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ORIGINAL ARTICLE The Journal of Nursing Research h VOL. 22, NO.

3, SEPTEMBER 2014

The Effect of Yoga Exercise on Improving


Depression, Anxiety, and Fatigue in
Women With Breast Cancer: A
Randomized Controlled Trial
Chao-Jung Taso1 & Huey-Shyan Lin2 & Wen-Li Lin3 & Shu-Ming Chen4*
Wen-Tsung Huang5 & Shang-Wen Chen6

1
PhD, Cancer Center, Chi Mei Medical Center & 2PhD, School of Nursing, Fooyin University & 3MSN, RN, Cancer
Center, Chi Mei Medical Center & 4PhD, RN, Assistant Professor, School of Nursing, Fooyin University &
5
MD, Cancer Center, Chi Mei Medical Center & 6MD, Cancer Center, Chi Mei Medical Center.

KEY WORDS:
ABSTRACT yoga, breast cancer, depression, anxiety, fatigue.
Background: Depression, anxiety, and fatigue are among the
most significant problems that influence the quality of life of patients
with breast cancer who receive adjuvant chemotherapy. Although
evidence has shown yoga to decrease anxiety, depression, and
Introduction
fatigue in patients with cancer, few studies on the effects of yoga Cancer is an important global health issue. New cases of can-
have targeted patients with breast cancer. Yoga interventions cer are estimated to reach 21.4 million per annum globally by
should be tested to promote the psychological and physical health 2030. Breast cancer is one of the most important diseases
of women with breast cancer. affecting women’s health worldwide (World Health Organi-
Purpose: This study examines the effectiveness of an 8-week
zation, 2011) and an increasingly important cause of cancer
yoga exercise program in promoting the psychological and physical and cancer mortality in Taiwan. In 2008, 8,136 of the 34,647
health of women with breast cancer undergoing adjuvant chemo- cancer diagnoses in women in Taiwan were breast cancer
therapy in terms of depression, anxiety, and fatigue. (Ministry of Health and Welfare, 2013). Surgery is the most
prevalent intervention for breast surgery, followed by adju-
Methods: A sample of 60 women with nonmetastatic breast
vant systemic therapy (Smith, 2013). Chemotherapy is the
cancer was recruited. Participants were randomly assigned into
either the experimental group (n = 30) or the control group (n = 30). most prevalent method used to treat breast cancer. However,
A 60-minute, twice-per-week yoga exercise was implemented for the side effects of this treatment interferes with the body’s
8 weeks as the intervention for the participants in the experimental metabolism and energy use, which increases tiredness, fa-
group. The control group received standard care only. tigue, anxiety, depression, and sensitivity to pain; patients
also experience diminished alertness during the day. Studies
Results: Analysis using the JohnsonYNeyman procedure found
that the yoga exercise reduced overall fatigue and the interference
indicate that 40%Y100% of women with breast cancer ex-
of fatigue in everyday life for the experimental group participants. perience depression, anxiety, emotional distress, and fatigue
Significant reductions were obtained after 4 weeks of intervention during chemotherapy (Stasi, Abriani, Beccaglia, Terzoli,
participation for those experimental group patients with relatively
low starting baseline values (baseline item mean value G 3.31 and
3.22, respectively) and after 8 weeks for most patients (approxi-
mately 75%) with moderate starting baseline values (baseline item Accepted for publication: July 28, 2013
mean value G 7.30 and 5.34, respectively). The 8-week intervention *Address correspondence to: Shu-Ming Chen, No. 151, Chin-Hsueh
did not significantly improve the levels of depression (F = 1.29, Rd., Ta-Liao District, Kaohsiung City 83102, Taiwan, ROC.
p 9 .05) or anxiety (F = 2.7, p 9 .05). Tel: 886(7) 7811151 ext. 5614; E-mail: wenlilin2012@gmail.com

Conclusions/Implications for Practice: The 8-week yoga Cite this article as:
exercise program developed in this study effectively reduced Taso, C. J., Lin, H. S., Lin, W. L., Chen, S. M., Huang, W. T., &
fatigue in patients with breast cancer but did not reduce depression Chen, S. W. (2014). The effect of yoga exercise on improving
depression, anxiety, and fatigue in women with breast cancer: A
or anxiety. Oncology nurses should strengthen their clinical health
randomized controlled trial. The Journal of Nursing Research,
education and apply yoga to reduce the fatigue experienced by 22(3), 155Y164. doi:10.1097/jnr.0000000000000044
patients with breast cancer who undergo adjuvant chemotherapy.

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The Journal of Nursing Research Chao-Jung Taso et al.

& Amadori, 2003). Distress is thought to arise because of toms of anxiety, depression, and fatigue in patients with breast
decreased activity, fatigue, and depression, which in turn may cancer undergoing chemotherapy.
result in feelings of helplessness and even suicidal thoughts.
Clinicians tend to underestimate the presence of these
symptoms, especially emotional distress factors such as fatigue, Methods
anxiety, and depression. Chronic, untreated anxiety, depres-
sion, and fatigue may severely affect the quality of life Study Design
of patients and cause them to lose confidence and hope to Sixty (75.9%) of 79 eligible participants consented to par-
the point that they have suicidal thoughts (Harper & ticipate. Computer-generated numbers were used to randomly
Littlewood, 2005). Studies of aerobic exercise interventions assign these participants to the yoga intervention group (n =
performed on cancer populations have shown the effective- 30) or the standard care group (n = 30) before the inter-
ness of exercise in reducing anxiety and depression (Vadiraja vention. Randomization used opaque envelopes with group
et al., 2009; Wen & Fang, 2005). Yoga is a type of bodyYmind assignments, and personnel who had no involvement in the
health exercise and has been shown to alleviate the anxiety trial performed randomization. The envelopes were opened
(Rao et al., 2009), emotional distress (Bower, Woolery, & sequentially in the order of assignment during recruitment,
Garet, 2005; Culos-Reed, Carlson, Daroux, & Hately-Aldous, with the names and registration numbers of the participants
2006), and symptom distress (Bower et al., 2005) of patients written on the covers. Experimental group participants re-
undergoing chemotherapy. Yoga assists in improving sleep ceived standard care and maintained an ordinary daily activity
and effectively relieving cancer-related fatigue (Bower et al., routine with daily yoga exercise. Control group participants
2000, 2012; Cohen, Warneke, Fouladi, Rodriguze, & Choul- received standard care and maintained an ordinary daily ac-
Rech, 2004; Ripoll & Mahowald, 2002). Thus, yoga effec- tivity routine. All participants were assessed for anxiety, de-
tively alleviates the anxiety, depression (Vadiraja et al., 2009), pression, and fatigue immediately before the intervention and
and fatigue (Brown & Gerbard, 2005) that patients with can- at 4 and 8 weeks after completion of the intervention to identify
cer experience during the treatment period and improves impact over time.
quality of life (Carson, Carson, Porter, Keefe, & Seewaldt,
2009; Carson et al., 2007; Culos-Reed et al., 2006; Demark-
Wahnefried, 2007; Galantino et al., 2012; Lowe et al., 2012; Sample Size
Zhang, Yang, Tian, & Wang, 2012). Yoga provides significant The literature suggests that a mean difference of 3.28 in Profile
benefits and can play an important role in the physical and of Mood States depression subscale scores can be expected
mental healthcare regimens for cancer (Rao et al., 2009). between the experimental and control groups after the 7-week
Yoga intervention enhances mental health and psycho- yoga intervention, with a pooled standard deviation of 4.7
logical well-being, physical health, behavioral regulation, and (Culos-Reed et al., 2006). This study used Statistical Software
interpersonal behavior (Brown, Ryan, & Creswell, 2007; Sample Power 2.0 and adopted the analysis of covariance
Carson et al., 2007, 2009; Demark-Wahnefried, 2007). Mind- (ANCOVA) statistical method based on the research goals.
fulness intervention research has shown that yoga may con- Power was set at 0.8, alpha was .05, and the medium level of
currently reduce a variety of psychopathological symptoms covariate’s R2 was .13 (Cohen, 1988). Therefore, the effect
and enhance mental health and well-being (Brown et al., size of the covariate adjustment was set to .37. The calculated
2007). The theoretical foundations of meditation and the bodyY number of samples for each group was 30.
mind connection have been described in this intervention.
The yoga regimen adopted for this study is a safe and man-
ageable yoga program developed by Lisa (2005). Yoga classes Setting and Subjects
are appropriate for patients with breast cancer at all stages of After obtaining approval from the institutional review board,
illness. Yoga increases energy, strength, flexibility, and well- we used purposive sampling to recruit women with breast
being and may facilitate recovery from some of the side ef- cancer. All recruited women received chemotherapy between
fects of cancer treatment. Classes are comprehensive and include April 2011 and September 2011 at the Chi Mei Medical
breathing practice, yoga postures, awareness exercises, relaxa- Center in Tainan, Taiwan. Inclusion criteria for participation
tion, stretches, and meditation techniques. included (a) diagnosis of Stages 1Y3 of breast cancer; (b) aged
Evidence-based research has shown the positive effects of between 20 and 70 years with a performance status of 0Y2
yoga for cancer populations. However, research exploring (ambulatory 9 50% of time); (c) clear minded, literate, and able
the appropriate exercise frequency and exercise preferences to communicate in both Mandarin and Taiwanese; (d) cur-
of patients with breast cancer is limited. Furthermore, no in- rently receiving chemotherapy; (e) never performed yoga ex-
formation regarding the yoga practice preferences of patients ercises; (f) no history of a mental disorder; (g) willing to
with breast cancer is available in the literature. participate in this research; (h) healed open wounds; and
The goals of the study were to (a) design a yoga exercise (i) at least 1 month since breast cancer surgery. Exclusion
program appropriate for women with breast cancer and (b) criteria included (a) diagnosis of suspected bone metastasis
test the effectiveness of this program in improving the symp- or recurrence; (b) a hemoglobin level of less than 10 mg/dL;

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Yoga Intervention on Women With Breast Cancer VOL. 22, NO. 3, SEPTEMBER 2014

(c) a platelet count of less than 50,000; and (d) current use of ward. This program was provided twice a week for 60 minutes
antidepressant, antianxiety, or other psychotropic medications. each session during the chemotherapy treatment period over a
Sixty women recently diagnosed with breast cancer were total of 8 weeks.
enrolled as participants and randomly divided into the ex- To ensure intervention consistency across the study sites
perimental and control groups. As shown in Figure 1, the and among the instructors, an experienced instructor taught
experimental group’s attendance rate for the full yoga cur- each class using standardized yoga techniques and postures.
riculum exceeded 90%. Three participants were unable to Instructors recorded all signs and symptoms of participant
attend all 16 yoga sessions because of medical or personal discomfort that occurred during the yoga sessions.
factors. One of these attended 14 yoga sessions (attendance
rate = 87.5%), and two of these attended 13 yoga sessions
(attendance rate = 81.3%). Instruments

Profile of Mood State


This scale was established by McNair, Lorr, and Droppleman
Intervention (1971) and modified by Yang (1996). Subscales assess the
A systematic literature review (Chen, Lin, Lin, & Chang, depression and anxiety experienced by patients with cancer
2011; Smith & Pukall, 2009) indicates that yoga alleviates using 14 items (seven for depression and seven for anxiety) in
symptom distress in patients with breast cancer. For this the form of a 5-point (0Y4) Likert scale, with higher values indi-
study, a team of yoga instructors and rehabilitation teachers cating higher depression and anxiety. The Cronbach’s ! for this
designed a yoga exercise program appropriate for patients scale was measured as .80, and its content validity was measured
with breast cancer. This 60-minute program included warm-up, as 4.5 (on a 1- to 5-point scale). In this study, the Cronbach’s !
Anusara yoga, gentle stretching, and relaxation exercises. The was .91Y.99 for the depression subscale and .94Y.99 for the
program was implemented as the intervention for experimental anxiety subscale over the four measurement times.
group participants at several cancer centers. Experimental group
participants further received an introduction to the theoretical Brief Fatigue Inventory (Taiwan version)
foundations of relaxation and ‘‘bodyYmind connectedness.’’ The Brief Fatigue Inventory (BFI) is a nine-item questionnaire
The program cycled through three segments including (a) designed by Mendoza et al. (1999) to rapidly assess fatigue
10 minutes of meditation and breathing exercises that fo- severity in clinical settings. Lin et al.’s (2006) Taiwan version
cused participant attention on breathing and on internal body of the BFI has been used to assess the fatigue experienced by
sensations; (b) 40 minutes of yoga exercises, laying supine, with patients with cancer during chemotherapy treatment. The BFI
legs flexed at the hip and supported by a wall, a series of assesses fatigue-related psychological distress and mood dis-
10 modified yoga asanas composed of gentle stretching and turbances, fatigue severity, and fatigue impact on daily func-
strengthening exercises targeting specific groups of muscle, tions during the most recent 24-hour period. The nine items
tendons, and ligaments; and (c) 10 minutes of cool-down in the inventory include three addressing severity and six ad-
exercises during which the body is in a supine position with dressing impact. Items are scored on an 11-point (points 0Y10)
legs slightly abducted with the plantar side of the feet placed Likert scale, with higher values indicating higher fatigue and
on the floor, arms slightly abducted, and palms turned up- greater impact of fatigue on daily life. Internal consistency
has been indicated by Cronbach’s alphas of .96 for fatigue-
related severity and .95 for interference. TestYretest reliability
was .89 for fatigue severity and .91 for interference. In this
study, the Cronbach’s ! was .92Y.98 for fatigue severity and
.93Y.96 for interference over the four measurement times.

Statistical Analysis
The SPSS Version 17.0 (SPSS, Inc., Chicago, IL, USA) was
used to analyze the data. Descriptive statistics such as mean,
standard deviation, range, and frequency distribution were
used to describe the participants’ demographic data in each
group. A chi-square test (# 2 test) or a Fisher’s exact test com-
pared the categorical variables of the two groups. An indepen-
dent samples t test was conducted to compare the average pretest
values of the two groups. A mixed-design, analysis of variance
(ANOVA) was used to test whether group and time exhibited
Figure 1. Flowchart of the process undergone by the study significant interaction effects on depression, anxiety, and fatigue.
participants. A one-way repeated measures ANOVA was subsequently

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The Journal of Nursing Research Chao-Jung Taso et al.

performed on variables that exhibited this interaction effect fluences of the pretest measure on the posttest measure were
to analyze the simple main effect of different time points in the same between the two groups. When the assumption of
each group. In addition, an independent samples one-way homogenous regression coefficients was not validated, the
ANCOVA (with the pretest value as covariate) or JohnsonY JYN method rather than ANCOVA was used to determine
Neyman (JYN) method (Hayes & Matthes, 2009) was used to the range of pretest scores associated with a statistically sig-
test the effectiveness of the intervention in improving depres- nificant effect of intervention.
sion, anxiety, and fatigue.
Fatigue level
At Week 4 of the intervention, differences in regression
Results coefficients within the groups (F = 23.76, p G .001) resulted
in the JYN procedure showing a significantly stronger bene-
Baseline Comparisons Between the Two fit in experimental group participants than in control group
Groups participants for the category of participants with pretest
The average age of participants was 49.27 T 10.23 years. fatigue scores below 9.92 (8/60 = 18.3%, item mean G 3.31,
Most were married (44 of 60) and either high school grad- p G .05). However, for participants with higher pretest fa-
uates (27 of 60) or university graduates (20 of 60). Both tigue levels (24/60 = 40%; 916.55, i.e., item mean 9 5.52),
groups were statistically similar in terms of all demographic the fatigue of the experimental group was significantly
and medical profile variables (p 9 .05; Table 1). Independent higher (p G .05) than that of the control group (Figure 2a).
samples t test results identified insignificant differences be- Thus, at Week 4 of the intervention, the yoga exercise program
tween the groups in terms of depression, anxiety, fatigue, effectively reduced the fatigue levels only in those partici-
and the influence of fatigue on daily life (all ps 9 .05). pants (18.3%) with lower pretest fatigue and negatively af-
fected participants with higher pretest fatigue. At Week 8 of
the intervention, the regression coefficients within the groups
Interaction Effects Between Time and Group differed (F = 35.83, p G .001), with the JYN procedure show-
Results of mixed-design, two-way ANOVA indicated signif- ing that, among participants with pretest fatigue scores below
icant interaction effects between time points and groups for 21.89 (45/60 = 75%, item mean G 7.30), the experimental
fatigue level (F = 75.49, p G .001) and the influence of fa- group benefitted significantly more than the control group
tigue on patients’ daily lives (F = 51.71, p G .001) and no (p G .05), with the remaining 25% showing neither positive
significant interaction effects for depression and anxiety effects nor negative effects (Figure 2b). Therefore, the 8-week
variables (all ps 9 .05). Thus, the results do not support the yoga exercise intervention effectively reduced the fatigue. At
effectiveness of yoga exercises in reducing depression and 4 weeks after the conclusion of the intervention, the regres-
anxiety in women who have breast cancer. sion coefficients within the groups differed (F = 32.90, p G
.001). The JYN procedure results indicate a significantly lower
Simple Main Effect of Different Time score for the experimental group than for the control group
at 4 weeks after intervention for those participants with pre-
Points in Each Group test fatigue scores in the range of 2Y26 (p G .05; Figure 2c).
Thus, the fatigue-reduction effect of the yoga exercise inter-
Experimental group vention persisted in the experimental group 4 weeks after the
Fatigue level and the influence of fatigue on daily life were conclusion of the program.
both lower in the experimental group after the 8-week in-
tervention (F = 62.95, p G .001 and F = 53.53, p G .001,
respectively; Table 2). The influence of fatigue on participants’ daily life
At Week 4 of the intervention, the regression coefficients
Control group within the groups differed (F = 13.15, p G .001). The JYN
Significant changes in the control group were limited to fatigue procedure showed that, among participants (23/60 =
level (F = 25.39, p G .001) and the influence of fatigue on 38.3%) with pretest scores for the influence of fatigue on
daily life (F = 11.09, p G .001; see Table 3). However, these daily life below 19.34 (item mean G 3.22), the experimen-
changes were not positive. Fatigue level was significantly tal group benefitted significantly more than the control
prolonged, and the influence of fatigue on daily life increased group (p G .05). Among participants with higher pretest
(Table 3). scores for the influence of fatigue on daily life (12/60 =
20%; 935.79, i.e., item mean 9 5.97), this influence was
The Effects of the Yoga Exercise Program significantly greater in the experimental group than in the
at Each Time control group (p G .05; Figure 3a). At Week 8 of the
To assess the impact of the intervention at each follow-up intervention, the regression coefficients within the groups
time, this study used a one-way ANCOVA with the pretest differed (F = 9.25, p G .01). The JYN procedure showed that,
measure as the covariate on the assumption that the in- among participants with pretest scores for the influence of

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TABLE 1.
Participant Demographic and Medical Data (N = 60)
Experimental Control Group
Total Group (n = 30) (n = 30)
Variable n % n % n % #2 p

Age (years) 1.835 .607


Below 40 13 21.7 5 16.7 8 26.7
41Y50 20 33.3 12 40.0 8 26.7
51Y60 20 33.3 9 30.0 11 36.7
Over 61 7 11.7 4 13.3 3 10.0
Educational level 4.637 .200
Illiterate 3 5.0 0 0.0 3 10.0
Elementary school/middle school 10 16.7 7 23.3 3 10.0
High school/college 27 45.0 13 43.3 14 46.7
University and above 20 33.3 10 33.3 10 33.3
Religious beliefs 0.357 .837
Nonbeliever 14 14.0 7 23.3 7 23.3
Buddhism/Daoism 43 43.0 22 73.3 21 70.0
Christianity/Catholicism 3 3.0 1 3.3 2 6.7
Marriage status 0.001 9.990
Unmarried 10 16.7 5 16.7 5 16.7
Married 44 73.3 22 73.3 22 73.3
Divorced 6 10.0 3 10.0 3 10.0
Profession 9.990a
Employed 29 48.3 20 66.7 19 63.3
Unemployed 31 51.7 10 33.3 11 36.7
Diagnostic stage 0.099 .952
I 18 30.0 9 50.0 9 50.0
II 25 41.7 12 48.0 13 52.0
III 17 28.3 9 52.9 8 47.1
Chemotherapy type 2.855 .415
TAC 22 36.7 10 45.5 12 54.5
CAF 15 25.0 7 46.7 8 53.3
CMF 11 18.3 8 72.7 3 27.3
FEC 12 20.0 5 41.7 7 58.3
Antihormone drugs 0.001 9.990
Not received 2 3.3 1 3.3 1 3.3
Received before chemotherapy 24 40.0 12 40.0 12 40.0
Received after chemotherapy 34 56.7 17 56.7 17 56.7
Complications during treatment
Lack of appetite 1 3.6 0 0.0 1 7.1 9.990a
Nausea 2 7.1 1 7.1 1 7.1 9.990a
Insomnia 17 60.7 9 64.3 8 57.1 9.990a
Dry mouth 4 14.3 2 14.3 2 14.3 9.990a
Fever 3 10.7 1 7.1 2 14.3 9.990a
Numbness 1 3.6 1 7.1 0 0.0 9.990a

Note. TAC = taxotere, doxorubicin, and cyclophosphamide; CAF = cyclophosphamide, doxorubicin, and fluorouracil; CMF = cyclophosphamide, methotrex,
and fluorouracil; FEC = fluorouracil, epirubicin, and cyclophosphamide.
a
Fisher’s exact test.

fatigue on daily life below 32.05 (46/60 = 76.7%; item mean were identical (F = 2.14, p 9 .05), this study used ANCOVA
G 5.34), experimental group participants benefitted signifi- (with the pretest values as the covariate) to test the simple
cantly more than their control group peers (p G .05). The group effect for the influence of fatigue on daily life. The
remaining 23.3% showed neither positive nor negative effects results indicated a significant difference between the two
(Figure 3b). At 4 weeks after the conclusion of the inter- groups in terms of the adjusted mean for the influence of
vention, because the regression coefficients within the group fatigue on daily life (F = 134.72, p G .001). The value for

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TABLE 2.
Differences Among Pretest, Posttest 1 (Week 4 of the Intervention), Posttest 2
(Week 8 of the Intervention), and Posttest 3 (4 Weeks After the Conclusion of
the Intervention) for Variables With Significant Interaction Effects in the
Experimental Group (n = 30)
ffiPretest fflPosttest 1 Posttest 2 ÐPosttest 3
Bonferroni
Variable M SD M SD M SD M SD F p Post Hoc Test

Fatigue levelsa 16.1 7.1 16.8 6.7 10.9 6.9 5.4 3.0 62.95 G.001 ffi 9 , ffi, 9 Ð, ffl 9 ,
ffl 9 Ð,  9 Ð
Influence of fatigue 26.2 12.5 21.2 13.8 15.5 13.3 6.6 6.0 53.53 G.001 ffi 9 ffl, ffi 9 , ffi 9 Ð,
on daily lifea
ffl 9 , ffl 9 Ð,  9 Ð

Note. aHigher score indicated a worse situation.

TABLE 3.
Differences Among Pretest, Posttest 1 (Week 4 of the Intervention), Posttest 2
(Week 8 of the Intervention), and Posttest 3 (4 Weeks After the Conclusion of
the Intervention) for Variables With Significant Interaction Effects in the Control
Group (n = 30)
ffiPretest fflPosttest 1 Posttest 2 ÐPosttest 3 Bonferroni
Variable M SD M SD M SD M SD F p Post Hoc Test

Fatigue levelsa 15.4 7.0 14.9 4.4 20.4 5.0 25.1 3.6 25.39 G.001 Ð 9 ffi,  9 ffl,
Ð 9 ffl, Ð 9 
Influence of fatigue 21.3 11.3 20.7 9.7 25.1 9.1 30.5 9.8 11.09 G.001 Ð 9 ffi,  9 ffl,
on daily lifea Ð 9 ffl, Ð 9 

Note. aHigher score indicated a worse situation.

the experimental group (adjusted mean = 6.25) was signif- fatigue and the influence of fatigue on the daily lives were
icantly lower than that for the control group (adjusted congruent with previous studies done by Blank, Kittel, and
mean = 30.89). In other words, 4 weeks after the conclusion Haberman (2005) and Carson et al. (2009). Similar to the
of the yoga exercise intervention, the reduced influence of current findings, Moadel et al. (2007) revealed the existence
fatigue on daily life for patients in the experimental group of an overall significant difference in fatigue after practicing
persisted. a yoga exercise program, supporting the effectiveness of the
yoga exercise program in improving the fatigue outcomes.
Although exercise in general has been shown to reduce fatigue
Discussion in patients with cancer, the yoga exercise program is specif-
This study clearly shows the feasibility of conducting an ically designed to strengthen specific groups of muscles, ten-
established 8-week yoga intervention with women with breast dons, and ligaments of particular benefit to patients with
cancer. The high attendance rate further supports that the breast cancer. Through the progression of a sequence of static
participants enjoyed the program. The experimental group physical postures, yoga uses stretching to improve muscular
had a high completion rate (990%), indicating a high level of strength, which may be the possible reason for the reduced
commitment and adherence. Results indicate that fatigue fatigue and influence of fatigue on daily life. Alternatively, the
and the influence of fatigue on the daily life of the partic- lack of effect may also result in a wide range of scores on the
ipants in the experimental group had significantly improved outcome measures pretest, indicating the effect of the inter-
after the yoga intervention and that the improvements at ventions as contingent on pretest status. Those patients who
the 8-week point in the intervention were maintained through showed higher levels of fatigue and the influence of fatigue
4 weeks after the conclusion of the intervention. According to on daily life at the beginning of the study did not show sig-
Chen et al. (2011), yoga interventions must be performed for nificant improvements in these measures in the 4-week test.
at least 8 weeks to achieve significant improvements in fa- The yoga exercise program had effectively reduced the fatigue
tigue and the influence of fatigue on daily life. The improved and the influence of fatigue on daily life in participants with

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Figure 2. The regression line of fatigue level against baseline data in each group and the cut points of significant differences
between the two groups. (a) Week 4 of the intervention. (b) Week 8 of the intervention. (c) 4 weeks after the conclusion
of the intervention.

Figure 3. The regression line of ‘‘the influence of fatigue on daily lives’’ against baseline data in each group and the cut
points of significant differences between the two groups. (a) Week 4 of the intervention. (b) Week 8 of the intervention.

lower pretest values for fatigue (G9.92) and the influence of study. Those patients with initially high levels of fatigue and
fatigue on daily life (G19.34) at Week 4 and participants with the influence of fatigue on daily life experienced could not
moderate pretest values for fatigue (G21.89) and the influence be expected to show improvements on fatigue measures after
of fatigue on daily life (G32.05) at Week 8. On the other hand, 4 weeks of the intervention. However, there were no statis-
patients with higher pretest values for fatigue and the influ- tically significant group differences for the measures of depres-
ence of fatigue on daily life experienced the opposite effects at sion and anxiety in patients with breast cancer, which is
Week 4 of the intervention. Therefore, our study suggests that consistent with previous studies (Zhang et al., 2012). Rao
higher pretest values for fatigue (916.55) and the influence of et al. (2009) designed an intervention that included mindful-
fatigue on daily life (935.79) pose a barrier to adherence and ness meditation, yoga stretches, group support, and home
that these participants need a longer time (8 weeks rather than exercises. Similar to the current findings, Banerjee et al.
4 weeks) to validate the effect of the intervention. On the basis (2007) found that participants in the intervention group ex-
of the results of the JYN method, study findings provide evi- perienced decreased depression and anxiety. However, it is
dence for better clinic practice in patients with breast cancer. not clear whether the benefits were due specifically to yoga.
The yoga exercise showed a significant and positive effect on It is noteworthy that the form of yoga used in the current
improving fatigue through the 8-week intervention in this study was presented and taught in its traditional format, which

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The Journal of Nursing Research Chao-Jung Taso et al.

includes a number of components (Cohen et al., 2004). How- ticipants with lower pretest values for fatigue and influence of
ever, it is unlikely to be the only therapeutic element of the fatigue on daily life, the 8-week yoga exercise appeared to
intervention, as 57% of participants reported practicing yoga reduce fatigue and the influence of fatigue on daily life. A
at home once per week or more. Thus, although the yoga further aim of the study was to adjust the yoga exercise
program designed for this study appears to be useful for this program to ensure it is suitable for all patients with breast
population, there is no way to identify those aspects of the cancer and to develop programs for general use by patients
program that have more or less impact. Program evaluation with cancer. However, the developed 8-week yoga exercise
ratings reflect the importance of the social support benefits program did not reduce the levels of depression and anxiety
of the intervention, which was underscored by the relative of participants. By discussing with patients how to select the
disinclination toward home practice. appropriate type of yoga, including mindfulness meditation,
There are several possible explanations for why this study yoga stretches, group support, and home exercises, yoga
failed to find an effect of yoga on the measures of depression may be better integrated into cancer care. This may help in-
and anxiety. The current study was also not able to discern crease the professional autonomy of nurses and enhance the
the therapeutic factors operating in yoga, such as social sup- quality and uniqueness of clinical care. However, the results
port, physical poses, or meditation. In addition, the means recommended that the format of specific yoga programs
of depression and anxiety at baseline were 16.40 (scoring should be developed in consultation with other experts, in-
indicator = 58.57%) and 17.57 (scoring indicator = 62.75%), cluding rehabilitation experts and yoga instructors, and ad-
respectively. The scores for depression and anxiety at baseline justed based on cancer type to develop appropriate and safe
were low. Therefore, there was not much room for improve- yoga exercises while reducing the risk of negative events.
ment, which may be the reason for the unexpected nonsignif- Future research should conduct longer follow-up studies to
icant findings for depression and anxiety. Overall, significant provide a reference for application in clinical nursing as well
improvements were seen in patients participating in yoga ex- as to investigate the influence on fatigue level of patients’
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analysis, Zhang et al. indicated that yoga had no significant assist clinical healthcare workers to understand the hidden
effect on fatigue. However, results of the yoga studies have benefits of yoga and may serve as evidence for making ef-
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瑜珈運動於乳癌病人 The Journal of Nursing Research VOL. 22, NO. 3, SEPTEMBER 2014

瑜珈運動對乳癌病人憂鬱、焦慮及疲憊改善之成效:
隨機控制試驗
曹朝榮1 林惠賢2 林紋麗3 陳淑銘4* 黃文聰5 陳尚文6

1
奇美醫療財團法人柳營奇美醫院榮譽院長 2輔英科技大學健康事業管理系學程副教授 
3
奇美醫療財團法人柳營奇美醫院疾病管理師 4輔英科技大學護理系助理教授 
5
奇美醫療財團法人柳營奇美醫院癌症中心主任 6奇美醫療財團法人
柳營奇美醫院血液腫瘤科醫師

背 景 憂鬱 、焦慮及疲憊是乳癌病人於化學治療期間最困擾的症狀 ,影響病人的生活品質 ,


實證顯示瑜珈可緩解癌症病人的焦慮 、憂鬱及疲憊。然而 ,鮮少有關瑜珈於乳癌族群
之成效研究。因此 ,應該測試瑜珈的介入措施以提昇乳癌婦女的身心健康。

目 的 測試 8 週瑜珈運動對化學治療期間乳癌婦女身心健康 ,特別是憂鬱 、焦慮及疲憊之


成效。

方 法 收案未轉移乳癌病人共 60 位 ,隨機分派至實驗組(30 位)與對照組(30 位) 。實驗組接


受每週 2 次 ,每次 60 分鐘 ,共計 8 週瑜珈介入措施 ,對照組接受常規照護。

結 果 詹森內曼程序的分析顯示 ,瑜珈介入滿 4 週 ,對於前測值較小(疲憊程度前測值單項平


均 < 3.31,疲憊影響日常生活程度前測值單項平均 < 3.22)的病人有降低疲憊和疲憊影
響日常生活程度之效果。介入滿 8 週 ,則對於具適當前測值(疲憊程度前測值單項平均
< 7.30,及疲憊影響日常生活程度前測值單項平均 < 5.34)的更多病人(約佔 75%)有降
低疲憊和疲憊影響日常生活程度之效果。然而 ,8 週的瑜珈介入無法顯著的改善參與者
的憂鬱(F = 1.29, p > .05)及焦慮(F = 2.7, p > .05)。

結論 本研究所發展的 8 週瑜珈運動計畫 ,可有效的降低乳癌病人之疲憊 ,但未能有效的降低


實務應用 憂鬱及焦慮。腫瘤護理人員可強化臨床衛生教育 ,應用瑜珈協助改善乳癌病人於化學
治療期間之疲憊。

關鍵詞:瑜珈、乳癌、憂鬱、焦慮、疲憊。

接受刊載:102年7月28日
*通訊作者地址:陳淑銘  83102高雄市大寮區永芳里進學路151號
電話:(07)7811151-5614  E-mail: wenlilin2012@gmail.com

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