Effect of integrating Yoga along with multimodal pain management approach on post-mastectomy pain syndrome in patients undergoing breast cancer surgery.

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Prakash Gondode, Ashok Kumar Saxena, Geetanjali Chilkoti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3865638/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim & Background: To evaluate the efficacy of Yogic intervention (pranayama) along with integrated multimodal approach on the incidence and severity of post mastectomy pain syndrome (PMPS) in patients undergoing surgery for breast cancer. Materials and methods: Forty patients aged 20-65 years undergoing breast cancer surgery of American Society of Anaesthesiologists physical status I – II were included. All patients received thoracic paravertebral block and tablet pregabalin till the end of the fourth postoperative week. Patients were randomly allocated into one of the two groups; “Control” and “Yoga.” Patients in the Yoga group practiced yogic exercise “Anulom-vilom’’ from post operative day 3 till day 90. The primary outcome was incidence of PMPS and secondary outcomes include Pain Detect Questionnaire (PDQ) score, Neuropathic Pain Symptom Inventory (NPSI) score, Activity assessment scores (AAS) and Quality of Life (QoL) using Short Form (SF)-12 score. Results : A reduced incidence of PMPS (10% vs 30%), mean VAS pain score, PDQ, and NPSI was observed in Yoga group along with improvement in SF-12 scores and AAS score in post mastectomy patients; however, not statistically significant. Conclusion: This study encourages the integration of yoga along with multimodal pain management approach for PMPS. Anulom Vilom Chronic pain Neuropathic pain Post Mastectomy Pain Syndrome Quality of Life Yoga Figures Figure 1 Study Highlights First study to evaluate the role of yoga ‘pranayama’ as an adjunct along with integrated multimodal pain management approach on the incidence and severity of PMPS. A decreased incidence of PMPS was observed in Yoga group (10%) as compared to the control group (30%). A greater fall in Pain Detect Questionnaire (PDQ) scores and Neuropathic Pain Symptom Inventory (NPSI) scores were observed in Yoga group reflecting its potential role as an adjunct in minimizing the neuropathic component of pain. An improvement in the functional status and the quality of life post-operatively. The present study encourages the integration of yoga along with the multimodal pain management approach using TPVB and pregabalin in patients undergoing breast cancer surgery. INTRODUCTION Post mastectomy pain syndrome (PMPS), a type of chronic neuropathic pain disorder is a common sequelae of breast cancer surgery and has been reported to be around 20%-70%. [ 1 – 3 ] Yoga is a popular form of many complementary and alternative medicine (CAM). It is an adjunctive approach and has been studied extensively as a potential intervention for patients with cancer. Various studies have evaluated the effect of yoga on breast cancer patients and survivors and have mainly studied psychologic health and quality of life (QoL). [ 4 – 6 ] On literature search, we could retrieve only two articles evaluating the impact of yoga therapy on pain symptoms in patients undergoing breast cancer surgery. Sudarshan et al studied the impact of yoga therapy on anxiety, depression and physical health in breast cancer patients and found that there was improvement in physical function in addition to a consistent amelioration in anxiety, depression and pain symptoms after a yoga intervention. Another study by Galentino et al studied the impact of yoga on objective functional outcomes, pain, and health-related quality of life for Aromatase Inhibitors -associated arthralgia in breast cancer survivors and found that yoga may reduce pain and improve balance and flexibility. The limitations of these studies were however; limited sample size, lack of control group, use of non-validated pain scale, and the neuropathic component of pain and PMPS were also not evaluated. [ 7 , 8 ] On PubMed and MEDLINE search, we also could not retrieve any study evaluating the integration of yogic exercises along with pregabalin and thoracic paravertebral block as a multimodal approach on the incidence of post-mastectomy pain syndrome. With this background, this study aimed to evaluate the efficacy of yogic exercises along with integrated approach encompassing pregabalin and thoracic paravertebral block on incidence of post-mastectomy pain syndrome. The secondary outcomes included the details of neuropathic component of PMPS using Pain Detect Questionnaire (PDQ) score and Neuropathic Pain Symptom Inventory (NPSI) score, psychological health using Hospital Anxiety and Depression scale (HADS), Activity assessment scale (AAS) and QoL using short form (SF)-12 questionnaire. MATERIALS AND METHODS This study was undertaken in accordance with the declaration of Helsinki following approval of institutional ethics committee- Human [IEC-Human, University college of Medical Sciences, Delhi University, India] and a written informed consent was taken from each patient. As a self-funded study, no additional financial support received from elsewhere. Patients of American Society of Anaesthesiologists (ASA) physical status I – II, aged 20–65 years, undergoing modified radical mastectomy for breast cancer were included in the study. Patients were excluded if had a history of seizure disorder, known sensitivity or contraindication to pregabalin, or on an active treatment with pregabalin, gabapentin or other opioids, or having diabetes mellitus, or with evidence of renal insufficiency, or concurrently enrolled in another yoga program. It Preoperatively, all the patients were oriented to the details of the various questionnaires and scales to which they were subjected for assessment at various designated intervals (at the end of 24hrs, end of 3rd day, 14th day, 30th day, 60th day, 90th, and 120th day post-operatively). All patients were assessed for their predisposition to development of chronic pain by assessing them for generalized pain syndromes like headache, low back pain, musculoskeletal pain, tendency for exaggerated pain at other than operated site. Also, a detailed psychological evaluation of patients was done using Hospital Anxiety and Depression scale (HADS) in the perioperative period. The normal HADS score is 0–7, and were labelled as borderline abnormal if it is 8–10, and abnormal if more than 11. The functional status of patients was assessed by Activity assessment scale (AAS) using a 12-points questionnaire. Preoperatively, all the patients were started on tablet pregabalin 75 mg BID a day before surgery and continued thereafter till four weeks post-operatively. All patients also received thoracic paravertebral block preoperatively and analgesia was continued till 72 hrs. On postoperative day 3, patients were randomly allocated into one of the two groups using a computer-generated random number table. Allocation concealment was done using sequentially-numbered opaque sealed envelopes. Patients in control group received integrated pain management approach using pregabalin and thoracic paravertebral block; however, patients in Yoga group in addition received yoga (pranayama) as an intervention. Standard anaesthesia technique was adopted in all patients that comprised of preoperative fluoroscopy-guided thoracic paravertebral catheter insertion followed by administration of general anaesthesia (GA). Anaesthesia was maintained using oxygen, nitrous oxide, isoflurane/sevoflurane, neuromuscular blockers, IV opioids, and paravertebral top-ups at regular intervals. A multimodal approach for perioperative pain management including intravenous (IV) paracetamol 1gm 6 hourly and paravertebral top ups of bupivacaine 0.25% was continued for 72 hours. On post-operative day 3, patients in Yoga group were familiarized with the “Anulom-Vilom” breathing exercise. In the postoperative period, a detailed evaluation for intensity and quality of pain was done by using three different questionnaires at various designated intervals. All the patients were oriented to respond to the final details of the various questionnaires such as Visual Analogue Scale (VAS) [ 9 ], Pain Detect Questionnaire (PDQ) [ 10 ] and Neuropathic Pain Symptoms Inventory (NPSI). [ 11 ] Visual Analogue Scale (VAS) Pain Scores: A detailed evaluation for intensity of pain was done by using VAS at varying intervals (mild = 1–3, moderate = 4–6 and severe = > 7). Pain Detect Questionnaire (PDQ): An evaluation of neuropathic component of pain was done by PDQ scoring at designated time intervals (score range between 0 to 35, possibility of neuropathic component of pain between 13–18, & highly likely if more than 18). Neuropathic Pain Symptom Inventory (NPSI): NPSI was evaluated at designated time intervals and was graded from a scale of 0–10. The aforementioned data collection tools are validated and reliable. Before discharge from the hospital all patients were instructed to note the pain in operated breast, surrounding area and ipsilateral upper limb. These patients were followed up at designated time points i.e., at 24 hours, Day 3, 14, 30, 60 and Day 90. Patients were labelled to have PMPS if found to have “chronic pain in the anterior aspect of the thorax, axilla, and / or upper half of the arm beginning after mastectomy and persisting at the end of for third month after the surgery”. [ 3 ] In the event of unsatisfactory pain relief (VAS ≥ 3/10), rescue analgesia was supplemented with oral administration of combination of tab. acetaminophen 325 mg + tramadol 37.5 mg. Adequate record of the weekly consumption of rescue analgesia therapy was maintained in the pain diary. The functional status of the patients was assessed by Activity assessment scale (AAS), using a 12-point questionnaire post-operatively. The quality-of-life assessment was done using short form 12 (SF-12) questionnaire post-operatively. The quality of life was studied using SF-12 questionnaire which consisted of two components i.e., physical component summary (PCS) and mental component summary (MCS). The PCS and MCS scores have a range of 0 to 100 and were designed to have a mean score of 50 and a standard deviation of 10. Thus, a score greater than 50 represents an above average health status. Activity assessment scale involves a set of 12 questions to assess the functional activity of the patient, during the past 24 hours and each activity is scaled from 1–5 i.e., from “no difficulty’’ to “not able to do’’. If the patient did not perform that activity due to some other reason, a score of 8 was given. The AAS scores were recorded at Preoperative day, Day 3, Day 60, and Day 90 and SF-12 scores were recorded at Day 3, Day 60, and Day 90. Any untoward side-effects of the multimodal analgesia approach like dizziness, somnolence, weight gain, headache, nausea and vomiting all were recorded. Yogic Intervention Yogic breathing exercise/ pranayama “Anulom-Vilom” was started on the postoperative day 3 and was continued throughout the study period i.e., till day 90. The yoga instructor demonstrated the pranayama to the patients, also a two-minute video of anulom vilom was shared with the participants. The patients were instructed to perform it, and any deviation from the recommended methodology was corrected by the instructor. Patients were observed daily till the time they got discharged, to ensure they follow the correct method to perform anulom vilom for 10 minutes every day and were also asked to maintain a diary in which every day’s yogic exercise was entered along with the need for rescue analgesia, if needed. Methodology of ‘’Anulom-Vilom’’: Patients were asked to sit in the meditative posture keeping the spine and head erect with eyes closed. Patient was instructed to inhale through left nostril for four seconds and exhale through right nostril for six seconds, then inhale through right nostril for four seconds and exhale through left nostril for six seconds, and continue this cycle for five minutes. The breath should be slow, steady and controlled. Slowly, the duration was increased to 10 minutes. Sample size and Statistical Analysis Sample size: As we could not find a similar study, evaluating a non-pharmacological intervention like yogic exercise like pranayama ‘anulom vilom’, along with an integrated multimodal approach using pregabalin and thoracic paravertebral block on PMPS. we enrolled as many as 40 participants 20 in each group, as per the frequency of breast cancer cases operated for modified radical mastectomy at our institute. The statistical analysis of pool data was done using SPSS software (Version-20). The mean and standard deviation were calculated for various scores, assuming the variance between groups is to be equal, unpaired t-test was used to compare the two groups. Proportions were compared using chi-square test. A p value ≤ 0.05 was considered statistically significant RESULTS A total of forty-seven patients met the inclusion criteria and were included in the study. Four patients in Yoga group and three in the control group could not be followed up till the completion of the study period. Finally, forty patients were included in the study [Figure.1] Demographic parameters i.e. age, weight, ASA physical status and duration of surgery were found to be comparable between the two groups. A detailed preoperative psychological evaluation of patients was done using Hospital Anxiety and Depression scale (HADS) and AAS score are shown in the table and were found to be comparable. [Table 1]. A decreased mean VAS scores in Yoga group was observed when compared to the control groups at all time points; however, the difference was not found to be statistically significant [Table 2]. Eventually, at the end of third month, the number of patients in control group and Yoga group with VAS ≥3 was six (30%) and two (10 %) patients, respectively [Table 3]. Similarly, a greater fall in PDQ score was observed in Yoga group when compared to the control group at each designated time points. However, the difference was not found to be statistically significant [Table. 4]. Table 5 depicts the NPSI scoring for ‘’Burning sensation’’, ‘’Allodynia’’ and ‘’Pins and needles’’, respectively. In all, the fall was observed in NPSI scores in the Yoga group when compared to the control group; however, it did not reach the statistical significance. NPSI Scores for “Squeezing’’, “Pressure sensation”, “Stabbing’’, “Electric shock” and “Tingling sensation’’ could not be evaluated as the data generated was insufficient for statistical analysis due to the limited sample size. The quality of life was studied using SF-12 questionnaire and a greater rise in PCS scores was observed in Yoga group at day 90; however, it remained comparable at day 30 and day 60. Similarly, in MCS score a rise was observed in day 60 and day 90 in Yoga group when compared to the control group. The difference; however, was not observed to be statistically significant for both PCS and MCS at any time point. Decrease in AAS score was observed in Yoga group at all time points i.e., day 3, 60 and 90. However, the difference was not found to be statistically significant [Table. 6]. All the adverse effects were observed for the first six weeks of follow up and no patient required any active medical intervention. DISCUSSION This is the first study evaluating a non-pharmacological intervention like yogic exercise like pranayama ‘anulom vilom’, along with an integrated multimodal approach using pregabalin and thoracic paravertebral block on PMPS, psychological health and QoL. We observed a decreased mean VAS score, PDQ scores, NPSI scores; however, not significant. Also, we observed an improvement in AAS score and SF-12 scores depicting improved functional status and quality of life, respectively in the Yoga group. In the present study, Yoga intervention along with the aforementioned integrated multimodal approach has shown a reduced incidence of PMPS i.e. (10%, n = 2) when compared to the control group (30%: n = 6). As far as the neuropathic component of pain is concerned, the results in terms of reduced PDQ score and NPSI scores reflects the potential role of yoga intervention on the neuropathic component of pain; however, not statistically significant except for “Allodynia”. Most of the RCTs have shown that yoga-based interventions decrease fatigue, depressions, anxiety and improves other subjective measures of well-being. [ 4 , 5 , 12 – 14 ] We cannot compare the findings of our study, as the present study is the first RCT evaluating the role of yoga intervention along with integrated pain management approach on the incidence and severity of a pain modality like PMPS. In the present study, a decreased mean VAS scores were observed in the Yoga group when compared to the control group at all time points; however, not statistically significant. In the only cohort study by Sudarshan et al, involving 14 patients observed that yoga intervention improved pain symptoms in breast cancer patients along with anxiety, depression and physical function. The study used the Dallas pain questionnaire (DPQ), a 16-item scale to evaluate the impact of pain on daily activity, work, anxiety/ depression and social life; however, its application in oncology is still limited. Each item was graded by the patient on the basis of VAS. Similar to our study, decreasing trends were reflected in terms of the effect of pain on daily activity (6 vs 13), work and leisure (5 vs 3), and anxiety/ depression (6 vs 14) when compared to the pre-treatment mean values. But again, the results did not reach statistical significance. [ 8 ] The exact mechanism of yoga on pain mechanism has still been a mystery. However, Wren et al described various possible mechanisms that could potentially explain the benefits of yoga for persistent pain conditions such as physiological changes that alter the pain experience like decreases in sympathetic nervous system activity (e.g., decreases in heart rate), reductions in inflammatory markers (e.g., tumor necrosis factor, interleukin-II, CRP) and stress markers (e.g., cortisol), and increases in flexibility, strength, circulation, and cardiorespiratory capacity. [ 15 – 20 ] Also, yoga may produce behavioral changes and psychological changes that can influence the pain perception. [ 21 ] Yoga has also been shown to increase the frequency of positive emotions which could potentially undo the physiological effects of negative emotions, broaden cognitive processes (e.g., taking a broader perspective on problems), and thus building physical (e.g., improved sense of health), social (e.g., improved social support) and psychological (e.g., optimism) resources. [ 21 – 23 ] Despite all aforementioned advantages no study till now has evaluated its role as an adjunct for postoperative pain management in postmastectomy patients. The functional status and QoL as assessed by AAS and SF-12 questionnaire were found to be improved in the patients in Yoga group at all time points; however, not statistically significant. The finding was in concordance to the systematic review by Cramer et al, where they assessed the effect of yoga on health-related QoL, mental health and cancer-related symptoms in women undergoing treatment or those who have completed treatment for breast cancer and found yoga to be more effective than no therapy. Both the groups were found to be comparable in terms of the preoperative anxiety, depression and activity status of the patients as recorded from HADS and AAS. The relationship between psychological morbidity and development of PMPS is well established. HAD score is expected to be abnormal in patients with carcinoma due to underlying anxiety and depression. Seah et al. did a study on metastatic breast cancer patients and observed that 20% of patients met the criteria of anxiety and depression after one year of diagnosis, this is in contrast to normal HAD score in breast cancer patients included in the present study. [ 24 ] Khan et al integrated Yogic exercises (Anulom vilom) in patients undergoing VATS and robotic thoracic surgery. Wherein Yoga exercises were taught to the patient in the pre-operative clinic. They found that integrated practice is beneficial in terms of early recovery, reduced complications and overcoming of thoracotomy pain, and that the integrative practice is cost effective. [ 25 ] The components of yoga which are very commonly applied for health benefits are asanas (physical postures), pranayama (regulated breathing) and meditation. The components of yoga like breath regulation (anulom vilom/ pranayama), mindfulness (meditation) during practice, and importance given to maintenance of postures (asanas) are some of the elements which differentiate yoga practices from physical exercises. Govindraj et al found yoga to be equal or superior to physical exercise in most outcome measure. [ 26 ] The study dealt with few limitations, Firstly, we included only pranayama ‘Anulom vilom’. The addition of other components of yoga would have yielded better results; however, it is not feasible in postoperative period. Secondly, all patients received epidural tops and not continuous epidural analgesia due to logistic issues. Furthermore, the patients enrolled in Yoga group could not be supervised round-the-clock following their discharge, there was no cut-off number for the completed sessions before the final analysis. However, the patients were educated to perform yoga and maintain their dairy. Finally, a small sample size and data from a single academic institute is another limitation. Although a strong trend towards improvement in pain intensity and wellbeing scores were observed, it did not reach statistical significance which could be attributed to the limited sample size. Conclusion This is the first study evaluating yogic intervention/ pranayama along with the multimodal pain management approach in patients undergoing Breast cancer surgeries. A decreased incidence of PMPS was observed in Yoga group (10%) as compared to the control group (30%); however not statistically significant. Similarly, improvement in the neuropathic component, functional status and quality of life were also observed with yoga. The study encourages the integration of yoga, a simple, cost effective non pharmacological intervention which is easy to learn and perform like yogic exercise along with the multimodal pain management approach in patients undergoing breast cancer surgery. Further multicentric randomized controlled trials with a larger sample size is needed to validate the findings of the present study Declarations Author Contribution P.G., A.S, G.C. made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; P.G., G.C, drafted the work or revised it critically for important intellectual content; A.S, P.G. approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors reviewed the manuscript. Conflict of Interest: None Source of Funding: None. References Kakati B, Nair N, Chatterjee A. Post mastectomy pain syndrome at an Indian tertiary cancer centre and its impact on quality of life. Indian J Cancer. 2023 Apr-Jun;60(2):275–281. doi: 10.4103/ijc.ijc_861_21 . PMID: 37530253. 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Complement Ther Med. 2007;15(3):164–71. doi: 10.1016/j.ctim.2006.06.008 . Epub 2006 Aug 22. PMID: 17709061. Carson JW, Carson KM, Porter LS, Keefe FJ, Shaw H, Miller JM. Yoga for women with metastatic breast cancer: results from a pilot study. J Pain Symptom Manage. 2007;33(3):331 – 41. doi: 10.1016/j.jpainsymman.2006.08.009. PMID: 17349503. Galantino ML, Bzdewka TM, Eissler-Russo JL, Holbrook ML, Mogck EP, Geigle P, Farrar JT. The impact of modified Hatha yoga on chronic low back pain: a pilot study. Altern Ther Health Med. 2004 Mar-Apr;10(2):56–9. PMID: 15055095. Fredrickson BL, Tugade MM, Waugh CE, Larkin GR. What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. J Pers Soc Psychol. 2003;84(2):365–76. doi: 10.1037//0022-3514.84.2.365 . PMID: 12585810; PMCID: PMC2755263. Seah DS, Lin NU, Curley C, Weiner EP, Partridge AH. Informational needs and the quality of life of patients in their first year after metastatic breast cancer diagnosis. J Community Support Oncol. 2014;12(10):347 – 54. doi: 10.12788/jcso.0077 . PMID: 25853256. Khan AZ, Pillai GG. From 200 BC to 2015 AD: an integration of robotic surgery and Ayurveda/Yoga. J Thorac Dis. 2016;8(Suppl 1):S84-92. doi: 10.3978/j.issn.2072-1439.2016.01.74 . PMID: 26941975; PMCID: PMC4756240. Govindaraj R, Karmani S, Varambally S, Gangadhar BN. Yoga and physical exercise - a review and comparison. Int Rev Psychiatry. 2016;28(3):242 – 53. doi: 10.3109/09540261.2016.1160878 . Epub 2016 Apr 4. PMID: 27044898. Tables Table 1: Patient Characteristics. Patient Characteristics Control Group Yoga Group p-value Demographic Parameters Age (years) 49.75 ± 9.89 Range : 35-64 48.90 ± 10.49 Range : 27-64 *0.79 Weight ( Kilograms) 54.65±4.98 Range :46 -67 55.75±6.69 Range : 47-65 *0.55 Duration of surgery ( minutes) 140.50±22.47 Range :110-180 143.45± 24.96 Range: 110-190 *0.69 ASA Grade- I number (%) 8 (40%) 7(35%) *0.744 ASA Grade- II number(%) 12 (60%) 13(65%) *0.50 Preoperative psychologic and activity assessment HADS (Anxiety score) (Mean ± SD) 8.10 ± 3.52 7.50 ± 3.53 *0.59 HADS (Depression score) (Mean ± SD) 7.10 ± 3.07 6.15 ± 2.45 *0.28 Pre-operative AAS score (Mean ± SD) 29.40±11.57 23.25±10.56 *0.12 *p<0.05 significant Table 2: Visual Analogue Scale (VAS) Pain Scores 1-a Visual Analogue Scale (VAS) Pain Scores: (Mean±SD) Time interval Control Group (Mean±SD) Yoga Group (Mean±SD) F- value (Intergroup) Inter group p-value At 24 Hours 6.50±1.50 5.95±1.39 316.682 0.28* At Day 3 5.15±1.46 4.90±1.21 At Day 14 4.45±1.57 4.05±0.99 At Day 30 3.70±1.75 3.40±0.88 At Day 60 3.00±1.68 2.55±0.94 At Day 90 2.35±1.38 1.70±1.21 *p- value > 0.05 [Not significant] after intergroup adjustment for “sphericity correction” by “Mauchly’s test” Table 3: Frequency of patients with VAS Pain Score ≥ 3 at various interval Frequency of patients with VAS Pain Score ≥ 3 at various interval: Values are in number (%) Time Interval Control Group Yoga Group p- value At 30 days 14 (70%) 18 (90%) 0.235 At 60 Days 9 (45%) 7 (35%) 0.746 At 90 Days 6 (30%) 2 (10%) 0.235 *p<0.05 significant Table 4: Patient Detect Questionnaire (PDQ) score: values are in (Mean±SD) Time interval Control Group (Mean±SD) Yoga Group (Mean±SD) Inter group F value Inter group p-value At 24 Hours 17.95±6.26 15.85±5.38 2.109 0.155* At Day 3 15.5±6.35 12.90±4.78 At Day 14 13.0±6.36 10.60±5.26 At Day 30 11.20±6.70 8.55±4.91 At Day 60 9.80±6.80 6.70±4.73 At Day 90 8.20±6.91 5.20±5.02 *p- value > 0.05 [Not significant] after intergroup adjustment for “sphericity correction” by “Mauchly’s test” Table 5: Neuropathic Pain Symptom Inventory (NPSI) Scores Time interval Control Group (Mean ± SD) Yoga Group (Mean ± SD) Inter group F value Inter group p-value NPSI Scores for “Burning sensation”: At 24 Hours 4.11±3.11 4.80±2.72 0.226 0.637 At Day 3 3.53±2.95 3.65±2.41 At Day 14 3.16±2.75 2.70±2.17 At Day 30 2.63±2.38 1.95±2.01 At Day 60 2.26±2.23 1.40±1.78 At Day 90 1.79±1.81 0.90±1.48 NPSI Scores for “Allodynia” At 24 Hours 6.20±2.82 4.25±2.97 4.518 *0.040 At Day 3 4.30±2.13 2.90±2.19 At Day 14 3.25±1.77 2.10±1.80 At Day 30 2.10±1.37 1.40±1.46 At Day 60 1.55±1.35 0.95±1.09 At Day 90 0.85±0.81 0.40±0.68 NPSI Scores for “Pins & needle sensation” At 24 Hours 5.50±3.00 5.20±2.87 0.154 0.697 At Day 3 4.10±2.22 3.90±2.33 At Day 14 3.20±1.76 3.00±2.02 At Day 30 2.20±1.32 2.10±1.44 At Day 60 1.50±1.05 1.25±1.07 At Day 90 0.95±0.75 0.80±0.76 *p=0.040, p- value <0.05 [significant] after intergroup adjustment for “sphericity correction” by “Mauchly’s test” Table 6: Short Form -12 Quality of Life Questionnaire scores (SF-12 QoL scores) & Activity assessment scale (AAS) scores: Values are in Mean ±SD SF-12 for QoL PCS and MCS SF-12 PCS=Physical Component Summary Time Interval Control Group Yoga Group Inter group p- Value* Day 30 38.70±3.31 38.50±3.79 0.581 Day 60 44.50±2.68 43.80±3.00 Day 90 48.40±2.47 49.35±2.18 SF-12 MCS= Mental Component Summary Day 30 40.15±3.16 40.65±2.58 Day 60 46.20±2.19 47.15±1.95 Day 90 49.55±2.06 50.35±1.81 Activity assessment scale (AAS) scores AAS Scores Pre-operative 29.40±11.57 23.25±10.56 0.12 Day 3 35.25±16.07 28.45±14.799 Day 60 22.85±7.24 19.95±6.62 Day 90 15.85±3.46 14.25±2.33 PCS- Physical Component Summary, MCS Mental Component Summary *p- value > 0.05 [Not significant] after intergroup adjustment for “sphericity correction” by “Mauchly’s test”. Additional Declarations No competing interests reported. Supplementary Files GRAPHICALABSTRACT.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3865638","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267534036,"identity":"d7d5c107-7b50-4c0d-b70b-fe8c3467cc63","order_by":0,"name":"Prakash Gondode","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYDCCA1DCQP799x8fgGw2dqK1MCQYSM4AaWEmRYs0D4hDSAvf7bPHPvw4Y2dvznAgwdjm1zZ5PmYGxg8fc3BrkTyXlzyz50Zy4s7GhgPJuX23DduYGZglZ27DrcXgDI8xA88H5gSDw4wNh3N7bjMCtbAx8xLQwvjnQ729wTFmxmbLntv2RGlh5rlxmHHDGTZmZoYftxMJapE8w5fMLHPmeOKGGzxsjL0Nt5PbgLbh9QvfGd7DjG+OVdsbALUw/Phz23Z+e/PBDx/xaGFg4EFiM7aByQZ86tG0MPwhoHgUjIJRMApGJAAA1J1TqLU6tAkAAAAASUVORK5CYII=","orcid":"","institution":"All India Institute of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Gondode","suffix":""},{"id":267534037,"identity":"b325eaa8-3cec-4061-b20c-32cb527ce227","order_by":1,"name":"Ashok Kumar Saxena","email":"","orcid":"","institution":"University College of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ashok","middleName":"Kumar","lastName":"Saxena","suffix":""},{"id":267534038,"identity":"65820b94-e462-4fd7-8617-98d6495c377e","order_by":2,"name":"Geetanjali Chilkoti","email":"","orcid":"","institution":"University College of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Geetanjali","middleName":"","lastName":"Chilkoti","suffix":""}],"badges":[],"createdAt":"2024-01-15 06:59:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3865638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3865638/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49804380,"identity":"b91bc630-dff8-48ec-9178-aec14a66b23c","added_by":"auto","created_at":"2024-01-18 09:46:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":158828,"visible":true,"origin":"","legend":"\u003cp\u003eConsort Flow Diagram\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3865638/v1/43c3a88d31861316da1fbedd.png"},{"id":50951647,"identity":"679198cc-2af9-451c-936f-a11ea5dbcda5","added_by":"auto","created_at":"2024-02-10 12:00:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":519103,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3865638/v1/e3c1cfbd-a395-4fa1-9d81-36e913502877.pdf"},{"id":49804381,"identity":"c39d8a31-789a-4d68-8873-bb1c3e93657a","added_by":"auto","created_at":"2024-01-18 09:46:31","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":282143,"visible":true,"origin":"","legend":"","description":"","filename":"GRAPHICALABSTRACT.docx","url":"https://assets-eu.researchsquare.com/files/rs-3865638/v1/38ee33f2df86991847e44aea.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of integrating Yoga along with multimodal pain management approach on post-mastectomy pain syndrome in patients undergoing breast cancer surgery.","fulltext":[{"header":"Study Highlights","content":"\u003cul\u003e\n \u003cli\u003eFirst study to evaluate the role of yoga \u0026lsquo;pranayama\u0026rsquo; as an adjunct along with integrated multimodal pain management approach on the incidence and severity of PMPS.\u003c/li\u003e\n \u003cli\u003eA decreased incidence of PMPS was observed in Yoga group (10%) as compared to the control group (30%).\u003c/li\u003e\n \u003cli\u003eA greater fall in Pain Detect Questionnaire (PDQ) scores and Neuropathic Pain Symptom Inventory (NPSI) scores were observed in Yoga group reflecting its potential role as an adjunct in minimizing the neuropathic component of pain.\u003c/li\u003e\n \u003cli\u003eAn improvement in the functional status and the quality of life post-operatively.\u003c/li\u003e\n \u003cli\u003eThe present study encourages the integration of yoga along with the multimodal pain management approach using TPVB and pregabalin in patients undergoing breast cancer surgery. \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003ePost mastectomy pain syndrome (PMPS), a type of chronic neuropathic pain disorder is a common sequelae of breast cancer surgery and has been reported to be around 20%-70%. [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Yoga is a popular form of many complementary and alternative medicine (CAM). It is an adjunctive approach and has been studied extensively as a potential intervention for patients with cancer. Various studies have evaluated the effect of yoga on breast cancer patients and survivors and have mainly studied psychologic health and quality of life (QoL). [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOn literature search, we could retrieve only two articles evaluating the impact of yoga therapy on pain symptoms in patients undergoing breast cancer surgery. Sudarshan et al studied the impact of yoga therapy on anxiety, depression and physical health in breast cancer patients and found that there was improvement in physical function in addition to a consistent amelioration in anxiety, depression and pain symptoms after a yoga intervention. Another study by Galentino et al studied the impact of yoga on objective functional outcomes, pain, and health-related quality of life for Aromatase Inhibitors -associated arthralgia in breast cancer survivors and found that yoga may reduce pain and improve balance and flexibility. The limitations of these studies were however; limited sample size, lack of control group, use of non-validated pain scale, and the neuropathic component of pain and PMPS were also not evaluated. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOn PubMed and MEDLINE search, we also could not retrieve any study evaluating the integration of yogic exercises along with pregabalin and thoracic paravertebral block as a multimodal approach on the incidence of post-mastectomy pain syndrome. With this background, this study aimed to evaluate the efficacy of yogic exercises along with integrated approach encompassing pregabalin and thoracic paravertebral block on incidence of post-mastectomy pain syndrome. The secondary outcomes included the details of neuropathic component of PMPS using Pain Detect Questionnaire (PDQ) score and Neuropathic Pain Symptom Inventory (NPSI) score, psychological health using Hospital Anxiety and Depression scale (HADS), Activity assessment scale (AAS) and QoL using short form (SF)-12 questionnaire.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e This study was undertaken in accordance with the declaration of Helsinki following approval of institutional ethics committee- Human [IEC-Human, University college of Medical Sciences, Delhi University, India] and a written informed consent was taken from each patient. As a self-funded study, no additional financial support received from elsewhere. Patients of American Society of Anaesthesiologists (ASA) physical status I \u0026ndash; II, aged 20\u0026ndash;65 years, undergoing modified radical mastectomy for breast cancer were included in the study. Patients were excluded if had a history of seizure disorder, known sensitivity or contraindication to pregabalin, or on an active treatment with pregabalin, gabapentin or other opioids, or having diabetes mellitus, or with evidence of renal insufficiency, or concurrently enrolled in another yoga program. It\u003c/p\u003e \u003cp\u003ePreoperatively, all the patients were oriented to the details of the various questionnaires and scales to which they were subjected for assessment at various designated intervals (at the end of 24hrs, end of 3rd day, 14th day, 30th day, 60th day, 90th, and 120th day post-operatively). All patients were assessed for their predisposition to development of chronic pain by assessing them for generalized pain syndromes like headache, low back pain, musculoskeletal pain, tendency for exaggerated pain at other than operated site. Also, a detailed psychological evaluation of patients was done using Hospital Anxiety and Depression scale (HADS) in the perioperative period. The normal HADS score is 0\u0026ndash;7, and were labelled as borderline abnormal if it is 8\u0026ndash;10, and abnormal if more than 11. The functional status of patients was assessed by Activity assessment scale (AAS) using a 12-points questionnaire.\u003c/p\u003e \u003cp\u003ePreoperatively, all the patients were started on tablet pregabalin 75 mg BID a day before surgery and continued thereafter till four weeks post-operatively. All patients also received thoracic paravertebral block preoperatively and analgesia was continued till 72 hrs. On postoperative day 3, patients were randomly allocated into one of the two groups using a computer-generated random number table. Allocation concealment was done using sequentially-numbered opaque sealed envelopes. Patients in control group received integrated pain management approach using pregabalin and thoracic paravertebral block; however, patients in Yoga group in addition received yoga (pranayama) as an intervention.\u003c/p\u003e \u003cp\u003eStandard anaesthesia technique was adopted in all patients that comprised of preoperative fluoroscopy-guided thoracic paravertebral catheter insertion followed by administration of general anaesthesia (GA). Anaesthesia was maintained using oxygen, nitrous oxide, isoflurane/sevoflurane, neuromuscular blockers, IV opioids, and paravertebral top-ups at regular intervals.\u003c/p\u003e \u003cp\u003eA multimodal approach for perioperative pain management including intravenous (IV) paracetamol 1gm 6 hourly and paravertebral top ups of bupivacaine 0.25% was continued for 72 hours. On post-operative day 3, patients in Yoga group were familiarized with the \u0026ldquo;Anulom-Vilom\u0026rdquo; breathing exercise.\u003c/p\u003e \u003cp\u003eIn the postoperative period, a detailed evaluation for intensity and quality of pain was done by using three different questionnaires at various designated intervals. All the patients were oriented to respond to the final details of the various questionnaires such as Visual Analogue Scale (VAS) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], Pain Detect Questionnaire (PDQ) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and Neuropathic Pain Symptoms Inventory (NPSI). [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eVisual Analogue Scale (VAS) Pain Scores: A detailed evaluation for intensity of pain was done by using VAS at varying intervals (mild\u0026thinsp;=\u0026thinsp;1\u0026ndash;3, moderate\u0026thinsp;=\u0026thinsp;4\u0026ndash;6 and severe\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;7). Pain Detect Questionnaire (PDQ): An evaluation of neuropathic component of pain was done by PDQ scoring at designated time intervals (score range between 0 to 35, possibility of neuropathic component of pain between 13\u0026ndash;18, \u0026amp; highly likely if more than 18). Neuropathic Pain Symptom Inventory (NPSI): NPSI was evaluated at designated time intervals and was graded from a scale of 0\u0026ndash;10. The aforementioned data collection tools are validated and reliable. Before discharge from the hospital all patients were instructed to note the pain in operated breast, surrounding area and ipsilateral upper limb. These patients were followed up at designated time points i.e., at 24 hours, Day 3, 14, 30, 60 and Day 90.\u003c/p\u003e \u003cp\u003ePatients were labelled to have PMPS if found to have \u0026ldquo;chronic pain in the anterior aspect of the thorax, axilla, and / or upper half of the arm beginning after mastectomy and persisting at the end of for third month after the surgery\u0026rdquo;. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn the event of unsatisfactory pain relief (VAS\u0026thinsp;\u0026ge;\u0026thinsp;3/10), rescue analgesia was supplemented with oral administration of combination of tab. acetaminophen 325 mg\u0026thinsp;+\u0026thinsp;tramadol 37.5 mg. Adequate record of the weekly consumption of rescue analgesia therapy was maintained in the pain diary.\u003c/p\u003e \u003cp\u003eThe functional status of the patients was assessed by Activity assessment scale (AAS), using a 12-point questionnaire post-operatively. The quality-of-life assessment was done using short form 12 (SF-12) questionnaire post-operatively. The quality of life was studied using SF-12 questionnaire which consisted of two components i.e., physical component summary (PCS) and mental component summary (MCS). The PCS and MCS scores have a range of 0 to 100 and were designed to have a mean score of 50 and a standard deviation of 10. Thus, a score greater than 50 represents an above average health status. Activity assessment scale involves a set of 12 questions to assess the functional activity of the patient, during the past 24 hours and each activity is scaled from 1\u0026ndash;5 i.e., from \u0026ldquo;no difficulty\u0026rsquo;\u0026rsquo; to \u0026ldquo;not able to do\u0026rsquo;\u0026rsquo;. If the patient did not perform that activity due to some other reason, a score of 8 was given. The AAS scores were recorded at Preoperative day, Day 3, Day 60, and Day 90 and SF-12 scores were recorded at Day 3, Day 60, and Day 90.\u003c/p\u003e \u003cp\u003eAny untoward side-effects of the multimodal analgesia approach like dizziness, somnolence, weight gain, headache, nausea and vomiting all were recorded.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eYogic Intervention\u003c/h2\u003e \u003cp\u003eYogic breathing exercise/ pranayama \u0026ldquo;Anulom-Vilom\u0026rdquo; was started on the postoperative day 3 and was continued throughout the study period i.e., till day 90. The yoga instructor demonstrated the pranayama to the patients, also a two-minute video of anulom vilom was shared with the participants. The patients were instructed to perform it, and any deviation from the recommended methodology was corrected by the instructor. Patients were observed daily till the time they got discharged, to ensure they follow the correct method to perform anulom vilom for 10 minutes every day and were also asked to maintain a diary in which every day\u0026rsquo;s yogic exercise was entered along with the need for rescue analgesia, if needed.\u003c/p\u003e \u003cp\u003eMethodology of \u0026lsquo;\u0026rsquo;Anulom-Vilom\u0026rsquo;\u0026rsquo;: Patients were asked to sit in the meditative posture keeping the spine and head erect with eyes closed. Patient was instructed to inhale through left nostril for four seconds and exhale through right nostril for six seconds, then inhale through right nostril for four seconds and exhale through left nostril for six seconds, and continue this cycle for five minutes. The breath should be slow, steady and controlled. Slowly, the duration was increased to 10 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSample size and Statistical Analysis\u003c/h2\u003e \u003cp\u003eSample size: As we could not find a similar study, evaluating a non-pharmacological intervention like yogic exercise like pranayama \u0026lsquo;anulom vilom\u0026rsquo;, along with an integrated multimodal approach using pregabalin and thoracic paravertebral block on PMPS. we enrolled as many as 40 participants 20 in each group, as per the frequency of breast cancer cases operated for modified radical mastectomy at our institute.\u003c/p\u003e \u003cp\u003eThe statistical analysis of pool data was done using SPSS software (Version-20). The mean and standard deviation were calculated for various scores, assuming the variance between groups is to be equal, unpaired t-test was used to compare the two groups. Proportions were compared using chi-square test. A p value\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered statistically significant\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of forty-seven patients met the inclusion criteria and were included in the study. Four patients in Yoga group and three in the control group could not be followed up till the completion of the study period. Finally, forty patients were included in the study [Figure.1] \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDemographic parameters i.e. \u0026nbsp;age, weight, ASA physical status and duration of surgery were found to be comparable between the two groups. A detailed preoperative psychological evaluation of patients was done using Hospital Anxiety and Depression scale (HADS) and AAS score are shown in the table and were found to be comparable. [Table 1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA decreased mean VAS scores in Yoga group was observed when compared to the control groups at all time points; however, the difference was not found to be statistically significant [Table 2]. Eventually, at the end of third month, the number of patients in control group and Yoga group with VAS \u0026ge;3 was six (30%) and two (10 %) patients, respectively [Table 3]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, a greater fall in PDQ score was observed in Yoga group when compared to the control group at each designated time points. However, the difference was not found to be statistically significant [Table. 4]. Table 5 depicts the NPSI scoring for \u0026lsquo;\u0026rsquo;Burning sensation\u0026rsquo;\u0026rsquo;, \u0026lsquo;\u0026rsquo;Allodynia\u0026rsquo;\u0026rsquo; and \u0026lsquo;\u0026rsquo;Pins and needles\u0026rsquo;\u0026rsquo;, respectively. In all, the fall was observed in NPSI scores in the Yoga group when compared to the control group; however, it did not reach the statistical significance. NPSI Scores for \u0026ldquo;Squeezing\u0026rsquo;\u0026rsquo;, \u0026ldquo;Pressure sensation\u0026rdquo;, \u0026ldquo;Stabbing\u0026rsquo;\u0026rsquo;, \u0026ldquo;Electric shock\u0026rdquo; and \u0026ldquo;Tingling sensation\u0026rsquo;\u0026rsquo; could not be evaluated as the data generated was insufficient for statistical analysis due to the limited sample size.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe quality of life was studied using SF-12 questionnaire and a greater rise in PCS scores was observed in Yoga group at day 90; however, it remained comparable at day 30 and day 60. Similarly, in MCS score a rise was observed in day 60 and day 90 in Yoga group when compared to the control group. The difference; however, was not observed to be statistically significant for both PCS and MCS at any time point. Decrease in AAS score was observed in Yoga group at all time points i.e., day 3, 60 and 90. However, the difference was not found to be statistically significant [Table. 6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the adverse effects were observed for the first six weeks of follow up and no patient required any active medical intervention.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis is the first study evaluating a non-pharmacological intervention like yogic exercise like pranayama \u0026lsquo;anulom vilom\u0026rsquo;, along with an integrated multimodal approach using pregabalin and thoracic paravertebral block on PMPS, psychological health and QoL. We observed a decreased mean VAS score, PDQ scores, NPSI scores; however, not significant. Also, we observed an improvement in AAS score and SF-12 scores depicting improved functional status and quality of life, respectively in the Yoga group.\u003c/p\u003e \u003cp\u003eIn the present study, Yoga intervention along with the aforementioned integrated multimodal approach has shown a reduced incidence of PMPS i.e. (10%, n\u0026thinsp;=\u0026thinsp;2) when compared to the control group (30%: n\u0026thinsp;=\u0026thinsp;6). As far as the neuropathic component of pain is concerned, the results in terms of reduced PDQ score and NPSI scores reflects the potential role of yoga intervention on the neuropathic component of pain; however, not statistically significant except for \u0026ldquo;Allodynia\u0026rdquo;. Most of the RCTs have shown that yoga-based interventions decrease fatigue, depressions, anxiety and improves other subjective measures of well-being. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] We cannot compare the findings of our study, as the present study is the first RCT evaluating the role of yoga intervention along with integrated pain management approach on the incidence and severity of a pain modality like PMPS.\u003c/p\u003e \u003cp\u003eIn the present study, a decreased mean VAS scores were observed in the Yoga group when compared to the control group at all time points; however, not statistically significant. In the only cohort study by Sudarshan et al, involving 14 patients observed that yoga intervention improved pain symptoms in breast cancer patients along with anxiety, depression and physical function. The study used the Dallas pain questionnaire (DPQ), a 16-item scale to evaluate the impact of pain on daily activity, work, anxiety/ depression and social life; however, its application in oncology is still limited. Each item was graded by the patient on the basis of VAS. Similar to our study, decreasing trends were reflected in terms of the effect of pain on daily activity (6 vs 13), work and leisure (5 vs 3), and anxiety/ depression (6 vs 14) when compared to the pre-treatment mean values. But again, the results did not reach statistical significance. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe exact mechanism of yoga on pain mechanism has still been a mystery. However, Wren et al described various possible mechanisms that could potentially explain the benefits of yoga for persistent pain conditions such as physiological changes that alter the pain experience like decreases in sympathetic nervous system activity (e.g., decreases in heart rate), reductions in inflammatory markers (e.g., tumor necrosis factor, interleukin-II, CRP) and stress markers (e.g., cortisol), and increases in flexibility, strength, circulation, and cardiorespiratory capacity. [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Also, yoga may produce behavioral changes and psychological changes that can influence the pain perception. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] Yoga has also been shown to increase the frequency of positive emotions which could potentially undo the physiological effects of negative emotions, broaden cognitive processes (e.g., taking a broader perspective on problems), and thus building physical (e.g., improved sense of health), social (e.g., improved social support) and psychological (e.g., optimism) resources. [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Despite all aforementioned advantages no study till now has evaluated its role as an adjunct for postoperative pain management in postmastectomy patients.\u003c/p\u003e \u003cp\u003eThe functional status and QoL as assessed by AAS and SF-12 questionnaire were found to be improved in the patients in Yoga group at all time points; however, not statistically significant. The finding was in concordance to the systematic review by Cramer et al, where they assessed the effect of yoga on health-related QoL, mental health and cancer-related symptoms in women undergoing treatment or those who have completed treatment for breast cancer and found yoga to be more effective than no therapy.\u003c/p\u003e \u003cp\u003eBoth the groups were found to be comparable in terms of the preoperative anxiety, depression and activity status of the patients as recorded from HADS and AAS. The relationship between psychological morbidity and development of PMPS is well established. HAD score is expected to be abnormal in patients with carcinoma due to underlying anxiety and depression. Seah et al. did a study on metastatic breast cancer patients and observed that 20% of patients met the criteria of anxiety and depression after one year of diagnosis, this is in contrast to normal HAD score in breast cancer patients included in the present study. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eKhan et al integrated Yogic exercises (Anulom vilom) in patients undergoing VATS and robotic thoracic surgery. Wherein Yoga exercises were taught to the patient in the pre-operative clinic. They found that integrated practice is beneficial in terms of early recovery, reduced complications and overcoming of thoracotomy pain, and that the integrative practice is cost effective. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe components of yoga which are very commonly applied for health benefits are asanas (physical postures), pranayama (regulated breathing) and meditation. The components of yoga like breath regulation (anulom vilom/ pranayama), mindfulness (meditation) during practice, and importance given to maintenance of postures (asanas) are some of the elements which differentiate yoga practices from physical exercises. Govindraj et al found yoga to be equal or superior to physical exercise in most outcome measure. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe study dealt with few limitations, Firstly, we included only pranayama \u0026lsquo;Anulom vilom\u0026rsquo;. The addition of other components of yoga would have yielded better results; however, it is not feasible in postoperative period. Secondly, all patients received epidural tops and not continuous epidural analgesia due to logistic issues. Furthermore, the patients enrolled in Yoga group could not be supervised round-the-clock following their discharge, there was no cut-off number for the completed sessions before the final analysis. However, the patients were educated to perform yoga and maintain their dairy. Finally, a small sample size and data from a single academic institute is another limitation. Although a strong trend towards improvement in pain intensity and wellbeing scores were observed, it did not reach statistical significance which could be attributed to the limited sample size.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis is the first study evaluating yogic intervention/ pranayama along with the multimodal pain management approach in patients undergoing Breast cancer surgeries. A decreased incidence of PMPS was observed in Yoga group (10%) as compared to the control group (30%); however not statistically significant. Similarly, improvement in the neuropathic component, functional status and quality of life were also observed with yoga. The study encourages the integration of yoga, a simple, cost effective non pharmacological intervention which is easy to learn and perform like yogic exercise along with the multimodal pain management approach in patients undergoing breast cancer surgery. Further multicentric randomized controlled trials with a larger sample size is needed to validate the findings of the present study\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eP.G., A.S, G.C. made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; P.G., G.C, drafted the work or revised it critically for important intellectual content; A.S, P.G. approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors reviewed the manuscript.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflict of Interest: None\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding: None.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKakati B, Nair N, Chatterjee A. Post mastectomy pain syndrome at an Indian tertiary cancer centre and its impact on quality of life. Indian J Cancer. 2023 Apr-Jun;60(2):275\u0026ndash;281. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ijc.ijc_861_21\u003c/span\u003e\u003cspan address=\"10.4103/ijc.ijc_861_21\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37530253.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHetta DF, Mohamed SAB, Mohamed KH, Mahmoud TAE, Eltyb HA. 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Yoga and physical exercise - a review and comparison. Int Rev Psychiatry. 2016;28(3):242\u0026thinsp;\u0026ndash;\u0026thinsp;53. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/09540261.2016.1160878\u003c/span\u003e\u003cspan address=\"10.3109/09540261.2016.1160878\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 Apr 4. PMID: 27044898.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Patient Characteristics.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.857142857142854%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYoga Group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Parameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.673469387755105%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\"\u003e\n \u003cp\u003e49.75\u0026nbsp;\u0026plusmn;\u0026nbsp;9.89\u003c/p\u003e\n \u003cp\u003eRange : 35-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\"\u003e\n \u003cp\u003e48.90\u0026nbsp;\u0026plusmn;\u0026nbsp;10.49\u003c/p\u003e\n \u003cp\u003eRange : 27-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\"\u003e\n \u003cp\u003e*0.79\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\"\u003e\n \u003cp\u003eWeight ( Kilograms)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\"\u003e\n \u003cp\u003e54.65\u0026plusmn;4.98\u003c/p\u003e\n \u003cp\u003eRange :46 -67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\"\u003e\n \u003cp\u003e55.75\u0026plusmn;6.69\u003c/p\u003e\n \u003cp\u003eRange : 47-65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\"\u003e\n \u003cp\u003e*0.55\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\"\u003e\n \u003cp\u003eDuration of surgery\u003c/p\u003e\n \u003cp\u003e( minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\"\u003e\n \u003cp\u003e140.50\u0026plusmn;22.47\u003c/p\u003e\n \u003cp\u003eRange :110-180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\"\u003e\n \u003cp\u003e143.45\u0026plusmn;\u0026nbsp;24.96\u003c/p\u003e\n \u003cp\u003eRange: 110-190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\"\u003e\n \u003cp\u003e*0.69\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\"\u003e\n \u003cp\u003eASA Grade- I\u003c/p\u003e\n \u003cp\u003enumber (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\"\u003e\n \u003cp\u003e8 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\"\u003e\n \u003cp\u003e7(35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\"\u003e\n \u003cp\u003e*0.744\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\" valign=\"top\"\u003e\n \u003cp\u003eASA Grade- II\u003c/p\u003e\n \u003cp\u003enumber(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\" valign=\"top\"\u003e\n \u003cp\u003e12 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\" valign=\"top\"\u003e\n \u003cp\u003e13(65%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\" valign=\"top\"\u003e\n \u003cp\u003e*0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative psychologic and activity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eassessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.673469387755105%\"\u003e\n \u003cp\u003eHADS (Anxiety score) (Mean\u0026nbsp;\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\"\u003e\n \u003cp\u003e8.10\u0026nbsp;\u0026plusmn;\u0026nbsp;3.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.367346938775512%\"\u003e\n \u003cp\u003e7.50 \u0026plusmn; \u0026nbsp;3.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.346938775510203%\"\u003e\n \u003cp\u003e*0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\"\u003e\n \u003cp\u003eHADS (Depression score)\u0026nbsp;(Mean\u0026nbsp;\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\"\u003e\n \u003cp\u003e7.10\u0026nbsp;\u0026plusmn;\u0026nbsp;3.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\"\u003e\n \u003cp\u003e6.15\u0026nbsp;\u0026plusmn;\u0026nbsp;2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\"\u003e\n \u003cp\u003e*0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.07865168539326%\" valign=\"top\"\u003e\n \u003cp\u003ePre-operative\u003c/p\u003e\n \u003cp\u003eAAS score\u0026nbsp;(Mean\u0026nbsp;\u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.59550561797753%\" valign=\"top\"\u003e\n \u003cp\u003e29.40\u0026plusmn;11.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.224719101123597%\" valign=\"top\"\u003e\n \u003cp\u003e23.25\u0026plusmn;10.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.10112359550562%\" valign=\"top\"\u003e\n \u003cp\u003e*0.12\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;*p\u0026lt;0.05 significant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Visual Analogue Scale (VAS) Pain Scores\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e1-a Visual Analogue Scale (VAS) Pain Scores: (Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eTime interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003eControl Group (Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003eYoga Group (Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.235494880546074%\" valign=\"top\"\u003e\n \u003cp\u003eF- value (Intergroup)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.600682593856654%\" valign=\"top\"\u003e\n \u003cp\u003eInter group p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eAt 24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003e6.50\u0026plusmn;1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003e5.95\u0026plusmn;1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.235494880546074%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e316.682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.600682593856654%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.28*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.712765957446805%\" valign=\"top\"\u003e\n \u003cp\u003e5.15\u0026plusmn;1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.78723404255319%\" valign=\"top\"\u003e\n \u003cp\u003e4.90\u0026plusmn;1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.712765957446805%\" valign=\"top\"\u003e\n \u003cp\u003e4.45\u0026plusmn;1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.78723404255319%\" valign=\"top\"\u003e\n \u003cp\u003e4.05\u0026plusmn;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.712765957446805%\" valign=\"top\"\u003e\n \u003cp\u003e3.70\u0026plusmn;1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.78723404255319%\" valign=\"top\"\u003e\n \u003cp\u003e3.40\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.712765957446805%\" valign=\"top\"\u003e\n \u003cp\u003e3.00\u0026plusmn;1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.78723404255319%\" valign=\"top\"\u003e\n \u003cp\u003e2.55\u0026plusmn;0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.712765957446805%\" valign=\"top\"\u003e\n \u003cp\u003e2.35\u0026plusmn;1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.78723404255319%\" valign=\"top\"\u003e\n \u003cp\u003e1.70\u0026plusmn;1.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p- value \u0026gt; 0.05 [Not significant] after intergroup adjustment for \u0026ldquo;sphericity correction\u0026rdquo; by \u0026ldquo;Mauchly\u0026rsquo;s test\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFrequency\u0026nbsp;of\u0026nbsp;patients\u0026nbsp;with\u0026nbsp;VAS\u0026nbsp;Pain\u0026nbsp;Score\u0026nbsp;\u0026ge;\u0026nbsp;3\u0026nbsp;at\u0026nbsp;various\u0026nbsp;interval\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eFrequency\u0026nbsp;of\u0026nbsp;patients\u0026nbsp;with\u0026nbsp;VAS\u0026nbsp;Pain\u0026nbsp;Score\u0026nbsp;\u0026ge;\u0026nbsp;3\u0026nbsp;at\u0026nbsp;various\u0026nbsp;interval:\u0026nbsp;Values\u0026nbsp;are\u0026nbsp;in\u0026nbsp;number (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eTime Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Control Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003eYoga Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.83617747440273%\" valign=\"top\"\u003e\n \u003cp\u003ep- value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eAt 30 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003e14 (70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003e18 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.83617747440273%\" valign=\"top\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eAt 60 Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003e7 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.83617747440273%\" valign=\"top\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.061433447098977%\" valign=\"top\"\u003e\n \u003cp\u003eAt 90 Days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.98976109215017%\" valign=\"top\"\u003e\n \u003cp\u003e6 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.112627986348123%\" valign=\"top\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.83617747440273%\" valign=\"top\"\u003e\n \u003cp\u003e0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*p\u0026lt;0.05 significant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Patient Detect Questionnaire (PDQ) score: values are in (Mean\u0026plusmn;SD)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.104895104895103%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTime interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.454545454545453%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl Group (Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.32867132867133%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYoga Group (Mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInter group F value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.377622377622377%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInter group p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.104895104895103%\" valign=\"top\"\u003e\n \u003cp\u003eAt 24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.454545454545453%\" valign=\"top\"\u003e\n \u003cp\u003e17.95\u0026plusmn;6.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.32867132867133%\" valign=\"top\"\u003e\n \u003cp\u003e15.85\u0026plusmn;5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.734265734265735%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.377622377622377%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.155*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.48587570621469%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.05084745762712%\" valign=\"top\"\u003e\n \u003cp\u003e15.5\u0026plusmn;6.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.463276836158194%\" valign=\"top\"\u003e\n \u003cp\u003e12.90\u0026plusmn;4.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.48587570621469%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.05084745762712%\" valign=\"top\"\u003e\n \u003cp\u003e13.0\u0026plusmn;6.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.463276836158194%\" valign=\"top\"\u003e\n \u003cp\u003e10.60\u0026plusmn;5.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.48587570621469%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.05084745762712%\" valign=\"top\"\u003e\n \u003cp\u003e11.20\u0026plusmn;6.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.463276836158194%\" valign=\"top\"\u003e\n \u003cp\u003e8.55\u0026plusmn;4.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.48587570621469%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.05084745762712%\" valign=\"top\"\u003e\n \u003cp\u003e9.80\u0026plusmn;6.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.463276836158194%\" valign=\"top\"\u003e\n \u003cp\u003e6.70\u0026plusmn;4.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.48587570621469%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.05084745762712%\" valign=\"top\"\u003e\n \u003cp\u003e8.20\u0026plusmn;6.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.463276836158194%\" valign=\"top\"\u003e\n \u003cp\u003e5.20\u0026plusmn;5.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;*p- value \u0026gt; 0.05 [Not significant] after intergroup adjustment for \u0026ldquo;sphericity correction\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eby \u0026ldquo;Mauchly\u0026rsquo;s test\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Neuropathic Pain Symptom Inventory (NPSI) Scores\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.039735099337747%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTime interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.178807947019866%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl Group (Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eYoga Group (Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInter group F value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInter group p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eNPSI Scores for \u0026ldquo;Burning sensation\u0026rdquo;:\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.039735099337747%\" valign=\"top\"\u003e\n \u003cp\u003eAt 24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.178807947019866%\" valign=\"top\"\u003e\n \u003cp\u003e4.11\u0026plusmn;3.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4.80\u0026plusmn;2.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.637\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e3.53\u0026plusmn;2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e3.65\u0026plusmn;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e3.16\u0026plusmn;2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e2.70\u0026plusmn;2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e2.63\u0026plusmn;2.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e1.95\u0026plusmn;2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e2.26\u0026plusmn;2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e1.40\u0026plusmn;1.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1.79\u0026plusmn;1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e0.90\u0026plusmn;1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eNPSI Scores for \u0026ldquo;Allodynia\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.039735099337747%\" valign=\"top\"\u003e\n \u003cp\u003eAt 24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.178807947019866%\" valign=\"top\"\u003e\n \u003cp\u003e6.20\u0026plusmn;2.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e4.25\u0026plusmn;2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.518\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e*0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e4.30\u0026plusmn;2.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e2.90\u0026plusmn;2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e3.25\u0026plusmn;1.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e2.10\u0026plusmn;1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e2.10\u0026plusmn;1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e1.40\u0026plusmn;1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1.55\u0026plusmn;1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u0026plusmn;1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e0.85\u0026plusmn;0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e0.40\u0026plusmn;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eNPSI Scores for \u0026ldquo;Pins \u0026amp; needle sensation\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.039735099337747%\" valign=\"top\"\u003e\n \u003cp\u003eAt 24 Hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.178807947019866%\" valign=\"top\"\u003e\n \u003cp\u003e5.50\u0026plusmn;3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e5.20\u0026plusmn;2.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.562913907284768%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.218543046357617%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.697\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e4.10\u0026plusmn;2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e3.90\u0026plusmn;2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e3.20\u0026plusmn;1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e3.00\u0026plusmn;2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e2.20\u0026plusmn;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e2.10\u0026plusmn;1.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e1.50\u0026plusmn;1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e1.25\u0026plusmn;1.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.32512315270936%\" valign=\"top\"\u003e\n \u003cp\u003eAt Day 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u0026plusmn;0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.19211822660098%\" valign=\"top\"\u003e\n \u003cp\u003e0.80\u0026plusmn;0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;*p=0.040, p- value \u0026lt;0.05 [significant] after intergroup adjustment for \u0026ldquo;sphericity correction\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eby \u0026ldquo;Mauchly\u0026rsquo;s test\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Short Form -12 Quality of Life Questionnaire scores (SF-12 QoL scores) \u0026amp; Activity assessment scale (AAS) scores: Values are in Mean \u0026plusmn;SD\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eSF-12 for QoL PCS and MCS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.940199335548172%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSF-12\u003c/p\u003e\n \u003cp\u003ePCS=Physical\u003c/p\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003cp\u003eSummary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\" valign=\"top\"\u003e\n \u003cp\u003eTime Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.764119601328904%\" valign=\"top\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.26578073089701%\" valign=\"top\"\u003e\n \u003cp\u003eYoga Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.601328903654483%\" valign=\"top\"\u003e\n \u003cp\u003eInter group p-\u003c/p\u003e\n \u003cp\u003eValue*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.11336032388664%\" valign=\"top\"\u003e\n \u003cp\u003eDay 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.303643724696357%\" valign=\"top\"\u003e\n \u003cp\u003e38.70\u0026plusmn;3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.696356275303643%\" valign=\"top\"\u003e\n \u003cp\u003e38.50\u0026plusmn;3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.88663967611336%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e44.50\u0026plusmn;2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e43.80\u0026plusmn;3.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e48.40\u0026plusmn;2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e49.35\u0026plusmn;2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.31404958677686%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eSF-12\u003c/p\u003e\n \u003cp\u003eMCS= Mental\u003c/p\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003cp\u003eSummary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.65289256198347%\" valign=\"top\"\u003e\n \u003cp\u003eDay 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.826446280991735%\" valign=\"top\"\u003e\n \u003cp\u003e40.15\u0026plusmn;3.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.206611570247933%\" valign=\"top\"\u003e\n \u003cp\u003e40.65\u0026plusmn;2.58\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e46.20\u0026plusmn;2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e47.15\u0026plusmn;1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e49.55\u0026plusmn;2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e50.35\u0026plusmn;1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eActivity assessment scale (AAS) scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.940199335548172%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eAAS Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\" valign=\"top\"\u003e\n \u003cp\u003ePre-operative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.764119601328904%\" valign=\"top\"\u003e\n \u003cp\u003e29.40\u0026plusmn;11.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.26578073089701%\" valign=\"top\"\u003e\n \u003cp\u003e23.25\u0026plusmn;10.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.601328903654483%\" rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e35.25\u0026plusmn;16.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e28.45\u0026plusmn;14.799\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e22.85\u0026plusmn;7.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e19.95\u0026plusmn;6.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.308510638297875%\" valign=\"top\"\u003e\n \u003cp\u003eDay 90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.244680851063826%\" valign=\"top\"\u003e\n \u003cp\u003e15.85\u0026plusmn;3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.4468085106383%\" valign=\"top\"\u003e\n \u003cp\u003e14.25\u0026plusmn;2.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;PCS- Physical Component Summary, MCS Mental Component Summary\u003c/p\u003e\n\u003cp\u003e*p- value \u0026gt; 0.05 [Not significant] after intergroup adjustment for \u0026ldquo;sphericity correction\u0026rdquo; by \u0026ldquo;Mauchly\u0026rsquo;s test\u0026rdquo;.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anulom Vilom, Chronic pain, Neuropathic pain, Post Mastectomy Pain Syndrome, Quality of Life, Yoga","lastPublishedDoi":"10.21203/rs.3.rs-3865638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3865638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim \u0026amp; Background:\u003c/strong\u003e To evaluate the efficacy of Yogic intervention (pranayama) along with integrated multimodal approach on the incidence and severity of post mastectomy pain syndrome (PMPS) in patients undergoing surgery for breast cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods: \u003c/strong\u003eForty patients aged 20-65 years undergoing breast cancer surgery of American Society of Anaesthesiologists physical status I – II were included. All patients received thoracic paravertebral block and tablet pregabalin till the end of the fourth postoperative week. Patients were randomly allocated into one of the two groups; “Control” and “Yoga.” Patients in the Yoga group practiced yogic exercise “Anulom-vilom’’ from post operative day 3 till day 90. The primary outcome was incidence of PMPS and secondary outcomes include Pain Detect Questionnaire (PDQ) score, Neuropathic Pain Symptom Inventory (NPSI) score, Activity assessment scores (AAS) and Quality of Life (QoL) using Short Form (SF)-12 score.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A reduced incidence of PMPS (10% vs 30%), mean VAS pain score, PDQ, and NPSI was observed in Yoga group along with improvement in SF-12 scores and AAS score in post mastectomy patients; however, not statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis study encourages the integration of yoga along with multimodal pain management approach for PMPS.\u003c/p\u003e","manuscriptTitle":"Effect of integrating Yoga along with multimodal pain management approach on post-mastectomy pain syndrome in patients undergoing breast cancer surgery.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-18 09:46:27","doi":"10.21203/rs.3.rs-3865638/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b0dfb9c-0fe2-49f3-ae06-7da76e7d2d77","owner":[],"postedDate":"January 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-10T12:00:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-18 09:46:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3865638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3865638","identity":"rs-3865638","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}