As part of my 500 hour yoga teacher training I was required to choose an area of specialisation. Any topic you wanted to deepen your knowledge on. I am an obsessive reader and at any given time I am reading about three books. So this wide invitation was quite a quest to narrow down, and ultimately I cheated a little, because I choose a diagnosis with symptoms in almost all areas of life. I choose Fibromyalgia (FM), because I felt inadequate in helping people with FM.
FM is a chronic pain condition, of unknown origin, that affects 15 million people in the USA and 6.6% of the population in Western Europe. The word “Fibromyalgia” stems from New Latin, “fibro”, meaning fibrous or connective tissue, “myo” meaning muscle, and “algos” meaning pain. The term fibromyalgia describes the symptoms precisely: “pain of the muscle and connective tissue”. Connective tissue is abundant in our bodies. It can be found in ligaments, tendons, blood vessels, between nerves and in fascia. Therefor symptoms of FM is widespread and don’t necessarily form a pattern. Symptoms of FM include:
- widespread musculoskeletal pain
- sleep disturbances (waking unrefreshed)
- irritable bowel syndrome (IBS)
- morning stiffness
There is no gold standard radiology or laboratory test to confirm FM diagnosis. Even with these staggering statistics the pathophysiology of FM is poorly understood, by health care professionals, patients and the general public alike. There is no cure for FM. Pharmacological treatment may have side effects and the risk of developing dependency. A treatment strategy is needed to address not only the physical symptoms, but also effective coping strategies.
Diagnosis is based on a history of widespread, chronic pain (three month duration) and acute tenderness or pain on local pressure applied to at least 11 of 18 tender points. The American College of Rheumatology (ACR) described the symptoms for diagnosis of FM for the first time in 1990. They used an image of the Three Graces by Babtiste to show the site of tender points.
Recently the ACR proposed the use of the wide spread pain index (WPI) and symptom severity (SS) scale, to supplement the physical examination.
The pathology can be traced back to altered pain processing, in both the central and peripheral nervous system, genetic factors, autonomic dysfunction and emotional, physical or environmental stressors. Abnormal pain processing (nociception) of a hyper aroused nervous system (central sensitization) causes allodynia. “Allodynia is the perception of pain resulting from a stimulus that would not normally be painful”, so something someone else may not even notice, can cause pain to someone with FM. This implies that fibromyalgia patients have a decreased threshold for nociception (pain perception) and that less stimulus is needed to cause a pain response than with a normal functioning nervous system. So double whammy from the start. This may be directly linked to metabolic dysfunction in the hippocampus (specifically the hypothalamic pituitary adrenal axis (HPA)), an area in the brain responsible for regulating sleep, nociception and cognitive function. Cortisol is a steroid hormone, released from the adrenal glands in response to low blood sugar levels or stress. Dysregulation of cortisol will lead to dysregulation of the HPA, and result in hormonal imbalance of cortisol, growth and thyroid hormones. Hormonal imbalance effects pain, fatigue, immune function, mood and sleep. It is not only the hyper arroused nervous system in FM patients, but the pain modulating system (responsible for dampening the intensity of pain sensation) is under active, with lower levels of serotonin, dopamine and norepinephrine.
Medication may be used for pain, anxiety, depression and sleep disturbances. Pharmacological intervention include nonsteroidal anti-inflammatory drugs (NSAIDs), opiods, antidepressants and anticonvulsions. According to Carson et al (2010) drug therapies are only 30% affective in symptom relief and 20% effective in improving function. Medication use have the risk of side effects and the Food and Drug Administration (FDA) are not currently testing any new drugs to treat FM. Other, less potentially dangerous treatment options are needed for FM. Newer treatment protocols advise combination of drug treatment with exercise and coping strategies.
Drum roll, please….as yoga enters the picture. In the last decade more research has been done to determine the potential benefits that yoga may have for patients with FM. Some of these studies, comparing yoga intervention with controls, will be discussed next. The Fibromyalgia Impact Questionnaire (FIQ) or Fibromyalgia Impact Questionnaire Revised (FIQR) was used to assess pre and post intervention symptom severity. Scores range from 0 – 100, higher scores indicate more burden from symptoms. The Visual Analogue Scale (VAS) was used to determine pain intensity.
Da Silva et al (2007) compared yoga with and without Tui Na (traditional eastern massage technique) treatment. Thirty three patients, aged 25 – 60, were enrolled in the study (17 patients were assigned to receive Tui Na treatment in conjunction with the yoga practice). The therapy consisted of eight weekly, one on one sessions, of 50 minute duration. Gentle single plane movements were included in the asana practice, followed by seven minutes of diaphragmatic breathing, whereafter 15 minutes of relaxation techniques ended the session. After the class different texts on yogic philosophy was read. The Tui Na technique was done on patients assigned to the group during their relaxation phase. Both groups showed statistically significant improvement in FIQ and VAS scores. This study demonstrated that yoga is a valid treatment option for FM patients.
Yoga of Awareness was used as an intervention in a randomized control trial. This program combined gentle yoga asana, meditation, pranayama and yoga based coping strategies. The study consisted of 53 woman, older than 21, meeting the ACR diagnostic criteria. Participants were randomly assigned to start the yoga program immediately or wait listed for three months (control group). The yoga intervention consisted of an eight week program, with once weekly 120 minutes group classes. The classes consisted of 40 minutes gentle asana, 25 minutes mindfulness meditation, 10 minutes pranayama, 20 minutes presentations of yogic principles for optimal coping and 25 minutes group discussion. Repetitive and eccentric contractions were minimized to reduce micro trauma to muscles, slow transitions were used to aid in autonomic nervous dysregulation. Improvement in pain, fatigue, stiffness, sleep, depression, memory, anxiety, tenderness, balance and strength were reported after intervention.
Hennard (2011) recruited 11 individuals, between the ages of 27 – 70 years, to participate in a Yoga for Fibromyalgia workshop. The workshop consisted of once weekly group sessions, for eight weeks, 75 minutes in duration. Sessions included 10 minutes pranayama, 15 minutes group discussion, 35 minutes asana practice and 15 minutes Savasana and meditation. Props were used and adjustments made where necessary. Students received a handout of each class to encourage a home practice. FIQ scores post eight week intervention showed significant improvement in the overall severity of symptoms.
Curtis et al (2011) enrolled 19 women (aged 17 – 71 years) to a yoga program. Participants attended two 75 minute Hatha yoga classes each week, for eight weeks. The classes consisted of modified asana, pranayama, meditation, intension setting, mindfulness exercises and an introduction to the eight limbs of yoga. The results suggest that a specific Hatha yoga program can “improve pain and increase pain acceptance and mindfulness in a FM population”. The total cortisol output increased post intervention, suggesting that the yoga program can contribute to normalizing HPA dysregulation.
A systematic review by Langhorst et al (2013) concluded that mindful movement therapies reduces sleep disturbances, depressed mood and restrictions of health related quality of life. Of the mindful movement therapies studied only yoga yielded significant effects on pain and fatigue.
Yoga increases parasympathetic nervous system activity. This promotes the relaxation response by decreasing heart rate, increasing breath volume and digestive function. Considering the pathology for FM, some simple adaptations can be made to allow a FM patient to return to their practice. It is important to not increase pain perception, as this can lead to abandonment of the practice. Slow paced movement is encouraged throughout the asana practice. Options need to be given and guidance to not force any asana is important. Avoid inversions if the patient has complaints of dizziness or headaches. Pain inhibits deep breathing, shallow breaths increases anxiety. Nadi Shodhana pranayama stimulates the parasympathetic nervous system to increase feelings of calmness and relaxation and override the “fight and flight response” of an overactive sympathetic nervous system. Meditation may influence feelings of depression. It promotes compassion, appreciation for our place in the whole and relationship with others, therefor it can reduce feelings of isolation. A common compliant amongst FM patients is morning stiffness. Scheduling practice later in the day is therefor advisable.
Yoga offers a variety of benefits for a person diagnosed with FM. Yoga is a comprehensive option to address the symptoms of FM, without possibly dangerous side effects. A consistent yoga practice is an active treatment option, which gives a patient with FM strategies to manage their symptoms within their day to day life. These coping mechanisms gives a patient back their independence and sense of control. A group class setting can be a wonderful social support network, where patients can share their experience and feel less isolated.
If you have the opportunity to add yoga to your treatment you may need less medication and find an overall improvement in your quality of life. You definitely have nothing to lose.