Active Practice of Iyengar Yoga as an Intervention for Breast Cancer

INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 13 (2003) 51

Abstract

The Iyengar system of Yoga is well suited to meetthe guidelines for physical activity for breast cancersurvivors. Attention to alignment and symmetry, the useof props, and careful sequencing all improve stamina,strength, flexibility, and confidence, while decreasingstress and side effects. Women (n = 18, ages 48 to 69years) diagnosed with stage I–III breast cancer andreceiving antiestrogen or aromatase inhibitor hor-monal therapy were recruited for this study. The rangeof time since chemotherapy and/or radiation treatmentwas three months to eight years. The subjects were ran-domized to either a Yoga (n = 9) or wait-list controlgroup. Beginning level Iyengar Yoga classes were con-ducted two times per week for eight weeks. The womenwere given a home instruction sheet to practice once aweek at home for a total of three Yoga sessions perweek. A 92.9% ± 9.8% (mean ± SD) compliance ratefor weekly home practice was achieved. During thesixth week of classes, the subjects were asked to com-plete a 31-question self-report survey that focused ontheir feelings of stress, level of physical and mentaleffort during class sessions, and perceptions about howYoga practice had influenced their awareness. The pre-liminary findings indicate that the Yoga class was welltolerated by the participants. 75% of the womenreported that they would not prefer a slower pacedclass with less demanding poses. Yoga practice relieved

the joint aches and shoulder stiffness associated withthe side effects of hormonal treatment for 25% of theparticipants. Over 60% of the women reportedimproved mood and less anxiety as an outcome of theYoga practice.

Introduction

A small body of experimental evidence indicatesthat Iyengar Yoga may reduce physical symptoms,such as fatigue,1 and emotional distress, such as anxi-ety and depression,2 in clinical populations. Ourresearch focuses on the impact of active Yoga practice,taught in the Iyengar tradition, as an integrative med-ical intervention for breast cancer survivors. The pur-pose of this manuscript is twofold: 1) to consider theimportance of an active Yoga practice for breast cancersurvivorship and 2) to describe a pilot study of the ben-efits of an Iyengar Yoga intervention for breast cancersurvivors. The structured 8-week intervention providessystematic training in Yoga postures and relaxation asa self-regulation approach for reducing stress andfatigue.

Breast Cancer Survival

A cancer survivor is anyone diagnosed with cancer,from the time of diagnosis through the remainder of life.3

The cancer survivorship continuum includes those in

Active Practice of Iyengar Yoga as an Intervention for Breast Cancer SurvivorsSally E. Blank, Ph.D., Jacqueline Kittel, O.T.R./L., R.Y.T., and Mel R.Haberman, Ph.D.

52 INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 15 (2005)

recovery with no apparent diseaseand those living with advanced can-cer.4 As of January 2001, theNational Cancer Institute estimatedthat there were 9.6 million cancersurvivors in the United States; 22%of these survivors were women diag-nosed with breast cancer.5,6

Breast cancer is the most preva-lent type of invasive cancer amongwomen in the United States.7,8

Approximately 212,118 Americanwomen will be diagnosed with breastcancer in 2005.9 The lifetime probabil-ity of any woman living in the UnitedStates developing breast cancer is13.4%, or 1 in 8.10 From 1995–2000,the relative 5-year survival rate forbreast cancer survivors across raceand ethnic groups was 88%.11,12

Cancer Survival and PhysicalActivity

In 2003, the American CancerSociety (ACS) published guidelinesfor nutrition and physical activityduring and after cancer treatment.13

These guidelines, based on scientificevidence and best clinical practices,vary depending on the cancer site,phase of treatment and recovery, andthe unique needs and preferences ofeach survivor. A committee ofexperts stated there was insufficientscientific evidence to conclude thatincreasing physical activity duringtreatment alters survival rate or riskof breast cancer recurrence. How-ever, increasing physical activityduring treatment was found to haveprobable benefit for quality of life.In addition, the committee con-cluded that women who increasephysical activity after breast cancertreatment have possible benefit forreduced incidence of cancer recur-rence and increased overall survival,as well as probable benefit for qual-ity of life.

Breast cancer survivors whohave excess body fat have anincreased risk for recurrent diseaseand/or decreased survival.14,15 Inter-ventions that address weight control,weight maintenance, and/or increaselean body mass during and afterbreast cancer treatment should be

encouraged.16 The Surgeon Gen-eral17 and the ACS recommend 150minutes/week of moderate to vigor-ous intensity sports or recreationalphysical activity, excluding house-hold and gardening activities, forthe general population. Decreasingbody fat and preventing weightgain, however, may require morephysical activity than recommendedby the Surgeon General. Accordingto the 2005 Dietary Guidelines forAmericans, one must “participate inat least 60 to 90 minutes of dailymoderate-intensity physical activitywhile not exceeding caloric intakerequirements” to sustain weightloss.18

A population-based, multi-cen-ter, multi-ethnic, prospective cohortstudy of breast cancer survivorsfound that only 32% of breast can-cer survivors participated in theSurgeon General’s recommendedlevel of sports/recreational physicalactivity.19 When participation inhousehold and gardening activitieswas included, however, 73% of thebreast cancer survivors engaged in150 minutes/week of moderate-intensity physical activity. The

authors of this study concluded thatbreast cancer patients and survivorsbenefit from maintaining andincreasing their physical activityduring and following cancer treat-ment.

These results are consistent witha comprehensive literature review byChlebowski et al.20 on chronic diseasemanagement for women with breastcancer. The authors concluded thatincreased physical activity helps todecrease obesity or maintain ahealthy weight and improves breastcancer prognosis, perhaps by modi-fying hormonal regulation requiredfor breast cancer development.Another literature review, by Galvãoand Newton,21 reviewed exerciseintervention studies for survivorsduring and after cancer treatment.These authors concluded that partici-pation in regular exercise sessionsduring and after cancer treatmentprovides physiological benefits, suchas increased skeletal muscle massand strength and improved cardiopul-monary capacity. Based on theirreview, the authors recommended thefollowing physical activity guide-lines: 1) anabolic/resistance exercises(frequency: 1–3 sessions per week,volume: 1–4 sets per muscle group,intensity: 6–12 repetition maximum),2) cardiovascular exercise (fre-quency: 3–5 sessions per week, vol-ume: 20–60 minutes, intensity:55–90% age-predicted maximalheart rate, calculated as 220 minusage), 3) flexibility exercise (fre-quency: 2–3 sessions per week, vol-ume: 2–4 sets per muscle group,intensity: not determined).

Recent prospective research onbreast cancer survival supports theimportance of physical activity forbreast cancer survivors. Holmes etal.22 examined the self-reported phys-ical activity patterns of 2,987 womenenrolled in the Nurses’ Health Study

Breast cancer patientsand survivors benefitfrom maintaining andincreasing their physicalactivity during and fol-lowing cancer treatment.


(median duration of participation =38 months) who were diagnosed withstage I, II, or III breast cancer. Thosesurvivors who reported physicalactivity levels of greater than 3 MET-hours per week (equivalent to walk-ing at a pace of 2 to 3 mph for 1 houra week) had reduced risk of deathfrom breast cancer, compared to thosewho reported less than 3 MET-hoursper week. The improved survival ben-efits from physical activity were par-ticularly evident for women whoreported physical activity levels ofbetween 3 and 9 MET-hours perweek, women diagnosed with stageIII breast cancer, and women diag-nosed with hormone-responsivetumors. Factors that did not substan-tially change risk of death from breastcancer among these women included:amount of physical activity prior todiagnosis, type (e.g., walking, swim-ming, aerobic exercise, golfing,cycling, lawn mowing) of physicalactivity engaged in after diagnosis, orparticipation in vigorous exercise thatexceeded 9 MET-hours per week.Although the authors categorizedYoga practice as lower-intensityactivity similar to “stretching,” animportant conclusion drawn from thestudy was that active participation inphysical activity, regardless of thetype of activity, may help breast can-cer survivors live longer.

All of these general guidelinesfor type, frequency, duration, andintensity of physical activity must beadapted to the individual, taking intoaccount age, previous exercise experi-ence, type of cancer, stage of treat-ment, type of therapy, and comorbidconditions.23

Yoga as a Medical Interventionfor Cancer Survivors

Although many cancer centersoffer Yoga classes for survivors,

research is limited on the efficacy ofYoga intervention. A 16-monthstudy of the Stanford Cancer Sup-portive Care Program for cancerpatients found that restorative Yogawas effective at reducing stress andpain, and increasing energy, well-being, and restful sleep.24 A 7-weekclinical trial of Tibetan Yoga, whichemphasizes gentle, simple move-ments, controlled breathing, visuali-zation, and mindfulness techniques,was effective in improving overallsleep quality and reduced sleep med-ication use in lymphoma survivors.25

Several studies have examined thebenefits of mindfulness-based stressreduction (MBSR), a popular group-based clinical program used by over240 medical facilities worldwide thatincorporates gentle stretching andmindful Yoga into meditation prac-tices.26,27 Studies with early and latestage cancer survivors, includingbreast cancer, indicate that MBSRintervention plus home practice canreduce stress symptoms28 and im-prove sleep quality29,30 and overallquality of life.31

Because of the common physi-cal or cognitive dysfunction associ-ated with cancer treatment, manyYoga classes for cancer survivorsincorporate gentle or restorativepostures. These approaches typi-cally emphasize the relaxation com-ponent of Yoga practice. Therelaxation response, as described byBenson,32 is considered to be animportant component in the healingand recovery process. This well-characterized response, which occurswhen one performs “repetitive mentalor physical activity and passivelyignores distracting thoughts,”33 isassociated with rapid reductions insympathetic physiological responses,such as heart rate, arterial blood pres-sure, respiratory rate, and wholebody oxygen uptake.34,35 Therapeutic

use of the relaxation responseimproves symptoms related to vari-ous stress-related diseases, as well assome indices of immune status inbreast cancer survivors.36

An active âsana practice in theIyengar tradition differs from thegentle restorative practices typicallyoffered to cancer survivors by incor-porating all of the components ofphysical fitness. However, Yogataught in the Iyengar tradition alsoincludes some restorative poses anda deep relaxation at the end of thepractice session. For this reason, anIyengar Yoga practice may providemany of the same benefits as relax-ation-based Yoga interventions.

Yoga Âsana Practice and Physi-cal Activity Guidelines

How does Yoga taught in theIyengar tradition address the cancersurvivorship guidelines for physicalactivity? Yoga âsanas require mus-cular strength and endurance, flexi-bility, and balance, and each âsanacan be sustained for several sec-onds to 5–10 minutes or longer,depending on the skill level andgoals of the practitioner. Dynamicâsana sequences (vinyasa) andjumpings that are incorporated intoa Yoga practice constitute rigorouswhole body exercise. Moderate tostrenuous Yoga vinyasa and jump-ings would be expected to promotecardiovascular endurance if thepractice were sufficiently long.

Blank and Krieger37 evaluatedacute cardiovascular, metabolic,and ventilatory responses toHatha-Yoga âsanas practiced inthe Iyengar tradition. Intermedi-ate/advanced level Yoga practition-ers (n = 15 females) weremonitored for heart rate, wholebody oxygen uptake, and brachialarterial blood pressure (n = 9)


while following a 90-minutevideotaped instruction of an âsanapractice. The practice includedsupine, seated, and standing poses,as well as inversions and the fullback bend, ûrdhva-dhanurâsana.Poses were sustained for 1–5 min-utes. Cardiovascular, metabolic,and ventilatory responses were sig-

nificantly greater in standingâsanas, inversions, and ûrdhva-dhanurâsana, compared to supineand seated âsanas. The averagemetabolic expenditure (METs) ofeach pose did not exceed 5 METs(i.e., 5 x energy cost of rest). Aver-age heart rate did not exceed 80%of age-predicted maximal heartrate (220 minus age). The 90-minute âsana practice was classi-fied as mild to moderate intensityexercise (~1.9 MET-hours) with-out evidence of a sustained ele-vated heart rate. Intermediate andadvanced practitioners maintainedposes for up to 5 minutes withoutstimulating an undesirable pressorresponse (disproportionate in-crease in heart rate relative to thechange in whole body oxygenuptake). In general, the cardiores-piratory responses to âsanas weresimilar to changes observed insubjects who perform weightlift-ing circuit exercise.

The above physiological datafrom apparently healthy individu-als provide preliminary evidence

that Yoga can meet many of thephysical activity guidelines forbreast cancer survivors.38 An activeYoga practice can be designed tomeet the weekly energy expendi-ture (MET-hours) requirementsconsidered beneficial for survivalafter breast cancer diagnosis. Asdescribed above, the 90-minutepractice performed by intermedi-ate and advanced practitioners wasequivalent to 1.9 MET-hours.Three practices per week wouldexceed the minimum activity leveldescribed as beneficial to breastcancer survivorship. In compari-son to more advanced practition-ers, beginning Yoga students mayrequire more practice times perweek to compensate for âsanasequences that are less physicallydemanding. We recommend pre-screening this population for phys-ical and cognitive abilities prior tobeginning an active Yoga class anddesigning a progression of pos-tures that is optimal for all partici-pants.

A Preliminary Study of a YogaIntervention

To date, we have conductedtwo pilot studies for breast cancersurvivors using Yoga âsanastaught in the Iyengar tradition. Thefindings from our first study havebeen previously reported and willnot be included herein.39,40

A short-term goal for our Yogaintervention was to meet theguidelines for physical activitiesas described above, but not specif-ically to assess various dimensionsof physical fitness outcomes fromYoga practice. The findingsreported here focus on the abilityof breast cancer survivors to com-plete a Yoga intervention that

meets the guidelines for physicalactivities as well as provides thephysical and psychological bene-fits associated with the practice.

Method

Participants

Our second and ongoing studyincludes women (n = 18, ages 48to 69 years) diagnosed with stageI–III breast cancer and receivingantiestrogen or aromatase inhibitorhormonal therapy. Women wererecruited by an announcementdescribing the study, which wasendorsed by the attending oncolo-gists at a local cancer care facility.The announcement was sent to allbreast cancer patients under care atthis facility. Those women whomet the above primary inclusioncriteria and who were approved forparticipation by their physicianwere allowed to volunteer for thestudy.

Final inclusion criteria included:1) a minimum of eight weeks postchemotherapy, 2) estrogen receptorpositive status, 3) surgery forlumpectomy, modified mastectomy,or full mastectomy (with/withoutreconstruction), 4) a life expectancygreater than six months, 5) adequateblood cell counts and kidney, liver,and cardiac function, and 6) thephysical and mental ability to attendall the Yoga training sessions.Women on Herceptin® therapy, cur-rent steroid therapy, or other knownimmunomodulating medicationswere excluded. The following addi-tional exclusion criteria were ap-plied: 1) pregnancy or currentlactation, 2) a past or current historyof another neoplasm, active seriousinfection, or immune deficiency, 3)documented alcohol or drug abuse,

An active âsana prac-tice in the Iyengar tradi-tion differs from thegentle restorative prac-tices typically offered tocancer survivors.


and 4) a history of psychiatric dis-orders requiring use of psy-chotropic medications.

Design

Women were randomized toeither a Yoga (n = 9) or wait-list con-trol (n = 9) group. Yoga classes wereconducted two times per week foreight weeks. The women in the Yogagroup were given a home instructionsheet to practice once a week athome, for a total of three Yoga ses-sions per week. During the sixthweek of classes, the participantswere asked to complete a 31-ques-tion self-report survey about theirfeelings of stress, level of physicaland mental effort during class ses-sions, and perceptions about howYoga practice had influenced theirawareness. The study protocol wasapproved by Washington State Uni-versity’s Institutional Review Board,and written consent was obtainedbefore data collection.

Considerations for Working withBreast Cancer Survivors

Teaching Yoga to a group ofbreast cancer survivors undergoinghormonal therapy presents someunique challenges. These womenhave all faced their mortality andcontinue to live with the ongoingpsychological stress of the possibil-ity of cancer recurrence. The womenin our Yoga groups have completedtheir initial treatment for breast can-cer, which includes surgery(lumpectomy or mastectomy andpossibly lymph node dissection),followed by radiation and/orchemotherapy. When the originalcancer cells (estrogen receptor posi-tive, ER+) are fueled by estrogen,hormonal treatment is prescribed for

a number of years (generally 5 ormore). The medications act toreduce, as much as possible, theamount of estrogen in a woman’sbody.

In this study, 50% of the womenin the Yoga group had receivedchemotherapy for their breast can-cer. Over 60% of the women in thisgroup had also received radiationtherapy in their cancer treatment.The range of time since treatmentwas three months to eight years.Two of the women in the Yoga grouphad also undergone reconstructivebreast surgery using their own tis-sues as a transplant (TRAM flap). Inthe TRAM flap procedure, the lowerbelly skin, fat, and part of the trans-verse rectus abdominis muscle areremoved and sculpted to make a newbreast.

These treatments can leavewomen feeling emotionally andphysically traumatized, with theirsense of femininity compromised.Chemotherapy often causes a pre-menopausal woman to go intomenopause. Hormonal therapy canhave ongoing side effects, such ashot flashes, mood swings, difficultysleeping, sexual side effects, andjoint stiffness. There also are numer-ous physical consequences of treat-ment, many related to the chest andarm. A mastectomy with lymphnode dissection often results in verytight pectoralis major and minormuscles, as well as tightness in allmuscles that intersect the armpit.This tightness can then draw thehumerus (upper arm) bone forwardinto internal rotation, and thescapula (shoulder blade) into pro-traction, creating weak and over-stretched rhomboid muscles. Rangeof motion and strength in theaffected arm can be decreased bothinitially following treatment, and,

for many women, for years aftertreatment.

Women also typically experienceloss of sensation and awareness in theaffected side in the armpit/chest area.There is often tightness of the inter-costal muscles of the front and sideribcage, as well as tightness in thepectoralis muscle. These changes canreduce the capacity to fully inhaleand expand the ribcage. Manywomen experience asymmetry of theupper body. Lymphedema, a possibleside effect of lymph node dissectionor removal, can cause a swollen andpainful arm. One of the women in thestudy had lymphedema, and she worea compression sleeve during the Yogaclass to minimize edema.

Breast reconstruction, whiledesirable for many reasons, can alsoresult in residual discomfort. Diffi-culties following this surgery includethe loss of range of motion in trunkextension, as well as tightness in sidebending and twisting. There may besome weakness of the abdominalmuscles due to removal of part of thetransverse rectus abdominis for usein the TRAM flap procedure.

The Yoga Intervention

Our intervention focused on twoimportant benefits for cancer sur-vivors: meeting the recommendedguidelines for physical activity andinducing the relaxation response.

Our class was taught as a begin-ning level Iyengar Yoga class, as theIyengar system of Yoga is well suitedto meet the needs of these women.Attention to alignment and symmetry,the use of props, and careful sequenc-ing all improve stamina, strength,flexibility, and confidence, whiledecreasing stress and side effects.

The women in this study had noprevious experience with Iyengar


Yoga. Because of the advanced ageof many of the women, and thephysical challenges associated withaging and/or previous injuries notassociated with breast cancer sur-vivorship, the class was taken at aslower pace than would be expectedfor a younger group without theseconsiderations. Some poses wereadapted to the age and fitness levelof the women. Modifications toposes also were made on an individ-ual basis due to neck, knee, and rota-tor cuff conditions, as well as lowback pain. Approximately 50% ofthe women had high blood pressurethat was controlled by medication,and this also was taken into accountwhen sequencing the classes.

Each class started with a check-in period to discuss any questionsor concerns, and this discussionwas followed by 5 minutes ofseated meditation. After medita-tion, Yoga philosophy was intro-duced. An active âsana practicefollowed meditation, and was com-pleted with a restorative pose and10 minutes of shavâsana. Eachclass closed by chanting om in aseated position.

The following types of poseswere included over the eight-weekcourse:

Standing poses. Standing posesincluded: ardha-chandrâsana (halfmoon pose) with supporting arm onchair seat, prasârita-pâdottânâsana I(wide-legged standing forward bend),tâdâsana (mountain pose), utkatâsana(chair pose, or fierce pose), utthita-pârshvakonâsana (extended sideangle pose), utthita-trikonâsana (ex-tended triangle pose; see Figure 1),vîrabhadrâsana I (warrior I pose),vîrabhadrâsana II (warrior II pose;see Figure 2), and vrikshhâsana (treepose). Props and variations for stand-ing poses included a chair, blocks, a

strap for arms overhead as needed,and using the wall for alignment andsupport.

Chest and shoulder openers.Because of the side effects associatedwith breast cancer treatment, chestand shoulder opening poses wereemphasized more in this class than ina general beginning Iyengar class.Specific instructions directed to thearmpit/chest area can help improveawareness and movement despitenerve damage and loss of sensation.Following are examples of chest andshoulder opening âsanas included inthe class: ûrdhva-hastâsana (raisedarms pose, arms overhead and par-allel); ûrdhva-baddhanguliyâsana(raised interlocked fingers pose, armsoverhead, palms to ceiling); go-mukhâsana (cow face pose, armswith belt; see Figure 3); viparîta-karanî (legs up wall pose with armsoverhead); the pectoralis musclestretch: at the wall, or supine overblanket, block, or bolster at shoulderblades (see Figures 4 and 5);setubandha-sarvângâsana (bridgepose with crossed bolsters andsacrum on a block; see Figure 6); andchatushpâdâsana (like bridge pose,with a belt to front ankles; see Figure7). Supported setubandha-sarvâng-âsana was emphasized in accordancewith a traditional Iyengar Yogaapproach, as described by Sparroweand Walden.41 According to theseauthors, this pose can improve regu-lation of blood pressure and attenuateanxiety, mood swings, hot flashes,tension headaches, and depression.Ûrdhva-mukha-shvanâsana (upwardfacing dog pose using chair andblocks) and plank pose were taughtnear the end of the 8-week session.

Inversions. Beginning inversionsincluded in the class were: adho-mukha-shvanâsana (downward fac-ing dog pose; see Figure 8),

uttanâsana (standing forward bend),prasârita-pâdottânâsana (wide-leg-ged standing forward bend),viparîta-karanî (legs up the wall pose,

supported at the wall and unsupportedwith buttocks on one or two bolsters;see Figure 9). Inversions were empha-sized for their restorative effects.Viparîta-karanî was practiced regu-larly due to the ability of everyoneto achieve this pose, as well as forits many benefits. According to theteachings of B. K. S. Iyengar, vi-parîta-karanî can help calm nervesand balance the endocrine system42

and help with the regulation of bloodpressure.43 Shâlamba-sarvangâsana(shoulder stand) was not taught due tothe number of physical limitationspresent in the group. Had this not

Figure 1: Utthita-pârshvakonâsana (extendedside angle pose)

Figure 2: Vîrabhadrâsana II (warrior IIpose)


been the case, supported shoulderstand would have been taught near theend of the 8-week session.

Results

Reasons for participation. Thewomen in the Yoga group wereasked the primary reasons they vol-unteered to participate in a Yogastudy. Their answers included: adesire to try different things andhave new experiences, the oncolo-gist’s recommendation to partici-pate, the fact that the Yoga class waspart of a research study with thepotential to benefit other survivors,and a desire to gain health benefitsafter the physical and psychologicaltrauma from cancer treatment. Thewomen in the Yoga group were also

asked to state what they hoped toachieve by participating in the study.All respondents mentioned physicaloutcomes such as improved posture,reduced aches and pains, improvedflexibility, and improved physicalhealth. Sixty percent of the womenreported that they hoped to improvetheir ability to manage stress.

Appropriateness of the class forbreast cancer survivors. The sequenc-ing of the âsanas and progression ofthe classes were well tolerated by theparticipants. When asked if theywould have preferred a slower pacedclass with less demanding poses, over75% of the women responded that

they benefited from the structure ofthe class and would not prefer a moregentle Yoga class. One participantstated, “I am very grateful for the timespent in class, as I have renewedstrength, more mobility, a sense ofcaring about each other, and I wouldhighly recommend it to others, whichI have already done.”

Physical and psychological out-comes. Twenty-five percent of thewomen reported that Yoga practicerelieved the joint aches and shoulderstiffness associated with the sideeffects of hormonal treatment. All ofthe women reported that they feltless stressed immediately after class,compared with feelings of stresswhen they arrived for class. Eighty-eight percent of the women reportedthat they felt more relaxed in theirdaily lives, were more aware of theirbody posture, and had improvedbody image. Sixty-three percent ofthe women reported improved moodand less anxiety as an outcome ofthe Yoga practice. On a scale of

Figure 3: Gomukhâsana (cow face pose, armswith belt)

Figure 5: Pectoralis muscle stretch, armswith belt

Figure 8: Adho-mukha-shvanâsana (down-ward facing dog pose)

Figure 6: Setubandha-sarvângâsana (bridgepose with crossed bolsters and sacrum on ablock)

Figure 7: Chatushpâdâsana (like bridge pose,with a belt to front ankles)

Figure 4: Pectoralis muscle stretch, supineover blanket

Figure 9: Viparîta-karanî (legs up the wallpose, unsupported with buttocks on one ortwo bolsters)


1–10, where 1 is “not at all relaxed”and 10 is “very relaxed,” the abilityto relax the body in shavâsana wasrated as 8.5 ±1.8, the ability to relaxthe mind was rated as 8.4 ±1.4, andthe ability to achieve inner quiet wasrated as 8.9 ±1.3.

After the intervention. Due tothe brevity of the Yoga session (8weeks), we were interested inwhether the participants intended tocontinue their Yoga practice at homeand/or in formal Yoga classesoffered within the local community.On a scale of 1–10, where 1 is“unlikely” and 10 is “extremelylikely,” the intent to continue prac-ticing at home was rated as 6.2 ± 2.7and intent to continue practicing informal classes was rated as 5.5 ±3.4. Reasons given for not continu-ing practice included financial con-straints, family responsibilities,and/or job conflicts.

Discussion

The preliminary findings ofthis study indicate that the Yogaintervention was beneficial forimproving body image and reduc-ing self-reported symptoms ofstress in female breast cancer sur-vivors. Offering an active Yogapractice to this population createdopportunities for the practitioner toexplore physical and psychologicallimitations due to breast cancertreatment and/or other comorbidconditions.

The success of the Yoga inter-vention was highly dependent onthe Yoga instructor’s ability toevaluate the physical and cognitiveabilities of the students duringclass participation. Women whohad physical limitations, such asjoint range of motion restrictions,required modifications of the

poses. It was apparent from obser-vation that the emphasis onchest/shoulder opening poses pre-

sented the most challenges to thewomen. Women who had difficultyfollowing the verbal instructionsgiven in class required more tactileadjustments during âsana practice.

An active Yoga practice is partic-ularly promising because increasedphysical activity is associated with anumber of important physical andpsychological benefits for breastcancer survivors. This study demon-strates that an active Yoga practicetaught in the Iyengar tradition can besuccessfully offered to breast cancersurvivors who are at least threemonths post-chemotherapy treat-ment and who are receiving antie-strogen or aromatase inhibitorhormonal therapy.

Future Directions

We look forward to the contin-ued progress of this study and planto conduct quantitative analyses onthe effects of this Yoga interventionon the quality of life and selectedimmune indices of breast cancersurvivors. It is our hope that thesepreliminary investigations will pro-vide sufficient scientific evidence tosupport more rigorous and long-term research studies on the efficacy

of Yoga intervention for cancer sur-vivors.

Endnotes

1. Oken, B. S., S. Kishiyama, D. Zajdel,D. Bourdette, J. Carlsen, M. Haas, C.Hugos, D. F. Kraemer, J. Lawrence, andM. Mass. Randomized controlled trial ofyoga and exercise in multiple sclerosis.Neurology, 2004, 62:2058–2064.

2. Woolery, A., H. Myers, B. Sternlieb,and L. A. Zeltzer. Yoga intervention foryoung adults with elevated symptoms ofdepression. Alternative Therapies inHealth and Medicine, 2004, 10:60–63.

3. Brown, J. K., T. Byers, C. Doyle, et al.Nutrition and physical activity during andafter cancer treatment: An American Can-cer Society guide for informed choices.CA: A Cancer Journal for Clinicians, 2003,53:268–291.

4. Ibid, pp. 268–291.

5. Ries, L. A. G., M. P. Eisner, C. L.Kosary, B. F. Hankey, B. A. Miller, L.Clegg, A. Mariotto, E. J. Feuer, and B. K.Edwards. SEER cancer statistics review,1975–2001. Bethesda, Md.: National Can-cer Institute, 2004. URL: http://seer.cancer.gov/csr/1975_2001.

6. National Cancer Institute. Cancer con-trol and population sciences: Researchfindings. Washington, D.C.: NationalCancer Institute, 2003. URL: http://dccps.nci.nih.gov/ocs/prevalence/index.html.

7. Brown et al., op. cit.

8. Ries et al., op. cit.

9. American Cancer Society. Cancer sta-tistics 2005: A presentation from theAmerican Cancer Society. Washington,D.C.: American Cancer Society, 2005.URL: http://www.cancer.org/docroot/PRO/ c o n t e n t / P RO _ 1 _ 1 _ C a n c e r _ S t a t i s -tics_2005_Presentation.asp.

10. National Cancer Institute. Probabilityof breast cancer in American women.Washington, D.C.: National Cancer Insti-tute, 2005. URL: http://cis.nci.nih.gov/fact/5_6.htm.

11. Ries et al., op. cit.

12. Jemal, A., L. X. Clegg, E. Ward, et al.Annual report to the nation on the statusof cancer, 1975–2001, with a special fea-

The Yoga interventionwas beneficial for im-proving body imageand reducing self-re-ported symptoms ofstress in female breastcancer survivors.


ture regarding survival. Cancer, 2004,101:3–27.

13. Brown et al., op. cit. pp. 268–291

14. Brown et al., op. cit., pp. 268–291.

15. Irwin, M. L., A. McTiernan, R. N.Baumgartner, K. B. Baumgartner, L.Bernstein, F. D. Gilliland, and R. Ballard-Barbash. Changes in body fat and weightafter a breast cancer diagnosis: Influenceof demographic, prognostic, and lifestylefactors. Journal of Clinical Oncology,2005, 23:774–782.


17. U.S. Department of Health and HumanServices, Centers for Disease Control andPrevention, National Center for ChronicDisease Prevention and Health Promotion.Physical activity and health: A report of theSurgeon General. Atlanta, Ga.: U.S. Depart-ment of Health and Human Services, Cen-ters for Disease control and Prevention,National Center for Chronic Disease Preven-tion and Health Promotion, 1996, p. 5.

18. U.S. Department of Health and HumanServices, U.S. Department of Agriculture.Dietary guidelines for Americans. Washing-ton, D.C.: U.S. Department of Health andHuman Services, U.S. Department of Agri-culture, 2005, pp. 19–21.

19. Irwin, M. L., A. McTiernan, L. Bernstein,F. D. Gilliland, R. N. Baumgartner, K. Baum-gartner, and R. Ballard-Barbash. Physicalactivity levels among breast cancer survivors.Medicine & Science in Sports & Exercise,2004, 36:1484–1491.

20. Chlebowski, R.T., E. Aiello, and A.McTiernan. Weight loss in breast cancerpatient management. Journal of ClinicalOncology, 2002, 20:1128–1143.

21. Galvão, D. A., and R. U. Newton. Reviewof exercise intervention studies in cancerpatients. Journal of Clinical Oncology, 2005,23:899–909.

22. Holmes, D. M., W. Y. Chen, D. Feskanich,C. H. Kroenke, and G. A. Colditz. Physicalactivity and survival after breast cancer diag-nosis. Journal of the American Medical Asso-ciation, 2005, 293: 2479– 2485.


24. Rosenbaum, E., H. Gautier, P. Fobair,et al. Cancer supportive care, improvingthe quality of life for cancer patients. Aprogram evaluation report. Supportive

Care in Cancer, 2004, 12:293–301.

25. Cohen, L., C. Warneke, R. T. Fouladi,M. A. Rodriguez, and A. Chaoul-Reich.Psychological adjustment and sleep qualityin a randomized trial of the effects ofTibetan Yoga intervention in patients withlymphoma. Cancer, 2004, 100:2253–2260.

26. Shapiro S. L., R. R. Bootzin, A. J.Figueredo, A. M. Lopez, and G. E.Schwartz. The efficacy of mindfulness-based stress reduction in the treatment ofsleep disturbance in women with breast can-cer: An exploratory study. Journal of Psy-chosomatic Research, 2003, 54:85–91.

27. Kabat-Zinn, J. An outpatient program inbehavioral medicine for chronic painpatients based on the practice of mindfulnessmeditation: Theoretical considerations andpreliminary results. General Hospital Psy-chiatry, 1984, 4:33–47.

28. Speca, M., L. Carlson, E. Goodey, and M.Angen. A randomized wait-list controlledtrial: The effects of a mindfulness meditation-based stress reduction program on mood andsymptoms of stress in cancer outpatients.Psychosomatic Medicine, 2000, 62:613–622.

29. Shapiro et al., op. cit., pp. 85–91.

30. Carlson, L. E., M. Speca, K. D. Patel, andE. Goodey. Mindfulness-based stress reductionin relation to quality of life, mood, symptomsof stress and levels of cortisol, dehy-droepiandrosterone sulfate (DHEAS) andmelatonin in breast and prostate cancer outpa-tients. Psychoneuroendocrinology, 2004,9:448–474.

31. Ibid.

32. Benson, H., J. F. Beary, and M. P.Carol. The relaxation response. Psychia-try, 1974, 37:37–45.

33. Esch, T., G. L. Fricchione, and G. B.Stefano. The therapeutic use of the relax-ation response in stress-related diseases.Medical Science Monitor, 2003, 9:RA-23–34.

34. Ibid., pp. RA23–34.

35. Benson et al., op. cit., pp. 37–45.

36. Esch et al., op. cit., pp. RA23–34.

37. Blank, S. E., and J. K. Krieger. Physi-ological responses to Iyengar Yoga per-formed by trained practitioners. (Underreview.)

38. Galvão and Newton, op. cit., pp.899–909.

39. Blank, S. E., J. L. Banasik, M. A.Crowe, M. Matson, J. C. Nichols, R. Ben-del, and M. R. Haberman. Immune andpsychosocial outcomes in stage II-IVHER-2+ breast cancer survivors followingan 8-week complementary yoga interven-tion. 11th Annual Meeting of the Psy-choNeuroImmunology Research Society,Titisee, Germany, 2004.

40. Crowe, M. A., M. R. Haberman, J. L.Banasik, J. C. Nichols, M. Matson, and S.E. Blank. Complementary yoga interven-tion increases nuclear NF-kB in stimu-lated lymphocytes of women with stageII-IV HER-2+ breast cancer. 11th AnnualMeeting of the PsychoNeuroImmunologyResearch Society, Titisee, Germany, 2004.

41. Sparrowe, L., and P. Walden. TheWoman’s Book of Yoga and Health: ALifelong Guide to Wellness. Boston,Mass.: Shambhala Publications, 2002, pp.51, 80.

42. Ibid.

43. Iyengar, B. K. S. The Path to HolisticHealth. London: Dorling Kindersley,2001, p. 216.

© Sally E. Blank, Jacqueline Kittel,and Mel R. Haberman 2005

Please address correspondence to:

Sally E. Blank, Ph.D.

Associate Professor and Director

Program in Health Sciences

Washington State Univ. Spokane

P.O. Box 1495

Spokane, Washington 99210-1495

Phone: 509-358-7633

Fax: 509-358-7627

Email: [email protected]

Websites:http://www.exercisescience.spokane.

wsu.edu http://www.spokane.wsu.edu/academic/exercisemetabolism

Documents

Active Practice of Iyengar Yoga as an Intervention for Breast Cancer