Yoga May Improve Treatment-related Symptoms in Patients with Chronic Chemotherapy-Induced Peripheral Neuropathy

According to the results of a recent study published in the Journal of Cancer Survivorship, yoga is a feasible non-pharmacological treatment modality in cancer survivors with chronic chemotherapy-induced peripheral neuropathy (CIPN) pain, but it cannot currently be considered as an efficacious treatment. Researchers from Dana-Farber Cancer Institute in Boston, and the University of Washington in Seattle, reported that compared with usual care, an 8-week yoga intervention led to statistically and/or clinically significant improvements in a number of patient-reported outcomes, including CIPN pain, fatigue, and depression, but no differences in changes in other patient-reported outcomes.

CIPN is a debilitating side-effect of neurotoxic cancer chemotherapy such as taxanes and platinum-based drugs, experienced by about 35% of patients for more than 3 months following chemotherapy. Effective treatments for CIPN pain are lacking. Patients are frequently prescribed pharmacological treatment, although there is no evidence that any drug is effective except duloxetine, the only agent recommended by the American Society of Clinical Oncology (ASCO), but infrequently prescribed to treat painful CIPN.

Yoga is one of several mind-body treatments being introduced by hospitals and cancer centers as part of an integrative approach to cancer management, based on evidence that yoga improves many aspects of quality of life, physiological outcomes, and biological processes. The Society for Integrative Oncology (SIO)/ASCO joint guideline on the use of integrative therapies during and after cancer treatment recommends yoga to improve cancer treatment-related symptoms including quality of life, mood, depression, fatigue, and sleep, all symptoms that cluster with CIPN. The National Comprehensive Cancer Network (NCCN) recommends considering yoga for improving some survivorship areas, including pain.

Researchers led by Robert Knoerl, PhD, RN, currently Assistant Professor in the Department of Health Behavior and Biological Sciences, at the University of Michigan School of Nursing, Ann Arbor, hypothesized that yoga would benefit patients with chronic CIPN pain because it focuses on improving strength and balance which could help alleviate the lower extremity sensory and motor symptoms associated with CIPN.  To test this hypothesis, they carried out a single-center pilot study in patients diagnosed with Stage I-IV breast, gastrointestinal, or gynecologic cancer who had completed taxane or platinum-based chemotherapy at least 3 months previously. All patients had self-reported ?4/10 worst CIPN pain over the week before recruitment. Regular yoga participants were excluded from the study. Eventually, 44 patients in total were randomized to an 8-week yoga program (28 patients) or usual care (16 patients).

The yoga intervention consisted of an initial one-on-one meeting with a trained yoga therapist at the Dana-Farber Center for Integrative Therapies and Healthy Living. This was followed by in-person group yoga sessions (one 45 minute per week), typically consisting of guided breathing exercises, upper and lower extremity stretching, and structured postures and movements to improve balance and strength (guided component), and prerecorded videos of yoga sessions and hand/foot stretches made available to participants by email (self-guided component). All exercises, stretches, and poses were modified for beginners. Usual care (controls) consisted of symptom management strategies without any study treatment or intervention.

After the start of the COVID-19 pandemic, the Dana-Farber Center for Integrative Therapies and Healthy Living closed to all appointments and programs in mid-March 2020. This impacted both study recruitment and in-person yoga sessions. In June, study participants switched to livestreamed yoga sessions delivered as Zoom webinars and participants continued to receive weekly calls from study staff.

Over the 8-week study period, 68% of the yoga intervention group completed ?12 sessions (average of 15 sessions completed). Participants appeared to prefer virtual yoga sessions, since the study showed greater accrual and adherence to virtual sessions compared with in-person sessions. This may have been due to travel barriers associated with accessing integrative oncology treatment, the researchers suggested.

During the study, yoga group participants reported significant improvements in CIPN pain, sensory CIPN, motor CIPN severity, physical function, and pain interference, but the improvements were not statistically significant compared with the usual care group. Yoga group participants also experienced improvements in depression and fatigue (statistically significant) and sleep and anxiety (nonsignificant) relative to usual care. These results did not differ between in-person and virtual session participants.

Dr. Knoerl and his colleagues acknowledged the limitations of their small study, which was carried out in mainly female, white, non-Hispanic patients and at one center, and which was complicated by changes that had to be made in the intervention format due to the COVID-19 pandemic. However, the virtual delivery of yoga sessions may have demonstrated the scalability of such interventions for diverse groups of cancer survivors who don’t have easy access to cancer management centers, they noted.

Overall, this study – led by a nurse scientist – points to the potential impact of yoga and other mind-body integrative therapies to treat CIPN pain. “Based on preliminary evidence suggesting that yoga appears to be a safe and feasible intervention for cancer survivors with chronic CIPN pain, oncology clinicians may consider referring patients to yoga for chronic CIPN pain management,” the researchers concluded.  Larger clinical trials are needed to evaluate the effect on clinical outcomes and to determine the efficacy of virtual yoga as well as the amount of yoga necessary and the appropriate active control comparison.