The Effectiveness of Yoga on Patients with Breast Cancer in Reducing Symptoms of Stress: Evidence-Based Review

This study was conducted to examine the scientific evidence regarding the effectiveness of yoga intervention on stress reduction for patients with breast cancer. PICO method was used to develop research question and a thorough review was conducted to identify most relevant evidence-based research related to the effectiveness of yoga on patients with breast cancer in reducing symptoms of stress. Our review revealed four studies suggesting that yoga exercises may reduce stress related symptoms associated with breast cancer patients. Yoga exercises are effective and helpful and could reduce symptoms of stress in patients with breast cancer.


Introduction
Patients with breast cancer may have psychological and physical discomfort. Emotional responses may create barriers that prevent these patients from fully participating in their daily routines. Yoga enhances the patient's ability to cope with their stressful situation Banerjee [1] & Moadel [2]. The purpose of this study was to examine the scientific evidence regarding the effectiveness of yoga intervention on stress reduction for patients with breast cancer. For this study, we created a clinical/research PICO question (Population, Intervention, Comparison, and Outcome), a key to evidence-based decision Richardson et al. [3]. The PICO formed for our study is as follows:

Methods
Review of literature and search strategy-A research has been made in the following databases: Ovid (MEDLINE, Psych INFO, and Global Health), and CINAHL. Keywords and Search items used to search articles for our study were Yoga, breast cancer, stress, distress mood. Four articles were selected related to the effectiveness of yoga on patients with breast cancer in reducing symptoms of stress. All articles were related to our PICO question. After all, the strongest evidence-based article was chosen using hierarchy of levels of evidence in evidence-based practice Hughes [4].  For treatment effects on daily outcomes after 8 weeks, the yoga program did not significantly reduce the daily distress or increase daily relaxation for patients with metastatic breast cancer. However, daily invigoration was significantly increased. Banerjee et al. [1] which examined the effects of an integrated yoga program in modulating psychological stress and radiationinduced genotoxic stress in breast cancer patients undergoing radiotherapy was selected as the strongest evidence in our study. It was a level II randomized control trial (RCT) with significance level of P <.001 after 6 weeks. Thus, clinical guidelines, recommendations, a plan and audit tool have been developed in our study to implement yoga in clinics (Table 3).

Conclusion
Our review suggested that yoga exercises are effective and helpful and could reduce symptoms of stress in patients with breast cancer [5,6]. Thus, clinical guidelines, recommendations, a plan and audit tool have been created in our study to implement yoga programs in clinics. The clinical guidelines for recommended intervention, the plan, and the audit tool recommend therapists to apply yoga exercises with patients with breast cancer and stress. Three therapists will be recruited and scheduled to attend the Yoga program training.
The three therapists will complete the Yoga training within two months.
A training file, which will be reviewed weekly, includes attendance sheets for each training session and a certificate for completing the two-month training.
If the therapists do not attend the program, a note will be recorded on the Yoga training file.
2. The trained therapists will make one set of Yoga movements for a 90-minute session.
The trained therapists develop a serious of Yoga movements for 90 minutes based on their training program.
The set of Yoga movements will be completed in one month after the trainers finish their training.
Within one month, the trainers will complete a template that includes purpose, procedure, and Yoga movement patterns for this program.
If the template is not completed within one month, a note will be recorded in the Yoga plan file 3. The trained therapists will make a Yoga teaching video.
Based on the template, two trained therapists will perform Yoga movements, and one trained therapist will verbally explain the teaching video.
The teaching video will be completed within two weeks.
The video will be available for every staff member.
If the video is not completed within two weeks, a note will be recorded in the Yoga plan file.
4. The trained therapists will teach other staff members how to perform the Yoga program.
For one hour during every lunch break, staff members will separate into groups (≦five members for each group) to learn each movement pattern.
Within one month, 100 % of staff members will learn 100% of the Yoga movements in this program.
The trained therapist will weekly review an attendant sheet for each learning session within the one-month training.
If the therapists do not attend the learning session, a note will be recorded in his/her training file.
5. All staff members will present the Yoga program.
Staff members will perform the set of Yoga movements one by one for the three trained therapists.
The staff members should reach an 80% accuracy of all movements during the Yoga performance.
The trained therapists will report the competence level of each staff member.