Yoga for Caregivers of Patients Suffering from Chronic Diseases such as Cancers and Neurological Disabilities: A Systematic Review

Abstract

To review the role of Yoga in improving the psychological and physical aspects of caregivers of patients with chronic conditions such as neurological disabilities and cancer. A systematic search was conducted on PubMed, ScienceDirect, and Cochrane according to the PRISMA guidelines. Randomized controlled trials exploring the role of Yoga for caregivers were included; case series, case reports, conference presentations, and non-English literature were excluded. Eight studies involving 252 participants were included in this systematic review. Five studies reported psychological outcomes, of which three reported significance. Quality of life was reported to improve in one study, while other studies reported mixed results. Physical outcomes demonstrated significant improvements in two studies. Most of the included studies were pilot studies with small sample sizes and with methodological limitations. This systematic review findings has shown that, Yoga has a potential role in improving the physical and psychological well-being of caregivers, particularly in neurorehabilitation and cancer care settings. Due to the heterogenicity in interventions and reported outcomes, a definitive conclusion cannot be made. Further research should focus on large well-designed trials with different yoga modules, and standardized outcomes should support the role of integrating yoga in a holistic approach to treat these patients.

Introduction

Patients with chronic conditions, such as neurological disabilities from stroke and patients receiving cancer therapy, often require prolonged hospitalization and home care. While most of the treatments focused primarily on patients, the informal caregivers who dedicate their time and efforts in providing care are often overlooked. These caregivers go through significant mental trauma, losing their free time, which may indirectly affect the care needed to be given to patients.[1]

Complementary medicine, which involves a variety of nonpharmacological therapies and practices, has been gaining popularity to address mental and emotional challenges.[2] Physicians and policymakers involved in the care of these patients should consider the health and well-being of caregivers, as caregivers’ health indirectly affects the patient’s ultimate care. Adopting a family-centered care model is crucial to achieve optimal outcomes.

There are Cochrane reviews exploring complementary or alternative medicine for caregivers,[3] but limited studies explored Yoga as a complementary therapy.[4,5] Yoga, a well-known practice, with its cultural familiarity and accessibility in countries like India, can enhance acceptance and compliance, making it an attractive option for caregiver support.

This review is intended to explore the role of Yoga in helping caregivers cope with psychological stress and anxiety while supporting their family members suffering from chronic disease.

PICO question

In caregivers (informal) of patients suffering from chronic conditions, such as neurological disabilities resulting from stroke, and those undergoing cancer therapy requiring prolonged hospitalization and home care, does Yoga, compared to psychoeducation or no therapy, provide psychological benefits in terms of reducing stress, anxiety, and depression?

Methods

This systematic review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.[6]

Search strategy

A systematic literature search was conducted across the PubMed, Cochrane Library, and ScienceDirect databases using the search terms outlined in Table 1. In addition, the reference lists of included studies were reviewed for potentially relevant articles. Three investigators independently screened abstracts, with selected articles undergoing full-text evaluation. Conflicts were resolved through consensus, resulting in a final list of studies.

Table 1.

Details of the search strategy

Database	Search details
Cochrane	19 Cochrane Reviews matching Yoga in all text AND caregiver in Title Abstract Keyword - (Word variations have been searched)
PubMed	(“yoga”[MeSH Terms] OR “yoga”[All Fields]) AND (“caregiver s”[All Fields] OR “caregivers”[MeSH Terms] OR “caregivers”[All Fields] OR “caregiver”[All Fields] OR “caregiving”[All Fields])
Science Direct	Title, abstract, keywords: Yoga and caregiver

Inclusion criteria

Studies investigating the role of Yoga in caregivers of patients with neurological disabilities, cancers, and other chronic disorders requiring prolonged care in the hospital or at home were included. Randomized and nonrandomized trials were included, and only articles in English were included.

Exclusion criteria

Studies exploring the role of Yoga in caregivers of dementia and schizophrenia were not included (as there are reviews that have already explored those conditions, and the care required is different from the conditions included in our review). Case series, case reports, conference presentations, etc., were excluded, along with articles in non-English literature.

Data extraction

Three investigators (MS, SKT, and AA) independently assessed studies and extracted data using a pre-designed pro forma based on the inclusion criteria. The study selection process is illustrated in Figure 1 using the PRISMA flowchart. Details extracted included Study ID, Journal, Country of Publication, Study Design, Number of Participants, Patient Characteristics, Objectives, Results, Key Conclusions, and Outcomes.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flow chart

Missing data

Authors were contacted for missing data, and any discrepancies were resolved through consensus.

Risk of bias and quality assessment

Two authors (MS and SKT) independently assessed the methodological quality of the included trials. Any disagreements were resolved by discussion. The quality of the included randomized controlled trials (RCTs) was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions[7] using the RevMan 5.3, Risk of Bias (ROB) 2.0 tool (The Cochrane Collaboration, London, United Kingdom). The assessment includes evaluation across the following domains: sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. The results of the ROB are presented as a ROB summary and a ROB graph.

Results

Study selection

The search strategy outlined in Table 1 yielded 176 articles. After removing 13 duplicates, the remaining 163 articles were screened based on Title and Abstract, from which 11 articles were sought for full-text review. Three articles[8,9,10] were excluded for the reasons mentioned in Table 2. The remaining eight articles were included in the qualitative synthesis.

Table 2.

Characteristics of excluded studies

Study author (year)	Reason for exclusion
Milbury et al., 2019 -3[8]	Study protocol
Rabe et al., 2024[9]	Study protocol
Snyder et al., 2021[10]	Control group also received yoga

Study characteristics

All eight included studies were RCTs, but four were pilot studies. The studies are from India (n = 2), the USA (n = 5), and Canada (n = 1). Five studies involved exclusively on caregivers, and the remaining three involved both caregivers and patients. A total of 252 participants (males = 86, females = 134; 32 participants’ sex was not mentioned) were involved across all the studies combined. The average age of the participants was 50.73 years (15.92 years). Patients were from neuro-rehabilitation (n = 2) and cancer (n = 4), not mentioned in the two studies. Different Yoga modules used were the Caregiver Yoga module, Iyengar Yoga module, Vinyasa Yoga module, and Hata yoga module. The duration of the Yoga sessions varied from 35 min per day to 60 min per day, and the overall intervention duration varied from 4 weeks to 12 weeks. The details are mentioned in Table 3.

Table 3.

Characteristics of included studies

Author	Type of study	Country	Sample size	Age, mean±SD	Sex (male/female)	Participants	Intervention	Outcome measured
Gandhi et al., 2019[4]	RCT	India	34 EG - 17 CG - 17	Not clear	EG - 14/3 CG - 12/5	Caregivers of patients under neurorehabilitation due to spinal cord injury/head injury etc.	Caregiver yoga module - 35 min/day for 4 weeks	PD - Kessler’s Psychological Distress Scale MWB - Warwick–Edinburgh’s Mental Well-being Scale
Lee et al., 2022[11]	RCT	USA	50 EG - 25 CG - 25	44.94±15.21	EG - 3/22 CG - 5/25	NIH caregivers of patients with cancers requiring allogeneic stem cell transplant	Iyengar yoga over 6 weeks	Stress-NIH toolbox perceived stress Depression and anxiety-PROMIS
Martin and Candow, 2019[12]	RCT	Canada	29 EG - 16 CG - 13	Not clear	11/18	Informal caregivers-patient details not mentioned	Vinyasa yoga for EG Taijifit for CG for 12 weeks (150 per week)	Muscle strength and endurance/tests of functionality/flexibility
Milbury et al., 2019-1[15]	RCT-pilot	USA	20 (caregiver) EG - 10 CG - 10	52.36±16.00	7/13	Caregivers and patients (dyads) receiving radiotherapy for glioma	Yoga program (SVYAS) 45 min sessions, 2–3 times per week over 6 weeks	Depression - CESD Fatigue - BFI QOL - the medical outcomes study SF - 36
Milbury et al., 2019-2[12]	RCT-pilot	USA	26 dyads EG - 13 CG - 13D	62.01±11.37	8/18	Caregivers and patients receiving thoracic radiotherapy-esophageal and lung cancers	Yoga program (SVYAS) 60 min sessions, 2–3 times per week over 6 weeks	Depression - CESD; physical function - 6-min walk test, QOL - the medical outcomes study SF-36
Milbury et al., 2024[13]	RCT-pilot phase 2	USA	37 dyads EG - 19 CG - 18	Range 37–72	Not clear	Caregivers and patients receiving chemoradiation for head and neck cancers	Yoga program (SVYAS) 45 min sessions, 2–3 times per week over 6 weeks	QOL - medical outcomes study SF-36 assessing 8 distinct domains yielding a mental and physical composite summary (MCS and PCS, respectively)
Umadevi et al., 2013[5]	RCT	India	43 EG - 20 CG - 23	Not clear	22/21	Caregivers of patients in neurorehabilitation (stroke, cerebral palsy, etc.)	Yoga module for 30 days	Anxiety and depression - Hospital Anxiety and Depression Scale; QOL-World Health Organization QOL-BREF
Van Puymbroeck et al., 2007[16]	RCT-pilot	USA	13 EG - 6 CG - 7	59.23±12.94	4/9	Informal caregivers-patient details not mentioned	Hata yoga-two sessions at 1.25 h each/week for 8 weeks	Coping-SOC Questionnaire; physical fitness

SD: Standard deviation, PD: Psychological distress, MWB: Mental wellbeing, PROMIS: Patient-reported outcomes measurement information system, CESD: Center for epidemiological studies-depression measure, BFI: Brief fatigue inventory, SF-36: 36-item short-form survey, SOC: Sense of coherence, RCT: Randomized controlled trial, QOL: Quality of life, MCS: Mental component summary, PCS: Physical component summary, CG: Control group, EG: Experimental group, NIH: National Institute of Health

Main outcomes

The main outcomes of our review included the psychological effects, particularly anxiety, stress, and depression, which were measured across the studies using various validated scales.

Gandhi et al. 2019[4] reported a statistically significant improvement in psychological distress measured with Kessler’s Psychological Distress Scale, and similar results were noted with Mental well-being measured by Warwick–Edinburgh’s mental well-being scale.

Lee et al. 2022[11] reported no significant improvement in stress, depression, and anxiety assessed by the National Institute of Health (NIH) toolbox Perceived Stress, Patient-Reported Outcomes Measurement Information System. Their main outcome was the effect of yoga on cardiometabolic biomarkers, in which there was significant improvement noticed.

Milbury et al. 2019-1[12] reported significant improvement in depression and fatigue in caregivers measured by the Center for Epidemiological Studies-Depression Measure (CESD) and Brief Fatigue Inventory. However, this study is a pilot study and they were given yoga for both patients and caregivers.

Milbury et al. 2019-2[13] reported no significant improvement in depression (even though there is some improvement which is not statistically significant) measured by the CESD. This study was also similar to the Milbury, 2019-1[12] in which this is a pilot study and yoga was given to both patients and caregivers, and their outcomes mainly focused on patients.

Umadevi et al. 2013[5] reported significant improvement in both anxiety and depression measured with the hospital anxiety and depression scale.

The detailed outcomes are presented in Table 4.

Table 4.

Results of the individual studies

Author	Results	Impression
Gandhi et al., 2019[4]	Psychological outcomes: PD - yoga group: 25.47 (8.58) baseline, 20.0 (8.96) at 29th day versus control Group: 27.41 (10.77) baseline, 27.29 (10.55) at 29th day, F between group 15.87 and P=0.001; MWB: F=5.48, P<0.03	There is a statistically significant improvement in PD and MWB in caregivers of the yoga group compared with controls
	Physical outcomes: NA
	QOL: NA
Lee et al., 2022[11]	Psychological outcomes: Perceived stress - (P>0.05) effect size 0.4, correlation 0.8, actual power - 32% (target 80%) Depression and anxiety (P>0.05)	Even though there is a significant improvement in cardiometabolic biomarkers, there is no significant improvement in perceived stress, depression, and anxiety (the study was underpowered to detect meaningful differences)
	Physical outcomes: NA
	QOL: NA
Martin and Candow, 2019[15]	Psychological outcomes: NA	Significant improvement was noted in the yoga group regarding strength and endurance compared to the Taijifit group
	Physical outcomes: Chest press endurance (yoga group: Pre - 19.25±5.90, post - 28.06±7.60 reps, Taijifit™ pre - 15.69±4.49, post - 21.07±5.85 reps; P=0.019) and abdominal endurance (Yoga group: Pre - 37.12±31.26, post - 68.43±55.07 reps, Taijifit pre - 19.23±19.00, post - 32.07±20.87 reps, P=0.034)
	QOL: NA
Milbury et al., 2019-1[12]	Psychological outcomes: Depression- LSM: Yoga group=−5.40 versus wait list group=3.60, F=6.14, P=0.03, d=1.12	Significant improvement was noted with depression and fatigue in caregivers and no difference in mental and physical QOL The study was done in patients and caregivers combined and it’s a feasibility study. The results presented here are for caregivers only
	Physical outcomes: NA
	QOL: Fatigue- LSM: Yoga group=–1.76, Waitlist group=2.5, F=3.96, P=0.07, d=0.89 QOL mental- significant improvement QOL physical- no significant improvement (values not mentioned)
Milbury et al., 2019-2[13]	Psychological outcomes: Depression- LSM: Yoga group=6.98, 95% CI (4.26–9.70) versus waitlist group=5.72 m, 95% CI (2.80–8.64), d=0.12	Significant improvement was not observed in depression and QOL scores, even though there is some improvement The study was done in patients and caregivers combined and it’s a feasibility study. The results presented here are for caregivers only
	Physical outcomes: NA
	QOL-LSM: Yoga group=52.78, 95% CI (48.82–56.74) versus waitlist=48.59, 95% CI (43.81–53.37), d=0.51
Milbury et al., 2024[14]	Psychological outcomes: NA	Significant improvement was not observed in depression and QOL scores, even though there is some improvement The study was done in patients and caregivers combined and it’s a feasibility study. The results presented here are for caregivers only
	Physical outcomes: NA
	QOL: Physical QOL (PSC, LSM: Yoga group=50.97 vs. waitlist=52.97; d=−0.27, P=0.28) Mental QOL (MCS, LSM: Yoga group=47.72 vs. waitlist=49.96, d=−0.23, P=0.40)
Umadevi et al., 2013[5]	Psychological outcomes: Anxiety - 9.45±4.75 (pretest), 1.9±2.33 (posttest) P<0.001, depression - 14±4.47 (pretest), 3.45±3.8 (posttest), P<0.001	Significant improvement was noted in anxiety, depression, and QOL in caregivers of the yoga group
	Physical outcomes: NA
	QOL: 48.78±10.4 (pretest), 63.65±8.13 (posttest) P<0.001
Van Puymbroeck et al., 2007[16]	Psychological outcomes: NA	Significant improvement was noted in lower body strength, but not in other parameters of strength
	Physical outcomes: Lower body strength before yoga to 8 weeks post-yoga - (Z=−2.207, P<0.05)
	QOL: NA

CI: Confidence interval, QOL: Quality of life, PD: Psychological distress, MWB: Mental well-being, NA: Not available, MCS: Mental component summary, PCS: Physical component summary, LSM: least mean square difference, CG: Control group, EG: Experimental group

Secondary outcomes

Quality of life

Milbury et al. 2019-1[12] reported significant improvement in mental quality of life (QOL) and no improvement in the physical part of QOL in The medical outcomes Study 36-item short-form survey.

Milbury et al. 2019-2[13] reported no significant improvement in QOL.

Milbury et al. 2024[14] no improvement in the QOL of caregivers, even though they showed improvement in patients.

Umadevi et al. 2013[5] reported significant improvement in the QOL of caregivers in the Yoga group.

Physical outcomes

Martin and Candow 2019[15] reported significant improvement in the Yoga group with respect to chest press endurance and abdominal endurance compared with the Taijifit group.

Van Puymbroeck et al. 2007[16] reported improved lower body strength in the yoga group but not in other parameters.

Due to the heterogenicity in Yoga techniques and reporting of outcomes, meta-analysis could not be performed.

Risk of bias

The majority of the studies included were having a lower ROB (n = 4),[11,12,13,14] and moderate ROB (n = 3),[5,15,16] but one study had a high ROB.[4] However, the details regarding allocation concealment are unclear in studies having a moderate ROB. Overall, the majority of the studies demonstrated low risk in random sequence generation, blinding of outcome assessment, incomplete outcome data, and selective reporting. High risk is noted with blinding of participants, which can be expected due to difficulty in blinding as the participants know whether they are doing Yoga or not. Overall, these results should be interpreted with caution. The risk of bias summary and graph details are presented in Figures 2 and 3.

Figure 2.

Summary of risk of bias

Figure 3.

Risk of bias graph

Discussion

Caregivers of patients with chronic disorders endure significant psychological distress. They have to help the patients with their daily needs, witnessing their physical suffering and making critical decisions for them. With these responsibilities, caregivers often neglect their own health. A family-centered approach, which can improve the physical and psychological health of caregivers, can improve the overall patient-related outcomes. However, these measures may not always be feasible because the caregivers are typically occupied all the time with the patients. Some of the studies in this review addressed this by combining therapy for patients and caregivers so that both can be engaged at the same time.[12,13,14]

An interesting observation in this review is that the majority of the studies are from the West, despite Yoga being routed and widely practiced in India. Another interesting aspect is that four of the included studies are pilot studies, and two of the excluded studies are protocols. This suggests a growing interest in caregiver-focused Yoga interventions in the West, but it is disheartening to note the limited research in this area from India. The pilot studies from Milbury et al. 2019[12] mentioned that they developed the manualized yoga program in collaboration with Swami Vivekananda Yoga Anusandhana Samsthana, Bangalore, India.

The different Yoga programs used across the studies, as mentioned in the results, were the Caregiver Yoga module, Iyengar Yoga module, and Vinyasa Yoga module, in addition to the manualized program by Milbury et al. 2019.[12] The caregiver yoga module is specially focused on the management of stress along with physical strength and flexibility. The Iyengar module is more focused on the elderly with supports like walls and chairs and mainly focused on physical activity apart from mental well-being. The Vinyasa module, a part of Hatha yoga, is more focused on physical activity, which is fast-paced compared to the Iyengar module and is more popular in the West. The outcomes reported in the results might be due to the different yoga modules used and their primary focus.

Five studies[4,5,11,13,14] in this review focused on psychological outcomes in caregivers with Yoga. Of these, three studies[4,5,13] reported significant improvement, and the other two studies[11,14] did not find any significance. However, these results should be interpreted with caution. If subgroup analysis is done with the two studies[4,5] where caregivers were tested exclusively, and for patients requiring neurorehabilitation settings with caregiver yoga module, there was a significant difference. The other study,[13] which showed improvement, is a pilot study done for both caregivers and patients combined, and their main focus is on patients. Of the studies that reported no significance, two of them were pilot studies mainly focused on feasibility rather than the actual outcomes required. Lee et al. 2022[11] main outcome was cardiometabolic markers, which showed significant improvement but failed to show any significance in physiological outcomes.

Four studies[5,13,14,15] reported quality of life measures with yoga. Except for one study Umadevi et al. 2013[5] the remaining studies did not show any significance. All three studies[13,14,15] were pilot studies, and one study actually showed significance with respect to metal QOL measures.

Physical outcomes were assessed in two studies,[12,16] and both studies showed significant improvement in some of the physical parameters.

These results indicate that yoga definitely has some role for caregivers of patients requiring prolonged care in neurorehabilitation wards, cancer therapies, and other chronic disorders. Due to variability in reporting outcomes, a definitive recommendation cannot be made yet. This review definitely encourages more RCTs on this topic with standardized outcomes to establish yoga as a part of holistic treatment for patients and caregivers. Further studies should explore the most suitable yoga module for different caregiver demographics, including elderly and younger caregivers while considering their physical health and comorbidities.

The main limitations of the studies in this review, as already discussed, are the predominance of pilot studies, small study samples, and bias in the methodology. Our review, in turn, is limited due to a small number of studies included with small sample sizes, heterogenicity, and not being able to make a definitive conclusion.

Conclusion

This review highlighted the potential role of Yoga for caregivers of patients with chronic conditions in improving their psychological well-being, physical health, and quality of life. There is heterogenicity in interventions and outcomes across the studies, making the overall evidence inconclusive at present. This review encourages more RCTs to explore different yoga modules for different patient caregiver demographics for a holistic therapeutic approach.

Registration and protocol details

This review is registered in Prospero -Registration Number is CRD42024387175.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.