by Nikhil Ramburn and Sat Bir Singh Khalsa, Ph.D.
For centuries, muscle pains have been known as rheumatism but the term Fibromyalgia (FM) was not coined until 1976. It was even more recently, in 1981 that the first clinical study validated the symptoms associated with FM, and there was some historical period of controversy as to the underpinnings of this disorder and whether this was in fact a credible and distinct disease condition. Fibromyalgia is a syndrome that affects muscles and soft connective tissue and the symptoms include chronic pain, fatigue, disturbed sleep, and mood issues. Somewhat unique to FM is the existence of painful tender points or trigger points across the body. Researchers believe that FM amplifies pain by affecting the way that the brain processes pain signals. Onset of this disorder can sometimes be attributed to physical trauma, surgery, infection, or psychological stress. FM is one of the most common chronic pain conditions with an estimated 10 million people affected in the U.S. While close to 90% of FM patients are women, the disorder also occurs in men and children of all ethnic groups. Conventional treatment includes pain medication, antidepressants, and sleeping pills aimed at managing symptoms. However, the common drug side effects include dizziness, nausea, fatigue, and the serotonin-norepinephrine reuptake inhibitor class of antidepressants may raise blood pressure and cause heart palpitations. Other conventional recommendations include physical therapy, relaxation training, and cognitive behavioral therapy, the latter treatment attesting to the role that thought processes and psychological factors play in pain syndromes.
Complementary and integrative treatment approaches such as yoga and meditation are also widely used by patients with FM in search of relief. Yoga provides many of the benefits associated with the treatments mentioned above and may be useful as complementary treatment for FM. Patients with FM tend towards inactivity and yoga provides light physical activity that can slowly improve physical conditioning. The increased flexibility is important for patients who present stiffness and muscular shortenings that can worsen fatigue and pain. In addition, the strength and cardiovascular gains from yoga may provide a basis for further aerobic exercises, which are indicated as beneficial for FM patients. Yoga, consistent with evidence in its positive role in pain regulation, can also contribute to the management of chronic pain by inhibiting brain activity in pain-related regions, such as the somatosensory cortex. Finally, the self-awareness and mindfulness developed by yoga may help to reduce levels of anxiety and depression, thereby also impacting the emotional components of pain. These gains in relaxation and pain reduction would also have positive effects on stress and sleep patterns.
In 2007 researchers from the University of Sao Paulo in Brazil, conducted the first clinical trial on the efficacy of yoga for FM treatment. Gerson Da Silva et al. studied 40 women who were randomized into a ‘yoga only’ group or a ‘yoga and massage’ group. For eight weeks, the subjects participated in stretching, breathing, and relaxing yoga techniques. In addition, the ’yoga and massage’ group also received Tui Na, which is a traditional form of Chinese bodywork. Researchers observed significant decreases in pain intensity and improvements on the Fibromyalgia Impact Questionnaire (a commonly used tool to evaluate the impact and symptoms of FM) in both groups. However, over time, contrary to the typical belief that more is better, the patients in the ‘yoga only’ group reported less pain intensity than the group that had added massage and bodywork, suggesting that a passive therapy could decrease control over FM symptoms and therapies which enhance self-efficacy may be preferable.
Another landmark study investigated the effects of yoga on cortisol levels in FM patients. Cortisol is a steroid hormone that is produced in response to stress and may have secondary effects on pain, fatigue, immune function, and sleep. Researchers from York University in Toronto, Canada investigated 22 female subjects who participated in 75-minute gentle Hatha yoga classes consisting of postures, breathing, and meditation, twice weekly for 8 weeks. The results suggested that a yoga intervention can reduce pain and catastrophizing (dysfunctional negative thoughts), increase acceptance, and alter total cortisol levels in women with FM. While the yoga intervention did not result in improvements in anxiety and depression scores, other yoga studies of women with FM have shown this additional benefit. Nonetheless, the observed changes in cortisol levels provide preliminary objective evidence for the mechanisms underlying the efficacy of yoga for FM patients.
A more recent study, published in the International Journal of Yoga Therapy in 2016 was led by yoga researcher James Carson of the Oregon Health & Science University in Portland, OR. His research team’s previous pilot studies showed significant improvement in FM patients after a yoga intervention. Long-term follow-up evaluations showed that patients sustained most of their treatment gains. The study collected pilot data on 7 female patients who participated in an 8-week yoga intervention, with 120-minute classes weekly. The classes included gentle stretching, meditation, breathing techniques, and didactic presentations on the application of yogic principles to optimal coping. They recorded significant changes in heat pain tolerance, pressure pain threshold, and heat pain after-sensations. These improvements suggest mitigation of several abnormalities associated with FM such as increased sensitivity to heat and lower pain tolerance. This small study sheds light on how yoga may affect pain pathways in FM patients and reveals some of the underlying mechanisms by which positive outcomes are achieved.
Not surprisingly, these early studies, while encouraging, are limited by small sample sizes and in some cases, the absence of a control group. Larger randomized control trials (RCTs) are required to add statistical power and better understand the mechanisms underlying the efficacy of yoga interventions. Furthermore, these studies have focused on females with the condition, and it would be useful to include male participants in future trials to increase the generalizability of the findings. An ongoing study sponsored by the U.S. Department of Veteran Affairs is, in fact, recruiting both male and female veterans with FM to participate in an RCT comparing the effectiveness of a yoga-based intervention with a structured exercise program.