CRITICALLY APPRAISED PAPER (CAP) Taso, C. J., Lin, H. S., Lin, W. L., Chen, S. M., Huang, W. T., & Chen, S. W. (2014). The effect of yoga exercise on improving depression, anxiety, and fatigue in women with breast cancer: A randomized controlled trial. Journal of Nursing Research, 22(3), 155 164. https://doi.org/10.1097/jnr.0000000000000044 CLINICAL BOTTOM LINE Chemotherapy is the predominant treatment used for patients with breast cancer. However, this method may physically and psychologically affect patients. A few side effects of chemotherapy include anxiety, depression, and increased fatigue. If these side effects are left untreated, they may significantly alter one s quality of life. Yoga is a form of exercise that incorporates the mind and body and has demonstrated positive effects on energy, flexibility, and well-being. Those diagnosed with breast cancer who are undergoing chemotherapy often report fatigue and psychological distress, which inhibit engagement in their everyday life. Occupational therapists frequently provide services to individuals with breast cancer in various settings, including hospitals, rehabilitation centers, and palliative care units. Properly trained occupational therapists can collaborate with their patients to identify the type of yoga that works best and teach or refer a specific yoga exercise as an intervention. These yoga interventions may be effective in reducing fatigue and strengthening particular muscles, tendons, and ligaments of patients with breast cancer. Furthermore, the reduction of fatigue may promote individuals engagement in their meaningful activities and daily roles. This Level I randomized controlled trial provides support for the utility of yoga exercise in conjunction with chemotherapy for patients with breast cancer. There are a few limitations in this study: Participants were not blind, both measures were self-report assessments, and followup was limited to 4 weeks after the conclusion of the intervention. Overall, this study indicates that yoga has feasibility and effectiveness in minimizing fatigue. Occupational therapists can use yoga exercise interventions to assist patients with breast cancer by reducing fatigue and restoring flexibility. RESEARCH OBJECTIVE(S) 1
Create a yoga exercise regimen suitable for women with breast cancer and examine whether its effects ease symptoms of anxiety, depression, and fatigue among women with breast cancer receiving chemotherapy DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Pretest posttest control group design; randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? Participants were recruited through purposive sampling from a population of women who received chemotherapy at Chi Mei Medical Center in Tainan, Taiwan, during a 5-month period in 2011. Seventy-nine participants were eligible; 60 participants consented to participate in the study. In the intervention group, out of 16 yoga sessions, 1 participant was able to attend 14 sessions, 2 participants were able to attend 13 sessions, and 3 participants were unable to join any of the yoga exercise sessions for medical or personal reasons. Inclusion criteria: Diagnosed with Stage 1 3 breast cancer Between 20 and 70 years of age Performance status between 0 and 2 in terms of activities of daily living and physical abilities (0 = fully active and no symptoms or minor symptoms of disease, 2 = ambulatory more than 50% of their waking hours) Lucid Able to read and write Able to communicate in Taiwanese and Mandarin Undergoing chemotherapy at the time of the research Had no yoga experience Had no previous mental health disorder Agreed to participate Had no open wounds Minimum of 1 month since breast cancer surgery Exclusion criteria: Diagnosis or return of suspected bone metastasis Hemoglobin level under 10mg/dL Platelet count under 50,000 At time of research, not taking any antidepressant, antianxiety, or other psychotropic 2
medications PARTICIPANT CHARACTERISTICS N=(Number of participants taking part in the study) 60 #/ % Male: 0/(0%) #/ % Female: 60/(100%) Ethnicity: Majority Taiwanese Disease/disability diagnosis: Stages 1 3 breast cancer INTERVENTION AND CONTROL GROUPS Group 1: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? All participants (in the control group and intervention group) obtained standard care and continued with their typical daily activities. 30 Group 2: Intervention group Brief description of the intervention How many participants in the group? Where did the intervention take place? The participants in the intervention group joined a yoga exercise program that was designed for patients with breast cancer. It strengthened particular muscles, tendons, and ligaments. Each session included 10 minutes of meditation and breathing exercises, 40 minutes of traditional yoga, and 10 minutes of cool-down exercises. Additionally, the intervention group was educated in the overview of the foundations of relaxation and body mind connectedness. 30 Various cancer centers in Taiwan 3
Who delivered? How often? For how long? Experienced instructors This information is unclear. The article indicates several times that the yoga intervention was administered two times a week for 1 hour each yoga exercise session. However, in one instance, the article states that the experimental group received daily yoga exercise. Total of 8 weeks during the chemotherapy treatment period INTERVENTION BIASES (Check yes or no, and include a brief explanation) Contamination: YES NO Co-intervention: Timing of intervention: YES NO Site of intervention: Explanation: Participants in the control group received standard care. Explanation: A number of participants (57% of the intervention group) stated that they practiced yoga one or more times per week at home. Explanation: Both groups were measured at pretest and at posttests (three) at the same time periods: before the intervention, at Week 4, at Week 8, and 4 weeks after the intervention was completed. Explanation: Interventions were administered in different cancer centers in Taiwan. Use of different therapists to provide intervention: Explanation: Experienced instructors administered all interventions and used the same standardized yoga techniques and postures. However, different instructors taught the interventions, which could have led to inconsistencies. Baseline equality: YES Explanation: Independent-sample t tests indicated insignificant variances NO between the groups in regard to anxiety, depression, and fatigue. MEASURES AND OUTCOMES Measure 1: Profile of Mood State Name/type of measure used: What outcome is measured? Profile of Mood State The researchers used this scale of 14 items to measure depression and anxiety experienced by the patients with cancer. 4
Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? Not Reported Not Reported Before the start of the intervention, at Week 4 of the intervention, at Week 8 of the intervention, and 4 weeks after completion of the intervention Measure 2: Brief Fatigue Inventory (Taiwan version) Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Brief Fatigue Inventory (Taiwan version) This 9-item questionnaire measures the psychological distress of patients with cancer who are undergoing chemotherapy, in relation to fatigue, the degree of fatigue, and how fatigue affects their daily life activities. Not Reported YES Not Reported Before the start of the intervention, at week 4 of the intervention, at week 8 of the intervention, and 4 weeks after the intervention was complete. MEASUREMENT BIASES Were the evaluators blind to treatment status? Was there recall or memory bias? Other measurement biases: N/A Explanation: Personnel who were not involved in the trial administered the randomized group assignments. However, there is potential bias, because details on the administration of the Profile of Mood and the Brief Fatigue Inventory were not reported. Explanation: Both measurement tools were self-report assessments. RESULTS List key findings based on study objectives: 5
After the yoga exercise intervention was complete, in comparison with the control group, the intervention group exhibited a decrease in overall fatigue (F = 75.49, p <.001) and a decrease in the impact of fatigue on daily life (F = 51.71, p <.001). No statistically significant measurement differences were found between the groups for depression (F = 1.29, p >.05) or anxiety (F = 2.7, p >.05). Was this study adequately powered (large enough to show a difference)? Explanation: The researchers used Statistical Software Sample Power 2.0 and analysis of covariance to calculate the number of samples required for each group. The calculation for each sample group was 30. Were the analysis methods appropriate? Explanation: The researchers used analysis of covariance or the Johnson Neyman method, as well as the chi-square test or Fisher s exact test. Were statistics appropriately reported (in written or table format)? Explanation: Statistics were provided in table and written format for fatigue levels and influence of fatigue on daily life. However, no tables were provided for statistics on depression and anxiety. Was participant dropout less than 20% in total sample and balanced between groups? YES NO Explanation: Three participants (10% of the intervention group, 5% out of both groups) did not attend the entire yoga exercise intervention because of medical or personal issues. All 30 participants of the control group completed the study and were analyzed. What are the overall study limitations? The study did not follow a double-blind approach because the intervention participants were not blind to the study and were aware they were receiving yoga intervention. This knowledge might have led to a Hawthorne effect, whereby participants might have yielded more positive answers than warranted. Moreover, the constrained quantity of variables restrained the synthesis and investigation of the impact of participants adaptive abilities and perspectives on the level of fatigue. CONCLUSIONS State the authors conclusions related to the research objectives. This study provides awareness of the effectiveness of this yoga intervention, because there is little research on implementing yoga exercise with patients who have breast cancer and are receiving chemotherapy. The results demonstrated positive outcomes when the tailored yoga exercise program was added to the standard care of the participants. Most important, the yoga exercise intervention seemed to minimize fatigue and the impact of fatigue on everyday life for 6
about 75% of the intervention group. The yoga exercise intervention did not significantly affect the anxiety and depression levels of the participants. However, the researchers indicated that the baseline scores for depression and anxiety were low before the intervention. The yoga exercise program was adapted to the needs of patients with breast cancer. Yoga may be better incorporated into cancer treatment through collaboration with patients and interdisciplinary teams in the identification of the appropriate form of yoga. Furthermore, longer follow-up studies should be implemented in future research to obtain additional information on the patients adaptability and outlook on the influence of fatigue. This work is based on the evidence-based literature review completed by Jennifer M. Tang, OTS, and Ashley Halle, OTD, OTR/L, faculty advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 7