Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 53  |  Issue : 2  |  Page : 82-90

Effect of yoga therapy on psychological distress and quality of life in head-and-neck cancer patients undergoing radiotherapy


1 Department of Psycho-Oncology, HCG NCHRI Cancer Centre, Nagpur, Maharashtra, India
2 HCG NCHRI Cancer Centre, Nagpur, Maharashtra, India
3 Ex- Faculty, Community Medicine Department, Government Medical College, Nagpur, Maharashtra, India

Date of Submission04-Sep-2021
Date of Acceptance09-Oct-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Anjali Mangesh Joshi
Khasra No. 50, 51, Mouja Wanjri, Bande Nawaz Nagar, Near Automotive Square, Kalamna Ring Road, Nagpur - 440 026, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ym.ym_97_21

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  Abstract 


Context: Significant psychological morbidity with stress, depression, and anxiety has been reported in head-and-neck cancer (HNC) patients undergoing curative treatment. Failure to detect and treat psychological distress affects the outcomes of cancer therapies and decreases patients' quality of life (QoL). Studies have reported the benefits of yoga for anxiety, symptom severity, and distress in cancer patients.
Aims: To identify the effects of yoga therapy on psychological distress and QoL in HNC patients undergoing radiotherapy.
Settings and Design: Single-group, pretest posttest study in a clinical setting.
Subjects and Methods: Psycho-Oncology Assessment Questionnaire, Distress Thermometer, European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 version 3.0, and EORTC QLQ-H&N35 questionnaires were administered to HNC patients (n = 22) before and after yoga intervention during 6 weeks of radiotherapy. The yoga intervention included loosening practices, asana, pranayama, and meditation.
Statistical Analysis: Data were analyzed in statistical software - STATA, version 10.1 (2011).
Results: Significant reduction in psychological distress (p = 0.0001) and improvement in the QoL (p = 0.0001) was observed. Significant improvement in physical, emotional, cognitive, social, and role functioning (p = 0.0001) was observed. Significant reduction in QLQ-C30 symptom subscale scores of insomnia, pain, appetite loss, and fatigue (p = 0.0001) was observed. Significant reduction in H&N35 symptom subscale scores related to swallowing, opening the mouth (p = 0.0001), trouble with social eating, trouble with social contact, and felt ill (p < 0.05) was observed.
Conclusion: Yoga therapy intervention significantly reduced the psychological distress, improved the QoL, improved functions, and reduced symptoms in HNC patients undergoing radiotherapy. Further validation is required by conducting randomized controlled trials with a larger sample size.

Keywords: Head-and-neck cancer, psychological distress, quality of life, radiotherapy, yoga therapy


How to cite this article:
Joshi AM, Mehta SA, Mehta AO, Ughade SN, Randhe KS. Effect of yoga therapy on psychological distress and quality of life in head-and-neck cancer patients undergoing radiotherapy. Yoga Mimamsa 2021;53:82-90

How to cite this URL:
Joshi AM, Mehta SA, Mehta AO, Ughade SN, Randhe KS. Effect of yoga therapy on psychological distress and quality of life in head-and-neck cancer patients undergoing radiotherapy. Yoga Mimamsa [serial online] 2021 [cited 2022 May 28];53:82-90. Available from: https://www.ym-kdham.in/text.asp?2021/53/2/82/333360




  Introduction Top


Head-and-neck cancer (HNC) is emerging as a major health problem in India, comprising about 30% of all the cancers in India. Asia, especially India, has around 57.5% of global HNC patients (Kulkarni, 2013). Patients with HNC have been reported to have disproportionately high amounts of emotional distress because of the possibility of physical disfigurement from disease progression and/or treatment. It is also caused by the impairment of basic human functions such as eating, speaking, and breathing (Pandey, Devi, Ramdas, Krishnan, & Kumar, 2009). Distress has been shown to significantly affect the health-related quality of life (HRQoL) and the occurrence of specific symptoms (Lewis, Salins, Kadam, & Rao, 2013). Failure to detect and treat psychological distress affects the outcomes of cancer therapies, decreases patients' QoL, and increases health-care costs (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi, 2001). Therefore, it is necessary to identify high-risk patients through psychosocial screening to provide early intervention.

Originated in India more than 5000 years ago, yoga is a science of right living that combines exercise (yogasana), breathing (pranayama), proper diet, relaxation, meditation and is intended to be incorporated into daily life. Yoga has been suggested as a safe, feasible, and potentially effective intervention for improving mood and reducing symptom severity in HNC patients (Adair, Murphy, Yarlagadda, Deng, Dietrich, & Ridner, 2018). Studies have consistently reported the benefits of yoga in reducing stress (Pattnaik, Prasad, Jyotirmay, & Nishant, 2020) and improving QoL (Bakshi & Goyal, 2021) in cancer patients.

Hypothesis

The present study was undertaken with the hypothesis that, a yoga intervention would reduce the psychological distress and improve QoL in HNC patients undergoing radiotherapy.

Objectives

To evaluate the effects of a 6-week yoga therapy program on the following parameters in HNC patients undergoing radiotherapy.

  • Psychological distress measured by distress thermometer
  • QoL measured by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL Questionnaire and QLQ-H&N35 (the HNC module).



  Subjects and Methods Top


Study design

This was a single-group, pretest posttest study carried out in a clinical setting at a cancer hospital in central India. Institutional Ethics Committee approval was taken. The study period was from December 2019 to March 2020. The convenience sampling method was used for the selection of study subjects. The patients coming to the hospital for radiotherapy during this period were enrolled for the study. The concept of the study was explained to the patients and their written informed consent was taken.

Sample size

Sample size estimation was done considering pretreatment and posttreatment differences in mean HRQoL scores from baseline to 6 weeks as the main outcome measure. A sample size of 23 subjects was considered sufficient for detecting a significant reduction of 22.91 in mean scores (Karimi et al., 2019) with 90% power and 95% confidence interval. Accounting for anticipated losses to follow-up in prospective visits, we recruited a sample of 34 subjects in this study [Figure 1].
Figure 1: Schematic representation of methodology

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Study participants

Inclusion criteria

  • Diagnosed with HNC (≤ Stage III)
  • HNC patients receiving radiotherapy with a curative intent
  • Between 20 and 75 years of age
  • Functional ability as per Eastern Cooperative Oncology Group Score 0–2
  • Distress thermometer score ≥5.


Exclusion criteria

  • Extreme mobility problems
  • A major psychiatric or neurological illness
  • Any other comorbid condition affecting the patients' participation in yoga
  • Patients who underwent tracheostomy and using the tracheostomy tube for breathing
  • Disease progression and serious complications during treatment.


Data collection tools

Permission to use EORTC questionnaires was obtained from the EORTC through email. The patients' responses were recorded using the interview technique by a clinical psychologist. The following questionnaires already validated elsewhere were administered before and after yoga intervention.

Psycho-Oncology Assessment Questionnaire

This included demographic information, detailed medical history, plan of treating doctor, social and family details, lifestyle including diet, sleep, psychological details about mood, behavior, and thought process.

Distress thermometer

This screening tool is used for oncology patients to improve the identification, management, and treatment of psychological distress. The level of distress felt in the past week is recorded on the scale of 0–10 scale where zero point means “no distress” and point 10 means “extreme distress.” A score of 4 or above indicates the need for intervention.

European Organization for Research and Treatment of Cancer QLQ-C30 version 3.0

This is an integrated system for assessing the HRQoL of cancer patients. The core questionnaire, the QLQ-C30 is a generic questionnaire of 30 items associated with different disease-specific modules (Aaronson et al., 1993). It has 4-point scales coded with the response categories “not at all,” “a little,” “quite a bit,” and “very much.” for the first 28 items and “very poor” to “excellent” on a 7 point Likert scale for the remaining 2 items.

European Organization for Research and Treatment of Cancer QLQ-H&N35

This is a supplementary questionnaire module of 35 items to be administered with the QLQ-C30. It has seven multi-item scales that assess pain, swallowing, senses (taste and smell), speech, social eating, social contact, and sexuality. Besides, 11 single items assess problems with teeth, opening the mouth, dry mouth, sticky saliva, coughing, feeling ill, use of painkillers, nutritional supplements, or a feeding tube, weight loss, and weight gain. It has 4-point scales coded with the response categories “not at all,” “a little,” “quite a bit,” and “very much.” for the first 30 items while “no” and “yes” responses for the remaining 5 items.

Yoga for Cancer Health Questionnaire

This questionnaire was used to assess the patients' medical condition concerning yoga practice. The presence of any comorbid condition, physical limitation, restriction of movements, or any other specific problem that could affect yoga practice was evaluated by the yoga therapist.

The yoga therapy intervention

Yoga is a complex intervention comprising different practices. The yoga program in our study aimed to develop a sense of calmness and relaxation to cope with everyday stressful life situations. Each session of 45 minutes included loosening practices (sharir sanchalan), gentle yoga poses with awareness (yogasana), yogic relaxation in the corpse pose (shavasana), regulated breathing (pranayama), Om chanting, and meditation. The details of yoga practices are given in [Table 1].
Table 1: Details of yoga practices

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The patients attended a minimum of 3 in-person supervised and customized yoga sessions per week for 6 weeks during their radiotherapy and practiced at home on all the remaining days. Each supervised session was administered by a trained yoga therapist either before or after radiotherapy.

For home practice, handout materials in the local language and audio of guided meditation in the yoga therapist's voice were provided to the patients. They maintained a diary of daily yoga practice for 6 weeks. Daily telephonic follow-up of the participants was done by the cancer counselor who was a member of the research team. Reminders to practice yoga were given by telephone calls and text messages daily.

Statistical analysis

Data were analyzed in statistical software -StataCorp, 4905 Lakeway Drive, College Station, Texas 77845, USA . Paired t-test was used to compare pretest and posttest differences in scores. p-value was set at 0.05 level for determining statistical significance.


  Results Top


[Table 2] describes the demographic characteristics of the study population (n = 22) including age, gender, clinical diagnosis, comorbidities, previous surgery, concurrent treatment, earlier exposure to yoga, and ease of movement. Out of 34 enrolled patients, 22 patients who completed 6 weeks of intervention were included in the pre-post analysis.

The results of this study indicate that 6 weeks of yoga therapy during radiotherapy resulted in a significant reduction in psychological distress (p = 0.0001; [Table 3] and [Figure 2]] and improvement in the QoL [p = 0.0001; [Figure 3]]. The effect size (in terms of percentage improvement) was 39.65% and 74.24%, respectively. Significant improvements in physical, emotional, cognitive, social, and role functioning (p = 0.0001) were observed [Figure 4]. The effect size was high for emotional (131.90%), role (100%), and social functioning (81.67%) while 31.98% for physical and 24.53% for cognitive functioning. A significant reduction in QLQ-C30 symptom subscale scores of insomnia, pain, appetite loss, and fatigue (p = 0.0001) was observed [Figure 5]. The effect size was 79.42% for insomnia, 70.26% for pain, 70.26% for appetite loss, and 49.18% for fatigue [Table 4].
Table 2: Demographic characteristics of study population (n=22)

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Table 3: Comparison of mean pre and post distress thermometer scores

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Figure 2: Comparison of mean pre and post distress thermometer scores

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Figure 3: Comparison of mean pre and post global health status scores on European Organization for Research and Treatment of Cancer QLQ-C30 scale

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{Figure 4
Figure 5: Comparison of mean pre and post scores on European Organization for Research and Treatment of Cancer QLQ-C30 symptoms scale for significant symptoms

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}
Table 4: Comparison of pre and post mean scores of European Organization for Research and Treatment of Cancer QLQC30 subscales

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A significant reduction in H&N35 symptoms subscale scores was observed [Figure 6]. These symptoms were related to swallowing, opening mouth (p = 0.0001), trouble with social eating, trouble with social contact, and felt ill (p < 0.05). The effect size was 51.60% for swallowing, 53.56% for opening mouth, 37.50% for trouble with social eating, 56.67% for trouble with social contact, and 53.63% for felt ill [Table 5].
Figure 6: CComparison of mean pre and post scores on European Organization for Research and Treatment of Cancer H&N35 scale for significant symptoms

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Table 5: Comparison of pre and post mean scores of European Organization for Research and Treatment of Cancer H&N35 subscales

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No significant improvement in QLQ-C30 symptom subscale scores of nausea, vomiting, dyspnea, constipation, diarrhea, financial difficulties was observed. No significant improvement in H&N35 symptom subscale scores of pain, sense problem, speech problem, sexuality, teeth, dry mouth, sticky saliva, coughing, need for painkillers, nutritional supplements, feeding tube problems, weight loss, and weight gain was observed.


  Discussion Top


In our study, a significant reduction in psychological distress and improvement in QoL in HNC patients after yoga intervention was observed. These findings are in agreement with studies that reported the efficacy of yoga intervention in reducing stress levels of oral cancer patients (Pattnaik et al., 2020; Bakshi & Goyal, 2021) and improving mood and reducing symptom severity in HNC patients (Adair et al., 2018).

HNC patients experience high levels of emotional distress because of impairment of basic human functions such as eating, speaking, breathing, and physical disfigurement from disease progression and/or treatment (Pandey et al., 2009). In our study, it was observed that those patients who had undergone surgery for the malignancy (n = 20) had facial deformities, impairment of speech, and eating difficulties. These factors affect the functioning and QoL adversely. Improvement in function and relief from symptoms can reduce psychological distress and improve the QoL. The effect of yoga on physical, emotional, cognitive, social, and role functioning along with a multitude of symptoms such as fatigue, pain, insomnia, swallowing, opening the mouth may have contributed to psychological outcomes and QoL. Yoga improves QoL by reducing stress, inducing relaxation, and helping cancer patients perform daily routine activities (Ülger & Yağlı, 2010). It also reduces fatigue, improves physical function, and buffers changes associated with radiotherapy (Cohen et al., 2011). Yoga is also suggested to be a prophylactic intervention in the initial stages of treatment for improved QoL outcomes in the future (Vadiraja et al., 2009).

Our observations are in agreement with a few studies on the effectiveness of yoga in HNC patients and survivors. Yoga has been found to be effective in the reduction of symptom burden in HNC survivors following a tailored hatha yoga program (Adair et al., 2018). Milbury et al. (2019) reported the effectiveness of yoga intervention for cancer-related symptoms, depressive symptoms, fatigue, and overall QoL in glioma patients undergoing radiotherapy.

Our results are also consistent with a study, where an integrated yoga program was shown to be effective in reducing psychological morbidity, distressful symptoms, toxicity, and improving the QoL in breast cancer outpatients undergoing radiotherapy (Vadiraja et al., 2009).

Mechanism of yoga practices

The reduction in pain and physical symptoms can be attributed to the strengthening of the muscles, the stability of the joints, reduction of stress in a specific area because of improvement in the posture, and antistress effect of yoga that may work synergistically to alleviate pain by regulating sympathetic and parasympathetic tone (Wang et al., 2018).

Improvement in physical function can be because of the loosening practices and yoga postures. Loosening practices mobilize the joints and strengthen the periarticular muscles (Ebnezar, Nagarathna, Yogitha, & Nagendra, 2012). Yoga postures reduce tension or stiffness in the muscles and joints and improve blood circulation and range of movement.

Several mechanisms of different yoga practices in reducing distress have been proposed. It has been suggested that yoga helps in managing psychological distress through the reduction in cortisol level and modulating circadian patterns of stress hormones (Raghavendra et al., 2009). The relaxation pose shavasana blunts the sympathetic response and enhances parasympathetic activity (Madanmohan, Udupa, Bhavanani, Krishnamurthy, & Pal, 2002). Slow-paced pranayama reduces stress, anxiety, anger, exhaustion, depression and improves the QoL (Brown, Gerbarg, & Muench, 2013). The yoga breathing practices increase parasympathetic dominance (Pramanik, Sharma, Mishra, Mishra, Prajapati, & Singh, 2009; Jerath, Edry, Barnes, & Jerath, 2006) and improve vagal tone and production of theta waves in the brain (Jerath et al., 2006).

Bhramari pranayama and Om chanting have a calming effect on the mind. They induce tranquility (Srivastava, Goyal, Tiwari, & Patel, 2017), help in stabilizing the brain, increase energy, and improve mind-body relaxation within minutes of practice (Gurjar, Ladhake, & Thakare, 2009). Chanting “Om” involves slow breathing, airway resistance, and vibrational effects, which increase vagal tone and physiologic relaxation (Telles, Nagarathna, & Nagendra, 1995).

Meditation is believed to reduce anxiety because of activation of the anterior cingulate cortex, ventromedial prefrontal cortex, and anterior insula (Zeidan & Vago, 2016). Meditation is found to be beneficial in reducing anxiety, depression, and emotional distress in HNC patients during their radiation therapy (Boxleitner, Jolie, Shaffer, Pasacreta, Bai, & McCorkle, 2017). In our study, apart from supervised sessions thrice a week, the participants practiced home meditation using guided audio in the yoga therapist's voice. It was investigated in a study (Boxleitner et al., 2017), that the method of instruction in meditation, with a coach or self-meditation with guided audio, did not seem to affect the outcome.

Safety considerations

General safety

The safety of the participants was given primary consideration. Patients' health was monitored by the radiation oncologist throughout radiotherapy. A few patients' health deteriorated due to disease progression and side effects of the treatment (n = 5). They were unrelated to yoga intervention. Appropriate medical care was provided for them. Since the study was carried out when COVID-19 pandemic had just started, the COVID protocol was strictly followed. Group sessions were avoided.

Safety-related to yoga intervention

Careful evaluation of the patients' medical history was made before starting the yoga intervention. The presence of comorbidities, whether undergoing concurrent chemotherapy and associated side effects of treatment were considered. The yoga practices included in the intervention were gentle and calming. Since patients undergoing cancer treatment often experience fatigue, vigorous, and dynamic yoga postures were avoided. Hyperventilation practices such as kapalbhati and bhastrika pranayama were also avoided. Yoga intervention was customized to suit the specific health conditions of the patients. The yoga poses were modified if required to ensure the safety of the patients. Chair yoga poses were considered for patients with physical limitations such as paresis of arm and leg (n = 1), stiffness in the back, arms, and shoulders (n = 4). The use of props such as cushions and blankets for relaxation poses was encouraged to enhance relaxation. The yoga intervention was tolerated well by the patients.

Challenges faced

A lot of misconceptions about yoga are prevalent in the population. Yoga is often perceived as only physical exercise by many. While screening, it was observed that many patients lacked interest because they felt they were not “fit enough” to practice yoga. Moreover, they declined to participate in the study since yoga was not a priority for them. The dropout rate was high due to health deterioration because of the disease and treatment, time constraints, lack of interest in yoga, and logistic challenges. Six patients were undergoing concurrent chemotherapy. The adverse effects of the treatment were more in these patients leading to dropout from the study. Because of the COVID-19 pandemic and the lockdown, a few patients had difficulty in attending the supervised yoga sessions. However, adherence to the intervention and overall motivation for a yoga practice at home was high. Other challenges were limited funding and personal resources.

Limitations of the study

This was a single group study. The sample size was small hence study findings may have limited generalizability to only those patients seeking care at study settings like ours. The possibility of bias cannot be ruled out as we relied on self-reported measures of psychological distress and QoL. The patients were expected to participate in the supervised yoga sessions with the yoga therapist at least thrice a week along with home practice for the remaining days. However, protocol violations and noncompliance by some patients were observed. Thus, inconsistency in attending all the required supervised sessions and daily home practice may have affected the outcome.

Strengths of the study

The existing scientific literature shows very limited evidence on the effect of a yoga intervention for HNC patients. Although a few studies have evaluated the effect of Individualized Mindfulness-Based Stress Reduction intervention (Pollard et al., 2017) and meditation-based programs for HNC patients undergoing active cancer treatment (Boxleitner et al., 2017), our review of the literature revealed very little published research on the effect of yoga therapy in HNC patients undergoing radiotherapy. To the best of our knowledge, this is the first study investigating the effects of yoga therapy in HNC patients in central India. It offers important preliminary evidence on the effects of yoga therapy in HNC patients undergoing radiotherapy. However, it needs to be substantiated with more directed work in this relatively less explored subject population in oncology settings.

Impact on practice

Yoga can be a safe intervention strategy for improving psychosocial health and QoL in a large population affected by HNC. The patients can derive long-term benefits of yoga in terms of symptom relief, psychological distress, improved QoL with a potential effect on the modulation of the course of the disease.


  Conclusion Top


Six weeks of yoga intervention as an add-on therapy for HNC patients undergoing radiotherapy was effective in significantly reducing the psychological distress and improving the QoL. It improved emotional, cognitive, social, and role functioning. A significant reduction in fatigue, pain, insomnia, and appetite loss was observed. Significant reduction in symptoms specific to HNC, such as swallowing, opening the mouth, trouble with social eating, trouble with social contact, and felt ill was also observed. Although the present study offers important preliminary evidence on the potential efficacy of yoga therapy during radiotherapy, further validation is required by conducting randomized controlled trials with larger sample size.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[27]



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Abstract
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