What are yoga and yoga therapy?

Aug 1

What is yoga?

Yoga is an ancient mind-body science that has been practiced in India for thousands of years. Historically, it was a contemplative practice aimed at self-transformation, but over the centuries, yoga practitioners recognized its remarkable potential to improve their physical and mental well-being. Fast forward to the twenty-first century, and today’s global yoga is widely known as a practice that reduces stress, promotes resilience, improves psychophysiological functioning, and prevents and manages lifestyle diseases.

The word yoga comes from the Sanskrit verb root yuj – “to yoke or connect.” In this context, it refers to the union of mind, body, and spirit, which a consistent yoga practice may facilitate. In the West, yoga often denotes a modern form of Haṭha yoga, a posture-based physical fitness, relaxation, and stress-relief practice. But in truth, there are many different styles and lineages of yoga and many disciplines within the practice. What most styles have in common, however, is their integrative approach that applies multiple yogic techniques simultaneously: breath regulation, mindfulness, meditative techniques, deep relaxation, and physical movement sequences that focus on stretching, strength, balance, and flexibility.

What is yoga therapy?

“Yoga Therapy rests under the broader umbrella of Yoga; it is neither separate from nor greater than Yoga” (Yoga Therapy Today, 2019, p. 44).

Although all yoga is potentially therapeutic and healing, yoga therapy is the specific application of yogic tools—postures/exercises, breathwork, meditation techniques, and more—to address an individual’s physical, mental, and emotional needs. The International Association of Yoga Therapists (IAYT)—the organization that credentials yoga therapists—defines yoga therapy as “the process of empowering individuals to progress toward improved health and well-being through the application of the teachings and practice of yoga” (International Association of Yoga Therapists, 2023). IAYT-certified yoga therapists (C-IAYTs) have in-depth training to assess their patients/clients and develop a personalized care plan to address patient/client-specific goals, medical conditions, and physical limitations. Yoga therapists assess patients/clients through the yogic pancha kosha (five sheaths) model, a lens that views the human system in five intertwined layers, i.e., physical, mental, emotional, energetic, and spiritual. The kosha system aligns with the biopsychosocial-spiritual approach to wellness.

Yoga and yoga therapy

While all yoga is therapeutic, two types of yoga professionals work in oncology: registered yoga teachers (who teach group yoga classes) and certified yoga therapists (who typically offer one-on-one or small group customized sessions, often in a hospital or clinical setting). The main difference between the two is their level of training and scope of practice. There is a role for both teachers and therapists in cancer care, depending on their level of yoga training, oncology education, and experience working with patients/survivors with unique medical needs.

· Registered Yoga teachers. Yoga teachers typically complete a 200 or 500-hour generalized yoga training program offered by a yoga school registered with the Yoga Alliance (YA), the largest nonprofit association representing the yoga community (Yoga Alliance, 2023). After training, teachers can register with YA as an RYT-200 or RYT-500 yoga teacher. Yoga teachers generally teach group classes in yoga studios and gyms, where the teacher chooses the class theme, and students/clients rely on the teacher’s instruction for engagement. The teacher’s knowledge of yoga may be limited and generalized, and they may not be trained to work with medical populations.

· Certified yoga therapists. Certified yoga therapists typically graduate from IAYT-accredited yoga therapy programs that include a minimum of 800-1000 hours of didactic and clinical training (International Association of Yoga Therapists, 2023). After taking a board exam, yoga therapists can apply for certification from the International Association of Yoga Therapists (IAYT), the nonprofit governing body that issues the C-IAYT credential. Many yoga therapists are licensed physicians, nurses, psychologists, physical therapists/occupational therapists, or social workers, and now several universities offer a master’s or doctorate degree in yoga therapy. Yoga therapists have in-depth training to help them assess patients/clients, develop customized therapeutic yoga sessions, and ensure a safe practice. They work with patients/clients one-on-one or in small groups, but all patients are assessed at every session. Certified yoga therapists are bound by the IAYT professional code of ethics and scope of practice that allow them to work within their training experience and the boundaries set by the professional body. Yoga therapists work alongside medical professionals to support clients through assessment and plan of care, but they do not offer diagnostic advice or advice about cancer treatments.

All yoga professionals - both teachers and therapists - should have advanced training in oncology before working with people in active cancer treatment or when working with survivors who have comorbid conditions and medical risk factors.

Yoga and yoga therapy for supportive cancer care (1)

Many people with cancer and cancer survivors turn to integrative therapies, such as yoga and meditation, to help reduce stress and manage the side effects of their cancer treatment. Many hospitals offer yoga therapy to their patients during and after cancer treatment. Well-designed research shows that practicing yoga during and after treatment can improve a person’s quality of life by helping them:

get a better night’s sleep (Lin et al., 2019; Mustian et al., 2013; Cohen et al., 2004),
reduce stress and distress (Banerjee et al., 2007; Pruthi et al., 2012; Carlson et al., 2014),
manage anxiety (Rao et al., 2009; Raghavendra et al., 2007; Dhruva et al., 2012; Taso et al., 2014)
relieve fatigue (Bower et al., 2011; Chandwani et al., 2010; Kiecolt-Glaser et al., 2014; Armer & Lutgendorf, 2019; Raghavendra et al., 2009), and
boost energy and mood (Armer & Lutgendorf, 2019; Cramer et al., 2013), among many other benefits.

Several United States and European guidelines for supportive cancer care recommend yoga during and after cancer treatment:

The National Comprehensive Cancer Network (NCCN) recommends yoga for managing fatigue, nausea, and vomiting and suggests considering yoga for distress pain, cognitive function, and menopausal symptoms in cancer patients (Ettinger et al., 2021; Mao et al., 2022).
The American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology (SIO) jointly recommend yoga for adults with:

breast or head/neck cancer for general cancer pain or musculoskeletal pain, and breast cancer for arthralgia pain due to aromatase inhibitors (Mao et al., 2023),
breast cancer for depression, stress reduction, anxiety, and to improve quality of life during and after treatment (Greenlee et al., 2017).
breast cancer or other cancers for symptoms of anxiety and depression during and after treatment (Carlson et al., 2023).

The European Society for Medical Oncology (ESMO) recommends yoga for cancer-related fatigue (Fabi et al., 2020).

Clinical practice guidelines in cancer are essential because they help oncologists and patients make educated decisions about the safe, effective use of integrative therapies to support and enhance wellness, improve quality of life, and relieve cancer symptoms and its treatment. Yoga is also beneficial for caregivers. A yoga practice can support their health and well-being, providing valuable tools to manage stress, improve physical fitness, and enhance their overall quality of life while actively caring for their loved ones. Given this, yoga is an essential evidence-based therapy that should be offered to everyone during standard cancer treatment and beyond.

How does yoga work?

Yoga is a multicomponent practice, and the various yogic techniques work synergistically. Recent randomized controlled trials (gold standard research) show that yoga and meditation positively impact gene expression and reduce chronic inflammation and harmful stress hormones such as cortisol and norepinephrine (Leibel & Pitman, 2022, pp. 71-73). The physiological changes invoked by yoga work against the environmental forces that trigger chronic stress, known to damage DNA and promote cancer formation.

How can yoga therapy help people affected by cancer throughout their care?

Yoga therapy takes a holistic “mind-body-spirit” approach to address cancer-related side effects, benefiting patients at every stage of the cancer care continuum. In addition to the cancer-related symptoms described above, yoga therapy fosters resilience, empowerment, and self-care, nurturing a positive body image and integrating the mind, body, and spirit. With personalized approaches, it suits individuals at various stages of diagnosis, treatment, recovery, and survivorship. Integrated into comprehensive cancer care, it complements medical treatments, enhances overall well-being, and improves the quality of life for those affected by cancer and their loved ones. Certified yoga therapists who are highly trained in oncology can customize the yoga practice for people experiencing lymphedema, pain, fatigue, neuropathy, osteoporosis, bone metastases, limited range of motion, and other conditions.

What to expect from yoga therapy?

You can expect a personalized approach tailored to your needs and goals during a yoga therapy session. A yoga therapist will conduct an initial assessment to understand your medical history, current condition, and goals and preferences. Next, they will work with you to design a customized yoga practice that suits your abilities, physical limitations, and challenges. Your yoga therapy treatment plan may include various yoga practices, including gentle movement, breathing exercises, meditation, relaxation techniques, and lifestyle modifications. These practices aim to address specific concerns or symptoms you may be experiencing due to cancer or its treatment. Your yoga therapist will provide clear instructions and demonstrations, ensuring you perform the yoga postures and movements safely and comfortably. They may also incorporate modifications or props to accommodate any physical limitations. Most importantly, a yoga therapist will offer compassionate support throughout your sessions, encouraging you to listen to your body, practice self-care and compassion, cultivate mindfulness, and integrate relaxation practices into your daily life. The frequency and duration of your sessions may vary depending on your needs and preferences. You may practice yoga in person or virtually.

How can I be sure the yoga or yoga therapy professional working with me is suitably qualified?

A cancer diagnosis and treatment can carry various side effects that may require each yoga session to be modified to a patient/client’s unique needs, so finding a qualified yoga professional is essential. Advanced practice yoga teachers and certified yoga therapists working in cancer care should have completed not only the required hours to become registered yoga teachers or certified yoga therapists but also additional coursework in oncology and oncology yoga. You can find certified yoga therapists through the International Association of Yoga Therapists database (https://yogatherapy.health/find-a-therapist/) and registered yoga teachers through the Yoga Alliance website (https://www.yogaalliance.org/directory). When searching for a yoga professional, read their bios and summaries to see if they have training and experience with yoga and cancer. And be sure to talk to them before beginning a session and ask more about their yoga and cancer-specific training.

Limitations on scope of practice and potential side effects

Yoga has a good safety profile, but people in active cancer treatment (or who are finished with treatment but have lingering side effects) may have physical limitations imposed by surgery, chemotherapy, radiotherapy, hormone therapy, and comorbid conditions. Therefore, working with yoga professionals who have specialty training in oncology and experience working with people with cancer is essential. Before beginning a yoga practice, you should always get medical clearance to engage in physical activity. Be sure to tell your yoga therapist and yoga teacher about your cancer and your treatment (or the treatment you’ve already had). Avoid any yoga practices that cause discomfort and pain.

How to access yoga or yoga therapy for cancer support

Free yoga for cancer classes or recordings are available through multiple charities and charitable initiatives by yoga teachers with some examples below:

This is far from an exhaustive list, and it is worth contacting local and UK-wide cancer charities to see what is on offer, as well as checking the Oncio app Explore screen for our free event schedule from multiple charities and reviewing the Oncio yoga programs. You can find certified yoga therapists through the International Association of Yoga Therapists database (https://yogatherapy.health/find-a-therapist/).

Many US hospitals offer yoga and yoga therapy for people with cancer. Ask your healthcare provider for information or a referral to a qualified yoga professional. You can also find certified yoga therapists worldwide through the International Association of Yoga Therapists database (https://yogatherapy.health/find-a-therapist/). You can find registered yoga teachers worldwide through the Yoga Alliance website (https://www.yogaalliance.org/directory). When searching for a yoga professional, read their bios and summaries to see if they have training and experience with yoga and cancer. Be sure to talk to them before beginning a session and ask more about their yoga and cancer-specific training.

Expert content written and reviewed by:

The Executive Committee of the Society for Integrative Oncology (SIO) Yoga Special Interest Group (Yoga SIG):

● Smitha Mallaiah, Ph.D. (c), M.Sc., C-IAYT (MD Anderson Cancer Center)

● Tina Walter, B.S., C-IAYT (UC Health)

● Tina Paul, M.S., C-IAYT (Memorial Sloan Kettering Cancer Center)

● Kelli Bethel, P.T., D.P.T, C-IAYT (Maryland University of Integrative Health)

● Nancy Sinton, M.B.A., C-IAYT (International Association of Yoga Therapists)

● Leigh Leibel, Ph.D. (c), M.Sc., ACSM-CET, C-IAYT (Columbia University Irving Medical Center)

References

Armer, J.S. and Lutgendorf, S.K. (2019) ‘The impact of yoga on fatigue in cancer survivorship: A meta-analysis’, JNCI Cancer Spectrum, 4(2). doi:10.1093/jncics/pkz098.

Banerjee, B. et al. (2007) ‘Effects of an integrated yoga program in modulating psychological stress and radiation-induced genotoxic stress in breast cancer patients undergoing radiotherapy’, Integrative Cancer Therapies, 6(3), pp. 242–250. doi:10.1177/1534735407306214.

Berger AM, Mooney K, Aranha O, et al: NCCN Clinical Practice Guidelines in Oncology: Cancer-Related Fatigue. Version 1.2021. Available at https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf. (Accessed: 29 July 2023).

Bower, J.E., Garet, D., Sternlieb, B., Ganz, P.A., Irwin, M.R., Olmstead, R. and Greendale, G. (2011). Yoga for persistent fatigue in breast cancer survivors. Cancer, [online] 118(15), pp.3766–3775. doi:https://doi.org/10.1002/cncr.26702.

Carlson LE, Ismaila N, Addington EL, Asher GN, Atreya C, Balneaves LG, Bradt J, Fuller-Shavel N, Goodman J, Hoffman CJ, Huston A, Mehta A, Paller CJ, Richardson K, Seely D, Siwik CJ, Temel JS, Rowland JH. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline. J Clin Oncol. 2023 Oct 1;41(28):4562-4591. doi: 10.1200/JCO.23.00857. Epub 2023 Aug 15. PMID: 37582238.

Carlson, L.E., Doll, R., Stephen, J., Faris, P., Tamagawa, R., Drysdale, E., Speca, M. and Alberta Health Services (2014). Randomized Controlled Trial of Mindfulness-Based Cancer Recovery Versus Supportive Expressive Group Therapy for Distressed Survivors of Breast Cancer (MINDSET). [online] doi:https://doi.org/10.1200/JCO.2012.47.5210.

Chandwani, K.D., Thornton, B., Perkins, G.H., Arun, B., Raghuram Nagarathna, HR Nagendra, Wei, Q. and Cohen, L. (2010). Yoga improves quality of life and benefit finding in women undergoing radiotherapy for breast cancer. J Soc Integr Oncol, not known, 8(2), pp.43–55

Cohen, L. et al. (2004) ‘Psychological adjustment and sleep quality in a randomized trial of the effects of a Tibetan yoga intervention in patients with lymphoma’, Cancer, 100(10), pp. 2253–2260. doi:10.1002/cncr.20236.

Cramer, H. et al. (2013) ‘Yoga for depression: A systematic review and meta-analysis’, Depression and Anxiety, 30(11), pp. 1068–1083. doi:10.1002/da.22166.

Denlinger CS, Sanft T, Baker KS, et al: NCCN Clinical Practice Guidelines in Oncology: Survivorship. Version 3.2018. Available at https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. (Accessed: 29 July 2023).

Dhruva, A., Miaskowski, C., Abrams, D., Acree, M., Cooper, B., Goodman, S. and Hecht, F.M. (2012). Yoga Breathing for Cancer Chemotherapy–Associated Symptoms and Quality of Life: Results of a Pilot Randomized Controlled Trial. The Journal of Alternative and Complementary Medicine, 18(5), pp.473–479. doi:https://doi.org/10.1089/acm.2011.0555

Ettinger DS;Armstrong DK;Barbour S;Berger MJ;Bierman PJ;Bradbury B;Ellis G;Kirkegaard S;Kloth DD;Kris MG;Lim D;Markiewicz MA;Nabati L;Nesheiwat C;Rugo HS;Sorscher SM;Stucky-Marshal L;Todaro B;Urba S; (no date) Antiemesis. clinical practice guidelines in oncology, Journal of the National Comprehensive Cancer Network : JNCCN. Available at: https://pubmed.ncbi.nlm.nih.gov/19460282/ (Accessed: 29 July 2023).

Fabi, A. et al. (2020) ‘Cancer-related fatigue: ESMO clinical practice guidelines for diagnosis and treatment’, Annals of Oncology, 31(6), pp. 713–723. doi:10.1016/j.annonc.2020.02.016.

Greenlee, H. et al. (2017) ‘Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment’, CA: A Cancer Journal for Clinicians, 67(3), pp. 194–232. doi:10.3322/caac.21397.

International Association of Yoga Therapists (2023). Website: https://yogatherapy.health/what-is-yoga-therapy/ (Accessed 29 July 2023).

Kiecolt-Glaser, J.K., Bennett, J.M., Andridge, R., Peng, J., Shapiro, C.L., Malarkey, W.B., Emery, C.F., Layman, R., Mrozek, E.E. and Glaser, R. (2014). Yoga’s Impact on Inflammation, Mood, and Fatigue in Breast Cancer Survivors: A Randomized Controlled Trial. Journal of Clinical Oncology, 32(10), pp.1040–1049. doi:https://doi.org/10.1200/jco.2013.51.8860.

Leibel, L. (2023). “Yoga Therapy for Supportive Cancer Care.”

Leibel, L. and Pitman, A. (2022) Yoga therapy across the cancer care continuum. Handspring Publishing, pp. 71-73.

Lin, P.-J. et al. (2019) ‘Influence of Yoga on cancer-related fatigue and on mediational relationships between changes in sleep and cancer-related fatigue: A nationwide, multicenter randomized controlled trial of yoga in cancer survivors’, Integrative Cancer Therapies, 18, p. 153473541985513. doi:10.1177/1534735419855134.

Mao, J.J. et al. (2023) ‘Integrative medicine for pain management in oncology: Society for integrative oncology-ASCO guideline summary and Q&A’, JCO Oncology Practice, 19(1), pp. 45–48. doi:10.1200/op.22.00622.

Mustian, K.M. et al. (2013) ‘Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors’, Journal of Clinical Oncology, 31(26), pp. 3233–3241. doi:10.1200/jco.2012.43.7707.

Pruthi, S. et al. (2012a) ‘P02.175. A randomized controlled pilot study assessing quality of life, stress and feasibility of yoga practice in women newly diagnosed with breast cancer’, BMC Complementary and Alternative Medicine, 12(S1). doi:10.1186/1472-6882-12-s1-p231.

Raghavendra, R.M. et al. (2009) ‘Effects of a yoga program on cortisol rhythm and mood states in early breast cancer patients undergoing adjuvant radiotherapy: A randomized controlled trial’, Integrative Cancer Therapies, 8(1), pp. 37–46. doi:10.1177/1534735409331456.

Raghavendra, R.M., Nagarathna, R., Nagendra, H.R., Gopinath, K.S., Srinath, B.S., Ravi, B.D., Patil, S., Ramesh, B.S. And Nalini, R. (2007). Effects Of An Integrated Yoga Programme On Chemotherapy-Induced Nausea And Emesis In Breast Cancer Patients. European Journal Of Cancer Care, 16(6), Pp.462–474. Doi:Https://Doi.Org/10.1111/J.1365-2354.2006.00739.X.

Rao, M.R., Raghuram, N., Nagendra, H.R., Gopinath, K.S., Srinath, B.S., Diwakar, R.B., Patil, S., Bilimagga, S.R., Rao, N. and Varambally, S. (2009). Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: A randomized controlled trial. Complementary Therapies in Medicine, 17(1), pp.1–8. doi:https://doi.org/10.1016/j.ctim.2008.05.005.

Taso, C.-J., Lin, H.-S., Lin, W.-L., Chen, S.-M., Huang, W.-T. and Chen, S.-W. (2014). The Effect of Yoga Exercise on Improving Depression, Anxiety, and Fatigue in Women With Breast Cancer. Journal of Nursing Research, [online] 22(3), pp.155–164. doi:https://doi.org/10.1097/jnr.0000000000000044

Yoga Therapy (no date) Go to YogaTherapy.Health. Available at: https://yogatherapy.health/what-is-yoga-therapy/ (Accessed: 29 July 2023).

Yoga Alliance (2023). Available at: https://www.yogaalliance.org (Accessed 29 July 2023).

Yoga Therapy Today, Summer 2019. “Foundations for Practice: The Language of Yoga Therapy, p. 44.”

Nina Fuller-Shavel