Yoga for the Treatment of Insomnia Among Cancer Patients— Evidence, Mechanisms of Action, and Clinical Recommendations

Oncology & Hematology Review, 2014;10(2):164–8

Biological Mechanisms
The pathophysiology of insomnia, as well as its relationship with cancer and cancer treatments, is largely unexplained.14,37,38 Research suggests that insomnia symptoms may arise through multiple pathophysiologic pathways, including dysregulated hypothalamic-pituitary-adrenal (HPA) axis function stemming from abnormal sleep/wake homeostasis; hyperarousal; disruptive cognitive and behavioral factors; and impaired circadian, physical (i.e. cardiopulmonary and muscular), and immune function. Cancer and its treatments directly and negatively influence these same physiologic processes and, therefore, can directly affect the development of insomnia. Cancer and its treatments also lead to a reduction in physical activity and exercise, resulting in physical deconditioning that, in turn, leads to diminished function in these same systems, further impairing sleep. Yoga is a form of exercise capable of positively influencing each of these systems and of improving circadian, physical, and immune function. While not exhaustive, we provide examples of plausible mechanistic pathways through which yoga may ameliorate the insomnia symptoms experienced by cancer patients.

Yoga and the Circadian Clock System
Yoga may regulate circadian function by acting as an exogenous behavioral nonphotosensitizer for the circadian clock system. The circadian clock system consists of a central component: the suprachiasmatic nucleus (SCN) of the hypothalamus, also known as the body’s ‘master clock,’ as well as peripheral components involving multiple organ- and tissue-specific ‘clocks.’ These peripheral clocks are synchronized through humoral and neural connections throughout the body that, in turn, affect behavioral and physiologic output rhythms (i.e. diurnal fluctuations in sleep, physical activity, heart rate, strength, and cytokines).39–41 The master clock, however, has its own intrinsic rhythm that is entrained or synchronized to a 24-hour cycle by exogenous photo- and nonphotosensitizers. While the strongest photosensitizer is light, one of the strongest nonphotosensitizers is exercise (e.g. yoga).41 Our prior research suggests that yoga favorably alters circadian activity rhythms as a behavioral nonphotosensitizer and can, thereby, address cancer-related insomnia.31

Yoga, the Immune System, and Inflammatory Responses
Yoga may regulate immune function in the same way as other modes of exercise: by dampening the chronically upregulated pro-inflammatory responses exhibited in cancer patients as a result of their disease and its treatments. This dampening, in turn, may normalize overall inflammatory responses and improve insomnia. Exercise reduces low-grade inflammation by triggering the immediate, but transient, release of interleukin (IL)- 6.42 IL-6 is released from skeletal muscle in proportion to exercise intensity and duration, the proportion of muscle mass used during an exercise bout, and training status.42 In this environment, IL-6 functions as an antiinflammatory molecule by triggering the release of tumor-necrosis factor receptor-1 (TNFR1), IL-10, and IL-1rα that, consequently, inhibits the production of tumor-necrosis factor alpha (TNFα), IL-8, IL-1α, and IFNγ and regulates overall inflammatory responses.42 Research suggests that yoga may improve inflammatory immune responses in cancer patients.43–45

Yoga and Physical Function in the Cardiopulmonary and Muscular Systems
Yoga may improve physical function (i.e. cardiopulmonary and muscular function) in the same way as other modes of exercise: by eliciting a physiologic conditioning response. This physical conditioning response may improve the reduced physical function exhibited by cancer patients as a result of their disease and its treatment, consequently improving insomnia. It is well documented that traditional modes of exercise, performed frequently at high enough intensities for a sufficient duration, improve cardiopulmonary and muscular function as part of a desirable physical conditioning response.46,47 In addition, regular exercise that improves physical function (cardiopulmonary and muscular) results in medium to large improvements in total sleep time, slow wave or ‘deep’ sleep, nighttime wakefulness, sleep onset latency, and insufficient sleep.48–51 Research suggests that participation in yoga improves cardiopulmonary and muscular function in healthy individuals and in those with other diseases.52–57

Yoga for the Treatment of Insomnia
Studies demonstrate that yoga may help to improve depression, anxiety, fatigue, and sleep difficulties in both a disease-free population and those with cancer.58–60 We review below the existing scientific literature on the use of yoga for the treatment of insomnia within an oncologic population.

Qualitative Yoga Studies/Yoga Program Evaluations
There have been a number of studies that obtained their data through program evaluations or through qualitative measures.61–64 Studies of this nature are useful in showing patient-reported benefits, but often carry less scientific weight because of their lack of randomization and validated outcome measures. One of the first examinations of yoga in cancer patients was performed by Joseph et al. in 1983.62 Cancer patients undergoing radiation therapy were offered yoga, meditation, or support therapy. Those in all three groups, reported improvements in sleep, treatment tolerance, mood, appetite, and QOL. A similar study was published in 2004, in which cancer patients were invited to participate in the Stanford Cancer Supportive Care Program (SCSCP).63 The SCSCP consisted of 11 activities, including fatigue management, nutrition, massage, and Restorative yoga. Of the 380 participants who participated in Restorative yoga and evaluated their experience, 96 % felt it reduced their stress, 74 % felt an increase in energy, and 65 % reported more restful sleep. In 2008, Duncan et al. described how yoga can be used to treat symptoms and QOL in cancer patients.61 Using pre/post analyses, yoga participants reported significant gains in overall well-being and reductions in the severity of their most bothersome symptoms. In a 2010 study of a yoga program of 17 breast cancer patients, yoga participants reported improvements in QOL and psychosocial functioning.64 Furthermore, yoga participants in two of these publications attributed improvements in strength, physical function, and physical fitness to their yoga program. While these results are extremely promising, they must be interpreted with caution due to their use of convenience samples and the lack of validated outcome measures for assessing sleep quality. Additionally, these programs did not use standardized versions of yoga, making it difficult to replicate the various interventions that were used.

Clinical Trials
A total of 11 clinical trials of yoga for insomnia and sleep difficulties in cancer patients were identified.20,25,28,30,34,36,65–69 Some of the trials used cancer patients on active therapy, while others used cancer patients who had already completed their primary therapy but still reported symptoms and side effects. These trials were very diverse, with the number of yoga classes ranging from one to five per week. Class duration also varied from 50 minutes to 120 minutes per session. There was also a very wide range regarding the duration of the intervention, with some studies lasting only 4 weeks and others lasting as long as 26 weeks. Perhaps most varied were the different types of yoga postures and poses used within these studies. Despite the use of different types of yoga, these studies showed that yoga was safe, feasible, and acceptable within cancer patient populations, reinforcing the findings from the previous section.

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Keywords: Yoga, sleep, insomnia, cancer, exercise