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

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

The first clinical trial of yoga in cancer patients for sleep difficulties was performed by Cohen et al. (2004) who found that yoga participants had better subjective sleep quality, faster sleep latency, longer sleep duration, and less use of sleep medications than wait-list controls.20 The yoga study by Bower et al. (2012) was the first to blind the participants to the study hypothesis and use a time and attention control in a yoga study for insomnia.65 Overall, eight of the randomized controlled trials (RCTs) compared yoga to a waitlist control,20,25,28,34,36,66,68,69 one to a support therapy control condition,30 one to a stretching control condition,67 and one to a health education control condition.65 The sample size in these trials also greatly varied, from 16 to 410. The largest study, by Mustian et al., was the only phase III and multicenter trial of yoga for sleep difficulties in cancer patients.68 In addition, that study was one of the only studies to use both validated patient-reported outcome measures and objective measures, via actigraphy, of sleep. The trial compared a standardized yoga intervention (YOCAS©®: 4 weeks, two times a week, 75 minutes/session; Gentle Hatha and Restorative yoga) to a usual care waitlist control condition among 410 cancer patients from 12 community oncology practices throughout the US. Yoga participants had statistically significant improvements in wake after sleep onset, sleep efficiency, self-reported sleep measures, and sleep medication usage compared with the controls.68 Overall, the results are encouraging, with seven trials reporting significant sleep-related benefits for yoga20,25,28,30,36,68,69 and four trials reporting null findings.34,65–67 However, there are a number of matters that should be considered when interpreting these results.

Empirical Limitations of Existing Research
There has only been one large phase III RCT on the effects of yoga on insomnia that suggests that yoga is effective to treat insomnia symptoms. Therefore, the existing literature on yoga needs to be interpreted with caution.

Several of the smaller phase I and II yoga studies need to be interpreted cautiously. Many were small (ranging in total sample size from 20 to 88) and did not use validated measures of insomnia. None of these studies were powered a priori to test the effects of yoga on insomnia as a primary outcome. Many of these treatment studies did not screen for baseline level of sleep difficulty as a criterion for study entry. Furthermore, the studies did not blind participants, with the exception of the Bower study.27 Importantly, yoga interventions were highly variable in content, type, intensity, and duration, making it difficult to determine the actual dose of yoga needed to effect improvements in insomnia symptoms. In many of the published studies, details regarding the format and components of the yoga interventions were not provided, making repeatability and standardization for dissemination difficult. Details on participant attendance, compliance, and attrition, as well as rates and types of adverse events, were also lacking. Details of the prescribed yoga dose versus the actual dose achieved (e.g. mode, frequency, intensity, duration) were limited, as was information on the sustainability of improvements in sleep quality impairment stemming from yoga. Lastly, only one study investigated the effects of yoga at several long-term follow-up time-points up to 6 months post-treatment.

The only phase III clinical trial conducted to date has addressed many of the limitations of the phase I and II clinical trials. This study was appropriately a priori designed and powered to test the effects of yoga on sleep quality as the primary outcome. It had a sample of 410 patients, screened for a predefined baseline level of sleep quality impairment, used validated patient report and objective measures of sleep, rigorously standardized the yoga intervention and checked for intervention quality, fidelity, and drift. The yoga prescription details were fully described as part of the published manuscript, as well as full reporting of unexpected and serious adverse events, attendance, compliance, and attrition. Furthermore, the authors described the achieved dose (in minutes) of yoga versus the prescribed dose.

While promising, this phase III RCT included only one specific type of yoga and was of only 4 weeks duration. This study, along with many of the pilot studies, include primarily Caucasian, well-educated, middle to upper-middle class women. There was little racial, economic, social, cultural, gender, or age diversity in sample populations, limiting external validity. Importantly, this limits the ability to determine which patient profile may be best suited for and have the best response to yoga therapy. Another major limitation is that none of the previously conducted studies compared yoga with a clinically approved therapy for insomnia. Yoga may improve insomnia or sleep quality impairment, but an important body of knowledge needs to be further developed in order to better tailor yoga prescriptions to improve insomnia, and meet the unique needs of individual cancer patients (e.g. the needs of a male patient versus a female patient; a nonwhite patient versus a white patient; and a breast cancer patient versus a colorectal cancer patient).

Clinical Recommendations
While yoga is increasingly popular throughout the world at gyms, via self-directed books and DVDs, and at cancer centers and community programs marketed toward cancer patients (e.g. ‘Gentle Yoga for Cancer Patients,’ ‘Yoga for Breast Cancer Patients and Survivors,’ and ‘Healing Yoga’), there is little, if any, scientific evidence as to the efficacy of these programs in improving insomnia symptoms among cancer patients. Often, these yoga programs are not professionally regulated in terms of instructor qualifications and licensure, or adherence to best practice, standard of care, or evidence-based therapeutic guidelines, resulting in significant variability in what is offered to cancer patients. For example, some yoga programs focus on gentle, low-intensity, meditative practices (e.g. Restorative, Integral, Svaroopa), while others focus on vigorous practices (e.g. Power, Ashtanga), or a combination of both (e.g. Hatha, Iyengar, Kundalini).53 Some programs modify the yoga environment by using heaters and humidifiers (e.g. Bikram) or props such as straps, blocks, ropes, and chairs (e.g. Iyengar).53 These variations lead to classes that vary widely in structure and overall formats.

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Keywords: Yoga, sleep, insomnia, cancer, exercise