis indicated that women in the intervention group showed significantly greater improvements vs controls for hot-flash frequency, severity, and total scores, joint pain, fatigue, sleep disturbance, symptom-related bother, and vigor at posttreatment reporting. At 3-month follow-up, patients maintained these treatment gains and showed additional significant gains in negative mood, relaxation, and acceptance.

References
  1. Norweg A, Collins EG. Evidence for cognitive-behavioral strategies improving dyspnea and related distress in COPD. Int J Chron Obstruct Pulmon Dis. 2013;8:439-451.
  2. Bower JE, Woolery A, Sternlieb B, et al. Yoga for cancer patients and survivors. Cancer Control. Jul 2005;12(3):165-171.
  3. Garfinkel MS, Singhal A, Katz WA, et al. Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA. Nov 11 1998;280(18):1601-1603.
  4. Kuttner L, Chambers CT, Hardial J, et al. A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain research & management : the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur. Winter 2006;11(4):217-223.
  5. Manocha R, Marks GB, Kenchington P, et al. Sahaja yoga in the management of moderate to severe asthma: a randomised controlled trial. Thorax. Feb 2002;57(2):110-115.
  6. Rajesh B, Jayachandran D, Mohandas G, et al. A pilot study of a yoga meditation protocol for patients with medically refractory epilepsy. J Altern Complement Med. May 2006;12(4):367-371.
  7. Kristal AR, Littman AJ, Benitez D, et al. Yoga practice is associated with attenuated weight gain in healthy, middle-aged men and women. Altern Ther Health Med. Jul-Aug 2005;11(4):28-33.
  8. Malhotra V, Singh S, Tandon OP, et al. The beneficial effect of yoga in diabetes. Nepal Med Coll J. Dec 2005;7(2):145-147.
  9. John PJ, Sharma N, Sharma CM, et al. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache. May 2007;47(5):654-661.
  10. Posadzki P, Ernst E. Yoga for low back pain: a systematic review of randomized clinical trials. Clin Rheumatol. Sep 2011;30(9):1257-1262.
  11. Buffart LM, van Uffelen JG, Riphagen, II, et al. Physical and psychosocial benefits of yoga in cancer patients and survivors, a systematic review and meta-analysis of randomized controlled trials. BMC Cancer. 2012;12:559.
  12. Cramer H, Lauche R, Langhorst J, et al. Yoga for depression: a systematic review and meta-analysis. Depress Anxiety. Nov 2013;30(11):1068-1083.
  13. Streeter CC, Jensen JE, Perlmutter RM, et al. Yoga Asana sessions increase brain GABA levels: a pilot study. J Altern Complement Med. May 2007;13(4):419-426.
  14. Streeter CC, Gerbarg PL, Saper RB, et al. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. May 2012;78(5):571-579.
  15. Cabral P, Meyer HB, Ames D. Effectiveness of yoga therapy as a complementary treatment for major psychiatric disorders: a meta-analysis. Prim Care Companion CNS Disord. 2011;13(4).
  16. Lakkireddy D, Atkins D, Pillarisetti J, et al. Effect of yoga on arrhythmia burden, anxiety, depression, and quality of life in paroxysmal atrial fibrillation: the YOGA My Heart Study. J Am Coll Cardiol. Mar 19 2013;61(11):1177-1182.
  17. Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. Aug 2013;178(8):854-860.
  18. Telles S, Singh N, Joshi M, et al. Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study. BMC Psychiatry. 2010;10:18.
  19. Williams-Orlando C. Yoga therapy for anxiety: a case report. Adv Mind Body Med. Fall 2013;27(4):18-21.
  20. Shannahoff-Khalsa DS. Patient perspectives: Kundalini yoga meditation techniques for psycho-oncology and as potential therapies for cancer. Integr Cancer Ther. Mar 2005;4(1):87-100.
  21. Carson JW, Carson KM, Porter LS, et al. Yoga for women with metastatic breast cancer: results from a pilot study. J Pain Symptom Manage. Mar 2007;33(3):331-341.
  22. Carson JW, Carson KM, Porter LS, et al. Yoga of Awareness program for menopausal symptoms in breast cancer survivors: results from a randomized trial. Support Care Cancer. Oct 2009;17(10):1301-1309.
  23. Rosenbaum E, Gautier H, Fobair P, et al. Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report. Support Care Cancer. May 2004;12(5):293-301.
  24. Rao MR, Raghuram N, Nagendra HR, et al. Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: a randomized controlled trial. Complement Ther Med. Jan 2009;17(1):1-8.
  25. Carlson LE, Speca M, Patel KD, et al. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients. Psychoneuroendocrinology. May 2004;29(4):448-474.
  26. Vadiraja HS, Raghavendra RM, Nagarathna R, et al. Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: a randomized controlled trial. Integr Cancer Ther. Mar 2009;8(1):37-46.
  27. Mustian KM, Sprod LK, Janelsins M, et al. Exercise Recommendations for Cancer-Related Fatigue, Cognitive Impairment, Sleep problems, Depression, Pain, Anxiety, and Physical Dysfunction: A Review. Oncol Hematol Rev. 2012;8(2):81-88.
  28. Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol. Sep 10 2013;31(26):3233-3241.
  29. Cohen L, Warneke C, Fouladi RT, et al. Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma. Cancer. May 15 2004;100(10):2253-2260.
  30. Moadel AB, Shah C, Wylie-Rosett J, et al. Randomized controlled trial of yoga among a multiethnic sample of breast cancer patients: effects on quality of life. J Clin Oncol. Oct 1 2007;25(28):4387-4395.
  31. Culos-Reed SN, Carlson LE, Daroux LM, et al. A pilot study of yoga for breast cancer survivors: physical and psychological benefits. Psychooncology. Oct 2006;15(10):891-897.
  32. Carlson LE, Doll R, Stephen J, et al. Randomized controlled trial of Mindfulness-based cancer recovery versus supportive expressive group therapy for distressed survivors of breast cancer. J Clin Oncol. Sep 1 2013;31(25):3119-3126.
  33. Bower JE, Garet D, Sternlieb B, et al. Yoga for persistent fatigue in breast cancer survivors: a randomized controlled trial. Cancer. Aug 1 2012;118(15):3766-3775.
  34. Chandwani KD, Perkins G, Nagendra HR, et al. Randomized, Controlled Trial of Yoga in Women With Breast Cancer Undergoing Radiotherapy. J Clin Oncol. Mar 3 2014.
  35. Fouladbakhsh JM, Davis JE, Yarandi HN. Using a standardized Viniyoga protocol for lung cancer survivors: a pilot study examining effects on breathing ease. Journal of complementary & integrative medicine. 2013;10.
  36. Bhasin MK, Dusek JA, Chang BH, et al. Relaxation response induces temporal transcriptome changes in energy metabolism, insulin secretion and inflammatory pathways. PLoS One. 2013;8(5):e62817.
  37. Naveen GH, Thirthalli J, Rao MG, et al. Positive therapeutic and neurotropic effects of yoga in depression: A comparative study. Indian J Psychiatry. Jul 2013;55(Suppl 3):S400-404.
  38. Choi Y, Lee D. A case of rectus sheath hematoma caused by yoga exercise. Am J Emerg Med. Sep 2009;27(7):899 e891-892.
  39. de Barros DS, Bazzaz S, Gheith ME, et al. Progressive optic neuropathy in congenital glaucoma associated with the Sirsasana yoga posture. Ophthalmic Surg Lasers Imaging. Jul-Aug 2008;39(4):339-340.
  40. Gallardo MJ, Aggarwal N, Cavanagh HD, et al. Progression of glaucoma associated with the Sirsasana (headstand) yoga posture. Adv Ther. Nov-Dec 2006;23(6):921-925.
  41. Bertschinger DR, Mendrinos E, Dosso A. Yoga can be dangerous—glaucomatous visual field defect worsening due to postural yoga. Br J Ophthalmol. Oct 2007;91(10):1413-1414.
  42. Reutter D, Hunziker R, Husmann M. Computed angiogram of the upper extremities for diagnosing a rare cause of brachial arterial embolism: the 'Pitcher Syndrome'. Eur Heart J. Nov 2010;31(22):2782.
  43. Patel SC, Parker DA. Isolated rupture of the lateral collateral ligament during yoga practice: a case report. J Orthop Surg (Hong Kong). Dec 2008;16(3):378-380.
  44. Kashyap AS, Anand KP, Kashyap S. Complications of yoga. Emerg Med J. Mar 2007;24(3):231.
  45. Johnson DB, Tierney MJ, Sadighi PJ. Kapalabhati pranayama: breath of fire or cause of pneumothorax? A case report. Chest. May 2004;125(5):1951-1952.

Consumer Information

How It Works

Bottom Line: Yoga improves quality of life in both newly diagnosed and long-term cancer survivors by reducing stress and fatigue, and improving sleep and mood.

Yoga is an ancient Indian philosophy that has been practiced for thousands of years. It involves regulated breathing, moving through various postures, and meditation to achieve physical and emotional health benefits. Yoga was shown to reduce symptoms of carpal tunnel syndrome, irritable bowel syndrome, asthma, seizures, diabetes, migraine headaches, depression, and anxiety. It is also practiced for weight maintenance. Cancer survivors including those recently diagnosed report better sleep, less stress, and improved quality of life with the practice of yoga. It is now offered in many cancer hospitals around the country.

Cancer patients interested in beginning yoga should first ask their physicians, because certain cancer treatments can cause physical limitations. It is also important that proper techniques are learned from certified instructors who have experience working with cancer patients.

Purported Uses
  • Anxiety
    Many different types of studies indicate that yoga can reduce anxiety.
  • Depression
    Some studies have linked yoga to reduced depression and more positive mood.
  • Breathing difficulty
    Small studies show that yoga may help problems such as shortness of breath and anxiety in COPD and lung cancer patients. More studies are needed.
  • Fatigue
    A study found that yoga can help reduce fatigue and improve vigor in breast cancer survivors.
  • Hot flashes
    Small studies show that yoga may be effective in cancer patients who have hot flashes and related symptoms.
  • Pain
    Yoga was shown in some studies to relieve pain.
  • Post-traumatic stress disorder
    Several yoga programs for survivors of war and natural disasters show it may be possible to use this practice in certain populations with post-traumatic stress disorder.
  • Sleep quality and sleep medication use
    A large study of a specific yoga program showed improved sleep quality and less sleep medication use in cancer survivors with sleep problems.
  • Stress
    Several studies support use of yoga to reduce stress.
Research Evidence

Menopause symptoms in breast cancer: A small study of yoga in 37 women with hot flashes after cancer treatment found that yoga was helpful for many symptoms including number and intensity of hot flashes, mood, joint pain, fatigue, and sleep disturbance. It also increased energy in participants.

Persistent cancer-related fatigue: A clinical study found that yoga could reduce fatigue in breast cancer survivors. Thirty-one women were randomly assigned to practice yoga for 12 weeks or to health education. Fatigue declined greatly and vigor increased for those who practiced yoga compared with those in the health education group.

Sleep quality and sleep medication use in cancer survivors: A large study that enrolled 410 participants among several leading medical centers found that a specific yoga program improved sleep quality for survivors with moderate or greater sleep disruption. It also helped to reduce the need for sleep medications.

Patient Warnings

Pregnant women and individuals with hypertension or glaucoma should use caution when practicing certain yoga postures.

Side Effects

Side effects from yoga are rare. However, blood clots, nerve damage, torn ligaments and difficulty breathing have been reported.

Special Point

If you are pregnant or have physical limitations, certain yoga techniques may not be advisable.

E-mail your questions and comments to aboutherbs@mskcc.org.