A Scoping Review of Combined Yoga and Resistance Exercise for Dyspnea in Lung Cancer Survivors
Shreya Rewar1, Mona Al Onazi1, Kaitlyn Boudreau1 and Margaret L McNeely1,2*
1Department of Physical Therapy, University of Alberta, Canada
2Rehabilitation Medicine, Cross Cancer Institute, Canada
Submission: February 12, 2018;Published: June 22, 2018
*Corresponding author: Margaret L McNeely, Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, Alberta T6G 2G4, Canada, Tel: +1-780-248-1531; Fax: +1-780-492-4429; Email:[email protected]
How to cite this article: Rewar S, Al Onazi M, Boudrea K, McNeely ML. A Scoping Review of Combined Yoga and Resistance Exercise for Dyspnea in
Lung Cancer Survivors. J Yoga & Physio. 2018; 5(3): 555664. DOI:10.19080/JYP.2018.05.555664
Introduction: Lung cancer is the second most common cancer and is the leading cause of death from cancer. Dyspnea, a self-reported subjective feeling of shortness of breath or breathlessness, is a common symptom experienced by survivors, especially those with advanced stage lung cancer.
Objectives: The purpose of this paper was to (1) perform a scoping review of the literature on yoga and resistance exercise interventions that included a breathing or pulmonary rehabilitation component to address dyspnea in survivors with lung cancer and (2) propose a physiotherapeutic protocol combining yoga with resistance exercise.
Results: A total of 3 single-group studies were found that examined supervised yoga interventions for survivors with lung cancer and 5 RCTs were found examining resistance exercise including a pulmonary rehabilitation component. The three yoga studies involved a total of 28 survivors with non-small cell lung cancer. Findings support feasibility and preliminary efficacy for sleep, mood, anxiety and aspects of quality of life. Five studies, involving 257 survivors with both small cell and non-small cell lung cancer, were found that examined combined resistance exercise intervention and a pulmonary rehabilitation component. Three studies were prehabilitation interventions carried out prior to lung cancer surgery. Benefits were found for measures of lung capacity, six-minute-walk-test distance and quality of life. Based on the findings, a physiotherapeutic protocol is proposed.
Conclusion: Given the scope of practice of physiotherapists and their training in cardiorespiratory therapy, it is hoped that this paper will encourage collaboration with yoga professionals to lead future research in the area.
Fifty percent of newly diagnosed cancers include those of lung and bronchus, breast, colorectal and prostate cancer . Lung cancer is the second most common cancer diagnosed among males and females each accounting for 14% of all new cases and is the leading cause of death from cancer . The diagnosis of lung cancer leads to debilitating symptoms for the survivor, not only from the cancer itself but also from the side effects of the treatment .
The largest proportion of cancer cases occur in older adults, and lung cancer is the most common cancer for individuals 70+ years of age for both genders . Unfortunately, older age is associated with increased symptom burden from the disease and its treatment . Authors of a recent qualitative study reported adverse effects including pain, fatigue, weakness and dyspnea . Dyspnea, a self-reported subjective feeling of shortness of breath, or breathlessness, is a common symptom experienced by survivors, especially those with advanced stage lung cancer [2,4,5]. Although highly prevalent and distressing, the impact of dyspnea is often under-recognized despite its negative effects on physical and psychological functioning .
Exercise has shown benefit in addressing pain, fatigue, physical fitness and quality of life across cancer types [6,7]. Exercise may prove beneficial for those with lung cancer by increasing muscle strength, attenuating losses in muscle mass, reducing fatigue, and by helping survivors cope with physical and emotional adverse effects related to the disease and its treatment . Survivors, however, report numerous barriers to exercise including low motivation; fear to exercise; lack of knowledge about benefits; and external barriers related to the environment, social support, and symptoms . In particular, the fear of worsening dyspnea with movement and physical activity is a primary reason for survivor unwillingness to participate in exercise [8,10]. Thus, there is a need for further exploration of personalized exercise interventions for survivors of lung cancer that address overall fitness and functioning, while considering symptoms such as dyspnea.
Resistance exercise training may prove valuable to attenuate
both sarcopenia and disease related declines in muscle mass
commonly seen in survivors with lung cancer . In addition
to improving muscle mass, resistance exercise has been shown
to increase peak oxygen uptake in deconditioned individuals
and muscle strength in older adults . Importantly, resistance
exercise training has been shown to improve an individual’s
ability to carry out daily activities, and to reduce symptoms
of fatigue in both healthy and chronic disease populations
[13,14]. Yoga is now widely practiced throughout the world as
a mind-body therapy and is considered part of complementary
and alternative medicine. Given its gentle nature and focus on
breathing and meditation, yoga may address barriers related to
dyspnea, and thus prove a viable exercise option for survivors of
lung cancer .
The purpose of this paper was to review the potential of a
physiotherapeutic approach to address dyspnea in survivors
with lung cancer that involves combining yoga with resistance
exercise training. First, we provide a summary of the evidence
on the benefits of exercise interventions in survivors with lung
cancer by highlighting findings of key systematic reviews in the
area. Next, we present the findings of our scoping review on yoga
and resistance exercise interventions for dyspnea in lung cancer.
Noting the limited direct research in the area of combined yoga
and resistance exercise interventions, we propose a protocol
for a physiotherapeutic approach involving yoga and resistance
exercise for survivors of lung cancer with a focus on dyspnea.
A Cochrane Systematic Review examined exercise
interventions following lung cancer resection . Three
randomized controlled trials (RCTs), with 178 patients, were
included in the review. Studies examined combinations of
aerobic and resistance exercise training, with only one study
including a focus on breathing/dyspnea management. Findings
showed a statistically and clinically significant benefit for sixminute
walk test (6MWT) distance (50.4m; 95% confidence
interval (CI): 15.4, 85.2). No significant benefits were found for
quality of life or measures of lung function.
Another recent systematic review examined the benefits
of home-based prehabilitation and rehabilitation programs
for survivors with non-small cell lung cancer . The review
included 11 intervention studies comprising home-based or
combined home and clinic/hospital-based supervised exercise.
While benefits were shown for physical fitness outcomes, most
of the studies involved survivors with early stage lung cancer
and only two studies included a focus on breathing/dyspnea
management. Importantly, low adherence rates to exercise
were common, with studies involving regular supervision
and personalized exercise resulting in better adherence and
retention of participants .
Exercise training has also shown promise for managing
dyspnea, both as a prehabilitation intervention and also
when delivered as an intervention in the early post-surgical
time period for lung cancer . In a systematic review,
including 15 studies, interventions primarily involved aerobic
(walking and cycling) and breathing exercises. Eight studies
involved prehabilitation exercise training (n=8 studies) and
findings showed shorter lengths of hospital stays, decreased
postoperative complications, and increased 6MWT distance.
Seven studies involved postoperative exercise interventions and
were found to improve both the 6MWT distance and dyspnea
score in survivors .
A scoping literature search of various databases including
Medline, CINAHL, Embase and PEDRO was performed to find
articles related to lung cancer and combined yoga and resistance
exercise with a focus on breathing/dyspnea. As no studies were
found examining the combination of interventions, we turned
our attention to articles involving (1) yoga with an emphasis on
breathing/ dyspnea and (2) resistance exercise intervention that
included a breathing or pulmonary rehabilitation component.
Participants: Participants were required to be adults
(17 years and older), diagnosed with lung cancer, where the
intervention was in an outpatient hospital or in a communitybased
setting. Participants could be actively receiving cancer
treatment or be in the post-treatment phase at the time of the
Participants: Participants were required to be adults
Intervention: The primary intervention was supervised
yoga with a breathing or meditation component OR supervised
resistance exercise intervention with a breathing or pulmonary
rehabilitation component. Programs that comprised homebased
interventions alone were excluded.
Outcomes: Studies were required to include one of the
following outcomes: dyspnea or a measure of lung function,
fatigue, muscle strength and quality of life.
Study design: As we anticipated fewer trials in the yoga area,
we considered clinical trials including single group pre-post
designs, controlled trials and randomized controlled trials. Only
randomized controlled trials were included for the resistance
exercise studies. Studies were required to be published in
Scoping review procedures: Four review members
screened the articles for inclusion in the review (SR, MAO,
KB, MM). Studies meeting the eligibility criteria underwent
independent data abstraction and review by three members of the
review team (SR, MAO, KB). Information regarding study
population, tumour group, methods, interventions, outcomes
and adverse events were collected using a structured data
abstraction form. Discrepancies were settled by consensus and
if necessary, involved a fourth member of the review team (MM).
A total of 3 studies [10,17,18] were found that examined
supervised yoga interventions for survivors with lung cancer
and a total of 5 RCTs [19-23] were found examining resistance
exercise including a pulmonary rehabilitation component. The
three yoga studies used a single-group design and involved a total
of 28 survivors with non-small cell lung cancer. Interventions
involved Hatha (n=2) or Tsa Lung yoga (n=1), and all involved
a breathing component. One study included both survivors and
their caregivers. Findings support feasibility and preliminary
efficacy for sleep, mood, anxiety and aspects of quality of life.
No studies reported outcomes related to dyspnea or a measure
of lung function. Further details on the included studies are
provided in Table 1.
NSCLC: Non-Small Cell Lung Cancer; QoL: Quality of Life; EORTC QLQ: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire; d=effect size
Five studies [19-23], involving 257 survivors with both small
cell and non-small cell lung cancer, were found that examined
resistance exercise along with a pulmonary rehabilitation
component (Table 2). One study was carried out in the posttreatment
phase and involved a 10-week group-based supervised
exercise program, once a week. No significant differences were
found between the intervention and control group for any
outcomes. Three studies were prehabilitation interventions
carried out prior to lung cancer surgery. Benefits were found for
measures of lung capacity, 6MWT distance and quality of life. The
final study examined exercise during palliative chemotherapy
and showed benefit for daily activities, functional capacity and
symptoms of dyspnea.
SCLC: Non-Small Cell Lung Cancer; QoL: Quality of Life; EORTC QLQ: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire; SF-36: medical Outcomes Short Form 36 Quality of Life Questionnaire.
Current exercise guidelines for cancer largely reflect physical
activity recommendations for the general population . At
present, the most beneficial exercise regimen for survivors of
lung cancer in terms of type, frequency, and duration is currently
not known [12,15,16,25,26]. Based on current evidence, it is
likely that an exercise program including a therapeutic yoga
focus on the mechanics of breathing as well as a resistance
exercise program that includes inspiratory muscle training
would be both acceptable to, and beneficial for survivors (Figure
1). Table 3 includes a rationale for a combined physiotherapeutic
yoga and resistance exercise protocol that aims to address
the needs of survivors of lung cancer. Key components of the
combined intervention include yoga practice with attention
to the mechanics of breathing, resistance exercise including
inspiratory muscle retraining, and a cool-down with a focus on
stretching of key muscles of respiration.
Resistance exercise: Resistance exercise training optimizes
physical efficiency and performance [27,28]. With repeated
bouts of appropriately prescribed resistance exercise the
musculoskeletal system undergoes a progressive positive
adaptation to the imposed stress, and the survivor’s ability to
resist physical fatigue is enhanced . Moreover, using the
similar principles, respiratory muscle training may be used to
optimize lung function by targeting the strength of inspiratory
muscles. Deeper, more efficient breathing allows more oxygen
to enter the bloodstream with each breath while strengthening
the breathing muscles. Interventions may include teaching
diaphragmatic breathing, segmental and purse-lipped breathing;
and inspiratory muscle training (IMT) using a breathing device
[29,30]. In other disease conditions, IMT has been shown to
improve inspiratory muscle function, decrease symptoms of
dyspnea and allow patients to exercise more comfortably .
As seen in the results of this scoping review, early evidence
supports its use in survivors of lung cancer.
Yoga component: Yoga is a way of life as based on the
eastern traditions of India, Tibet and China. Yoga consists
of three principal components as pranayama (breathing
exercises), Meditation (dhyana), and asanas (postures) .
There are many different styles and types of yoga commonly
practiced in the western world. Hatha yoga is a traditional
form of yoga from India. Hatha yoga involves a series physical
postures and breathing techniques, and is a method used to
calm the body, mind and spirit in preparation for meditation.
Hatha yoga includes the styles of Ashtanga, Iyengar, Anusara,
Vivekanada, and Vinyasa. Tsa Lung, a Tibetan form of yoga,
uses breath retention techniques with physical movements and
visualizations to promote relaxation and healing, and to still
the mind. Early evidence from this scoping review suggests
potential benefit from yoga for symptoms of dyspnea. Given
other reported benefits of yoga for sleep, cancer-related fatigue,
psychosocial distress, and musculoskeletal symptoms ;
further investigation of yoga as an intervention for survivors
with lung cancer is warranted.
Exercise safety considerations: Prior to performing
exercise testing or training, information must be collected
on important diagnostic and treatment variables such as the
survivor’s type and stage of lung cancer, cancer treatments
received or ongoing, and identify any acute or chronic adverse
effects related to the cancer and/or cancer treatment . Table
4 provides a list of precautions/potential contraindications to
exercise that includes considerations specific to lung cancer.
Given the older age of survivors with lung cancer further
screening for co-morbid conditions is needed. Following a simple
screening tool such as the Revised PAR-Q (Canadian Society for
Exercise Physiology’s web site http://www.csep.ca) may be
useful to identify survivors of lung cancer who require further
medical evaluation prior to taking part in exercise testing or training.
Pre-exercise screening should include assessment of
the survivor’s vital signs (blood pressure, heart rate, oxygen
saturation, respiration rate and dyspnea evaluation), as an
indication of overall health status . Prior to assessment,
survivors should rest for a period of at least 10 minutes. A heart
rate monitor can be provided to the survivor with lung cancer to
wear while exercising so that heart rate response can be easily
observed. Vital signs should be taken before, during and after
exercise testing and training to ascertain safety of exercise.
Survivors with abnormal readings should refrain from exercise
until such time as normal readings are obtained, or if remaining
abnormal should be referred to their oncologist or primary care
physician for further medical evaluation . A dyspnea visual
analog scale, such as the modified Borg Scale, can be used to
measure the perceived level of breathlessness before and after
the intervention . Oxygen saturation levels can be monitored
during exercise and may inform the need for rest/recovery.
Special considerations for dyspnea during Exercise:
Simple interventions to relieve breathing distress during
exercise, such as performing exercise in a supported sitting
position, may be introduced to allow for increased lung
expansion. In survivors with lung congestion, chest physical
therapy techniques may be incorporated to open airways prior
to exercise . Recovery or escape positions to ease breathing
should be demonstrated to the survivor with lung cancer and
their caregivers as a means to manage episodes of dyspnea
during exercise or daily activities . Importantly, survivors
should be taught to use escape positions to increase ventilatory
capacity when experiencing dyspnea during exercise testing
and training sessions. As an example, one escape position
involves leaning forward in a seated position and supporting the
thorax by bracing the forearms against a chair or on the knees.
Alternatively, the survivor can lean against a wall in a similarly
supported standing position . Pacing is another important
aspect for those with dyspnea and is critical to ensure exercise
performance falls within the limits of a survivor’s ventilatory
capacity. If a survivor becomes slightly short of breath, they are
instructed to stop the exercise, attain an escape position, and
use controlled purse-lip breathing (to increase end-expiratory
pressure and improve oxygenation) until the symptoms subside
As can be seen from the foregoing review of the literature
on yoga and resistance exercise for survivors of lung cancer, the
body of literature has been minimal and research supporting the
efficacy of interventions is generally lacking. There is a need for
further research examining the benefits of a lung cancer-specific
program involving combined yoga and resistance exercise
training for symptoms of dyspnea. Given the scope of practice of
physiotherapists and their training in cardiorespiratory therapy,
it is hoped that this paper will encourage collaboration with yoga
practitioners to lead future research examining rehabilitation
strategies for dyspnea in survivors of lung cancer.