Precautions for Yoga Practice are Necessary in Cancer Patients with Spinal Metastasis

There are moderate-quality evidence supports yoga as an intervention to improve health-related quality of life and decrease symptoms such as fatigue, sleep disturbances, depression, and anxiety [1]. However, most of these studies wereconducted in early-stage cancer patients [2,3]. Recently, yoga has been endorsed by The American Society of Clinical Oncology as an integrative therapy during and after breast cancer treatment [4]. With the increased evidences for yoga’s benefits, referral and acceptance in the oncology community have increased [5-7]. Unlike meditation, Yoga involves physical movement of the body, including the spine. Consensus on the precautions for cancer patientswere not reached and recommendations are scarce [8]. 

The patients with bone metastasis are especially vulnerable to potential complications during exercise or activities, such as yoga, that challenge their musculoskeletal system. Bone metastases are most commonly seen in several types of cancer: prostate, breast, kidney, thyroid, lung and multiple myeloma. Bubendorf et al., found that 70-90% of patients who died with breast and prostate cancer had bone metastases in a postmortem examination [9]. Similarly, in breast cancer patients, studies have shown 64 % of breast cancer patients are likely to have Skeletal-Related Events (SREs) without bisphosphonate [10,11]. Although zoledronic acid and denosumab havesignificantly reduced the risk for SREs, the risk still exists [12]. About 20% of patients with bone metastasis are asymptomatic [12]. The axial skeleton, most specifically the spine, is the most common location of bone metastasis, with the thoracic spine being involved in 60-70% of the cases. Spinal metastasis puts patients at risk for compression fracture, pain, and cord compression, which lead to significant loss of function and decreased survival [13]. Recommending yoga without clear knowledge of the bone status of cancer patients can lead to severe injuries. 

Yoga can be a beneficial addition to cancer treatment when the patient’s bone health and the risk for pathologic fractures are properly evaluated.Yet yoga movement can vary from very easy breathing and sitting to very difficult postures; it can also vary from group session to one on one session. Simply referral cancer patients to yoga program without first assessing their bone integrity can lead to injury and pain. This assessment should be conducted by physicians that have a good understanding of the pathophysiology of the specific tumor type, the biomechanics of the musculoskeletal system, and the impact that exercise and yoga positions have on the musculoskeletal system, such as cancer rehabilitation physicians. Tools such as The Spine Instability Neoplastic Score (SINS) that assess the risk of spinal instability in patients with malignant spine involvement could be helpful when determining the safety of yoga in cancer patients [14]. After a thorough evaluation, cancer patients that are found to be at minimal or no risk for spinal precaution should be provided a prescription that would allow them to engage in yoga or other types of physical activities. For those patients with bone metastasis, yoga prescriptions should include precautions and restrictions, which are based on each patient's uniquecondition.Yoga instructors who is treating cancer patients would benefit from certifications or obtaining knowledge in this area. We have the following suggestions for yoga instructors: asking patient about their cancer history and bone metastasis; asking for clearance from physician if patient has bone metastasis; be aware of the physical, mental and emotional impact of various cancer and its treatments; one-on-one yoga practice so that more tailored poses that have less spinal load or modified pose that decrease spinal load can be taught to patient in patients with spinal metastasis; avoiding pose that is associated with pain in the spine; frequent communication (every 2-3 months) with physician as patient’s condition may change; safe yoga practices like gentle breathing, relaxation, meditation can still address the needs of the patient without putting them in risk. 

Studies have shown that spinal load is increased when the spine is flexed, and when head or extremities are away to the spine. Upper extremity support can decrease spinal load. The details of how body postures can affect spinal load has been summarized [8]. Ensuring patient safety during yoga practicecan havegreat benefits while preventing skeletal-related events in cancer patients.

The authors declare no conflict of interest and no funding source. There is no primary data in this letter.