Christina Comeau

May 3, 2010

Laura Douglass

Yoga: Theory, Culture, and Practice

Yoga as Therapy for Cancer Patients

Introduction

Yoga is an ancient practice from India, recently brought to America. It has been practiced in India for thousands of year, with different kinds of practices for different purposes, such as exercise, therapy, meditation, etc. It is a rising trend in the United States. Saper et al. (2004) conducted a study in 1998 in which they surveyed people from across the nation in order to get a sense of who was practicing yoga and why. They found out that at that time there were approximately 15 million people who practiced yoga in the U.S. “Yoga users were more likely to be baby boomers, female, college educated, and were less likely to report a Christian religion” (p. 46). Yoga is also now being used more for healing and therapy for pains and chronic illness. Saper et al. also found in their study that “eighty-five percent [of yoga users] felt that using both conventional and alternative medical therapies was better than using either one alone” (p. 47). This seems to be the growing trend across America.

Medical centers are incorporating the mind-body therapy of yoga. “Medical and cancer centers across the country are offering yoga classes while incorporating integrative medicine into the mainstream” (Yoga, 2002, p.253). It seems that people around the world are incorporating both Western technology and Eastern medicine into their medical practices. “The phenomenal realities of ancient cultures are seen withstanding the test of time and emerging into the realms of biomedicine” (Jobst, 2003, p. 1). However, in our culture, we cannot simply accept the much simpler Eastern ways. Lucky for us however, the “energies” within our bodies can be “measured and tested scientifically and objectively in independently repeatable and verifiable ways” (p. 1). This paper will explore the current studies of yoga as a therapy for cancer patients, discuss the ways in which yoga benefits cancer patients, and finally point out some clashes between Eastern philosophy and Western culture.

Research on Yoga

The use of yoga as a therapy for cancer patients is a new concept in America. There is a lot of preliminary research surrounding the idea (Culos-Reed, 2006; Danhauer, 2009; DiStasio, 2008; Raghavendra, 2007); however, more detailed studies are needed. While studying the research literature, I noticed that one trend is that most of the studies included a majority of female patients with breast cancer (Danhauer, 2009; Culos-Reed, 2006; Raghavendra, 2007). Not only does that make the studies more homogeneous, but in some studies, the authors also stated that the women already had an interest in yoga (Culos-Reed, 2006; Danhauer, 2009). This makes me wonder whether this is a societal trend that yoga is most associated with women. These pilot tests all have the same purpose which is to measure the benefits of yoga for cancer patients, so that it could possibly be implemented in cancer treatment. The fact that most of the studies contain a majority of women is a huge limitation because both men and women can be diagnosed with cancer, and both should have the opportunity to test the benefits of yoga as a therapy.

Another limitation of many of the studies is the sample size. Many of the studies had relatively small sample sizes, with too many variables. This is typical of pilot studies and preliminary research; however, it would be highly beneficial to see a longitudinal study of yoga as a treatment for cancer patients. Raghavendra (2007) studied “whether a support intervention based on mind/body and psycho-spiritual interventions such as yoga might be a viable alternative to standard supportive therapy and coping preparation in reducing the frequency and intensity of nausea and emesis in chemotherapy-naïve stage II and III breast cancer patients receiving adjuvant chemotherapy” (p. 464). The biggest limitation within this study was the fact that the sample size included 62 subjects; 28 receiving the yoga intervention, and 34 as the control group. They did not mention why they chose to have more participants in the control group rather than an equal amount in both groups, which is something to consider. It would be beneficial to the reader to know why they chose to do that. Another limitation within this study was that, the participants did not only receive yoga as an intervention, they also received counseling sessions. Both the control group and intervention group received counseling, however, the intervention group received more counseling hours than the control group. This limits the validity of the study because it is unknown whether the benefits were a result of the yoga or the counseling sessions. Since the purpose of the study was to only study the effects of yoga, the counseling variable was not necessary. Having too many variables can sometimes decrease the validity of a study.

In another study, Danhauer (2009) was studying “the feasibility of a RY [restorative yoga] intervention as supportive therapy for women diagnosed with breast cancer; and to measure changes in fatigue, sleep, psychological distress (depression, negative affect) and well-being (positive affect), and health-related quality of life as compared to a randomized control group” (p. 361). The sample size contained 44 participants. The study was broad because it was designed to encourage future research; however, there were 6 different dependent variables within the study, including measured changes in fatigue, sleep, psychological distress, psychological well-being, health-related quality of life. They also measured feasibility (p. 361). Not only were there too many dependent variables, but the independent variable (of women with breast cancer) was too broad. These women could be at any stage of cancer and any stage of treatment post-surgery. Because of this limitation, we do not know at which stage of cancer, yoga treatment would be most beneficial.

A similar study carried out by Culos-Reed (2005) also had more than one dependent variable being studied. These variables consisted of changes in physical fitness, psychological outcomes of stress symptoms, mood states, and quality of life (p. 892). The purpose of this study was to “assess the physical and psychological benefits of yoga for cancer survivors in a pilot study” (p. 891). The independent variable (cancer survivors) had to be a minimum of three months post-treatment. They did not specify the deviation of time post-treatment. If it was a high deviation, the validity of the study would decrease unless they specified trends within the amount of time post-treatment. The sample size was also very small; consisting of 20 participants (10 with yoga intervention and 10 controls). Again, this is fine for a pilot study; however, it doesn’t give any real, valid information in terms of the actual benefits cancer patients receive from yoga as therapy.

When discussing the research on yoga as a benefit to cancer patients, DiStasio (2008) stated that “several of the yoga studies have methodologic limitations, including small sample sizes, lack of a control group, limited follow-up, brief intervention periods, and inadequate statistical analyses” (p. 127). She went on to talk about the many different kinds of yoga that were not always specified in studies, limiting the research even more and not allowing for study replication. She also mentioned how, much like in some of the studies previously discussed, in most studies, the participants were self-selected and already had an interest in exploring yoga (127). Despite all the limitations in the current yoga studies, however, she does recognize the potential benefits that yoga may provide for cancer patients.

The studies previously mentioned also show potential benefits for cancer patients practicing yoga. Perhaps as an effect of the many limitations, these studies found different and sometimes opposing results. Raghavendra (2007) found that yoga reduced chemotherapy-related nausea and vomiting. Specifically, “yoga intervention helped significantly to reduce the frequency and intensity of post-chemotherapy nausea by 18% as compared with the supportive therapy group. Our intervention was also helpful in significantly reducing the frequency and intensity of anticipatory nausea by 12% and 18%, and vomiting intensity by 9% as compared with controls” (p. 471). In this study, they found that yoga reduced the effects of chemotherapy in cancer patients. The other research study which also looked at the effects of yoga on cancer patients going through chemotherapy found that higher class attendance “was associated with higher physical health and health-related quality of life (particularly physical well-being and functional well-being)” (Danhauer, 2009). Women who had the yoga intervention showed improvement in mental health, depression, and spirituality. There was no significant difference between the groups with fatigue, or health-related quality of life, even though class attendance showed an improvement in these variables. This could be because of the limitations within the study.

The findings in the Danhauer study were similar to the results of the Culos-Reed study. She found that “yoga practice has a positive psychological impact on cancer survivors” (p. 896). Going against her hypothesis, she found that there “were no significant physical improvements in the yoga group as compared to the control group” (p. 896). This result is the same as the result in the Danhauer study; however, these results differ from the Raghavendra study which did find improvements in physical health. The results of the Culos-Reed study also differed from the Danhauer in that she found improvements in the quality of life for the yoga participants. Other variables such as mood disturbances (depression, tension, and confusion), although they made improvements, were not significant results. The reason for different results in these two studies was because one study was performed on cancer survivors, not currently receiving treatment, while the other two studies were on cancer patients receiving treatment. Therefore, the differences in results are important to note.

Other studies have shown similar results, pointing out the benefits of yoga. These positive results range from improving quality of sleep, decreasing fatigue, stress, and cancer-related symptoms, etc. (DiStasio, 2008). Results also showed positive yoga attendance rates, which is important to note if a cancer center is thinking of implementing a yoga class in their treatment. Studies have found that in general, “despite generally deteriorating medical conditions, participants in the yoga class reported experiencing physical, mental, and emotional improvement” (127). She also points out that cancer centers that offer specialized yoga classes can benefit cancer patients by providing group support. The patients attending class are all going through similar experiences, and are less likely to feel awkward when removing wigs, hats, etc, or less likely to feel embarrassed that they can’t perform the exercises to the extent that a normal, healthy person can (130).

Why Research is Important

After doing all of this research on the effects of yoga on cancer patients, I decided to consider why research is important. Why do Americans and other Western cultures do so much research? A common phrase in the news is “studies show…” followed by some research study that someone thought would be important for people to know. One reason I feel that Americans are so interested in research is because we are always comparing. It is our nature to compare. We want to make sure we are “keeping up with the Jones’s.” Much of our research stems from this nature to compare. We start asking questions, some of which compare products; which one works better? Some questions compare times; why do people do this now, when they never used to? In the case of yoga and cancer, people began to compare yoga to other treatments, to see if it was beneficial. In our culture, we find it important to study common trends in our society. We feed off of gossip and we are always trying to get the “dirt” on something new. It is just as our media shows with celebrities. The paparazzi are always trying to find the juicy details on the life of a celebrity. The need for research isn’t quite as dramatic as the gossip of celebrity life, however, there are similarities. On another note, we are simply a curious species. We are constantly asking the question “why?” Why is yoga being used in cancer centers?

America breads skepticism. We don’t want to change the ways we do things, especially if it is regressing to a way that we have already used and moved past. Once we have gotten used to a way, we are not eager to change it, especially when the media feeds into that paradigm. It is such with our Western technology and medicine. Many doctors really believe in our system, especially because they have spent years in school learning about it. They are the biggest skeptics when it comes to the use of alternative medicines. Not only that, but it takes away from their industry. It often comes down to a doctor being sick with the cancer themselves, that they finally open up to new forms of medicine. In the Yoga Journal, Sandy Boucher wrote about a doctor who was a perfect example of this. He never believed in the benefits of yoga for cancer patients until he himself was diagnosed with cancer. When he lost hope in modern technology to save him, he gave in to yoga as a therapy. However, he said he was only able to after he saw that “scientific evidence showed some measureable benefit from yoga and meditation” (p. 6). It just shows that in our culture, we are skeptical of thing because we are so technologically advanced. We want proof that something works, and we get that proof from science.

Yoga for Chronic Illness

Many yoga instructors and students find yoga helpful for chronic illness because of the mental aspect of it all. Yoga allows one to become more accepting of themselves and learn to appreciate what the body can and cannot do. Jnani Chapman (2000) wrote about yoga practice specifically for patients with chronic illness. She stated that “Hatha yoga practice gives us time to look at ourselves, and that time spent will be fruitful to the extent that we are genuinely willing to explore, discover, and honor our limits” (p. 1). There was an article in the Yoga Journal which was specifically about yoga for cancer patients. The author, Sandy Boucher, did not claim that yoga was a cure for cancer, but that it created healthier cancer patients with “generally improved results” (p. 3). She talked about yoga focusing on reducing the tremendous amounts of stress that cancer patients face. They are told that they have a disease that has no cure, and are then given a period of time in which they have to live. Then they have to suffer through bouts of chemotherapy and radiation which makes them very weak and sick. All the meanwhile, they are going through the psychological process of death.

Yoga helps to keep people focused on the present. Much of our stress comes from thinking about the past or worrying about the future. This stress is exacerbated when someone was a chronic illness. They begin to reflect on their past and how healthy they used to be, or think about whether or not they accomplished everything in life that they wanted to. When they are not thinking about the past, they are worrying about the future, and how much harder it is going to get, and wondering exactly how much time they have left. All of this stress makes life almost unbearable. Even in everyday life, “we tend to focus on so thoroughly on the external world… that we lose awareness of the actual, intimate, moment-by-moment experience of our own physical, mental, and emotional selves” (Boucher, p. 8). Yoga also helps with self-empowerment. It really allows people’s views change from trying to fight the illness, to learning how to accept it and live with it. This aspect of yoga really helps people in the end of life process.

Why Yoga is Helpful in End of Life Care?

It is proposed that yoga is helpful in end of life care, but why is that? One idea is that because yoga is focused so much on the present, it allows someone to be more accepting of their physical state, no matter what it is. Through meditation, one learns to appreciate what they have at that moment in time, and what they are still capable of doing. In Boucher’s article (2010), the same doctor mentioned above who was skeptical of yoga was offered another round of chemo when his tumor came back. The chemo would not get rid of the tumor, only reduce it in size. Because the doctor was now more capable of living in the present, he was able to easily decide not to do the chemo. He did not want to spend his last year being sick, but rather enjoy the rest of his life with health he had. He was able to be stronger without the chemo and also healthier with the help of the yoga.

Another reason why yoga is helpful in the end of life care is because of the spiritual aspect of it. The research studies discussed earlier, mentioned increased spirituality within the cancer patients practicing yoga, however they never discussed what the spirituality was. In Sanskrit there is a word “nirvana” which is also common in Buddhism. Nirvana is translated as “the going out of a flame once its fuel has been consumed; it thus suggests both the end of suffering and the cessation of desires that perpetuate bondage” (Columbia Electronic Encyclopedia). Nirvana is achieved through the practice of yoga. This idea helps allow for more acceptance, again. In an article discussing spirituality, Christina Puchalski (2002) talks about death being a natural occurrence, but how we do not accept it in our culture and how we try to prolong it. Because of this prolonged dying phase, we now have to learn better ways in which to live with dying. “Modern medicine has granted us more people an old age, but it slows the process of dying. The end of life can last several years” (p. 799). She also mentioned the importance of acceptance, “in chronic illness, healing may be experienced as the acceptance of limitations” (p. 800). She found that spirituality helps dying patients be more accepting of their conditions.

Yoga Clashes with Research

As I was reading all of the studies, followed by all of the stories from actual patients who had cancer and practiced yoga, I got the idea that the ideals for yoga as a treatment for cancer really clashed with the idea of researching the effects of yoga. Although there may be some measurable physical effects of yoga on cancer patients, the most rewarding effects, are the psychological effects which come from acceptance. I got the understanding that the main purpose of yoga as a form of therapy for cancer patients was to help them live in the present and accept themselves for who they are, no matter the condition. Research is the process of finding scientific proof of something. If we followed the ideas of yoga, we would simply accept that it has a positive effect on cancer patients; instead, we use research to try to prove the effects. Perhaps the true effects of yoga will never truly be understood because it is so much more spiritual. It is not meant to be proved. It is really putting your faith into something that you believe works. If it works for some people, why do we have to test it out? We need to learn to practice more of the ideas of yoga, and just accept things the way they are.

References

(2002). Yoga May Offer Benefits to Patients With Cancer. Clinical Journal of Oncology Nursing, 6(5), 253. Retrieved from Academic Search Premier database.

Boucher, S. (2010). Yoga for Cancer. Yoga Journal. Retrieved from http://www.yogajournal.com/health/126.

Culos-Reed, S., Carlson, L., Daroux, L., & Hately-Aldous, S. (2006). A pilot study of yoga for breast cancer survivors: physical and psychological benefits. Psycho-Oncology, 15(10), 891-897. doi:10.1002/pon.1021.

Danhauer, S., Mihalko, S., Russell, G., Campbell, C., Felder, L., Daley, K., et al. (2009). Restorative yoga for women with breast cancer: findings from a randomized pilot study. Psycho-Oncology, 18(4), 360-368. doi:10.1002/pon.1503.

Chapman, J. (2000). Yoga for Chronic Illness. Retrieved from http://www.cancerlinks.org/Yoga/illness.html

DiStasio, S. (2008). Integrating Yoga Into Cancer Care. Clinical Journal of Oncology Nursing, 12(1), 125-130. doi:10.1188/08.CJON.125-130.

Jobst, K., Curtis, B., Niemtzow, R., Ong, P., Jonas, W., & Curtis, M. (2003). Science and Healing: From Bioelectromagnetics to the Medicine of Light. Special Issue of JACM—Call for Papers. Journal of Alternative & Complementary Medicine, pp. 181-182. doi:10.1089/10755530360623275.

Nirvana. (2009). In Columbia Electronic Encyclopedia. Retrieved from Academic Search Premier database.

Puchalski, C. M. (2002). Spirituality. Principles and the Practice of Palliative Care and Supportive Oncology. 799-812.

Raghavendra, R., Nagarathna, R., Nagendra, H., Srinath, B., Ravi, B., et al. (2007). Effects of an integrated yoga programme on chemotherapy-induced nausea and emesis in breast cancer patients. European Journal of Cancer Care, 16(6), 462-474. doi:10.1111/j.1365-2354.2006.00739.x.

Saper, H., Eisenberg, D., Davis, R., Culpepper, L., & Phillips, R. (2004). PREVALENCE AND PATTERNS OF ADULT YOGA USE IN THE UNITED STATES: RESULTS OF A NATIONAL SURVEY. Alternative Therapies in Health & Medicine, 10(2), 44-49. Retrieved from Academic Search Premier database.