by Nikhil Ramburn and Sat Bir S. Khalsa, Ph.D.
Multiple Sclerosis (MS) is a chronic disease with an unpredictable course characterized by inflammation and neurodegeneration of the central nervous system, specifically demyelination (nerve cells in the brain are wrapped in myelin, which insulates and protects the cells and helps speed nerve transmission). These processes cause symptoms such as pain, muscle cramps, stiffness, spasms, and fatigue. Stress is an aggravating factor that exacerbates demyelination. This disorder is an autoimmune condition (in which the body’s immune system actually works against its own cells and tissues) and the trigger responsible for it is unknown. Like most autoimmune illnesses, female patients are affected 2 to 3 times more frequently than males. MS is the third most common cause of disability in the United States in individuals 15 to 50 years old. The premature morbidity and productivity lost to this disability results in major financial burdens on the patient, family, and healthcare system. An individual’s quality of life is likewise affected due to restricted mobility, chronic pain, and impaired social cognition that in turn often leads to decreased self-worth, anxiety, and depression. Unfortunately, pharmacological treatment is only modestly effective and is associated with serious side effects such as psychosis, seizures, and brain damage. On the other hand, conventional psychotherapy is a valuable part of MS management as it can help patients reduce chronic distress while improving psychosocial function.
To manage chronic stress, some patients have practiced complementary therapies such as Mindfulness Based Interventions (MBIs), which have provided improvements in quality of life, depression, and fatigue. The well-known Mindfulness-Based Stress Reduction program (MBSR) and other MBIs have become increasingly popular at managing different aspects of chronic illness in the last 30 years. Although published research studies of MBIs in MS are scarce, a 2014 review based on 3 studies of good methodological quality with a total of 183 patients indicated improvements in mental health and physical parameters such as fatigue. The beneficial effects of a mindfulness practice may be related to a decrease in emotional dysregulation and stress management as observed in lower levels of the stress hormone cortisol. There is strong evidence of improved activity and high adherence as well as a reduction in patient fatigue due to physical therapy. However, there is currently no definitive evidence for the effects of exercise on cognition in patients with MS.
Yoga may also prove to be a viable complementary therapy for MS since it provides the benefits of both physical activity and meditation and also includes breath regulation, which is known to be a useful strategy for pain management. Furthermore, traditional forms of yoga foster the cultivation of awareness, insight and spirituality which may further help patients cope with chronic pain. In fact, yoga has been shown to be as beneficial as aerobic exercise therapy and may be more practical for some MS patients as it is a low-impact form of exercise. Yoga as a therapeutic intervention is now well known to improve outcomes such as self-efficacy, mental health, and quality of life in a variety of conditions and is therefore a viable intervention candidate for MS patients and has been evaluated as such.
The first literature review and meta-analysis of studies of yoga for MS examined seven Randomized Control Trials (RCTs) with a total of 670 patients. This 2014 review was conducted by German researchers and a researcher from the Mashad University of Medical Sciences in Iran and revealed short-term benefits of yoga on fatigue and mood outcomes. In addition, yoga group participants reported fewer exacerbations of multiple sclerosis as compared to usual care or exercise treatment subjects. However, the current research has yet to highlight the impact of yoga on more objective physician-rated outcomes such as mobility and cognitive function in patients with MS and there is a potential methodological bias in studies to date. Despite such limitations, there is encouraging evidence that yoga is equally effective as conventional exercise interventions in improving both patient-reported and physician-rated outcomes.
The first randomized control trial of yoga in MS was published in 2014 and looked at a 6-month yoga intervention on 69 subjects who were randomized to one of three groups: yoga, exercise, or a control group. Weekly 90-minute modified Iyengar Yoga classes incorporated postures including support from walls and chairs to account for patient fatigue, spasticity, and cerebellar dysfunction. Classes emphasized breathing, relaxation, and meditation during the session and participants were also strongly encouraged to adhere to a daily home practice. The results demonstrated that the yoga program improved fatigue to the same degree as traditional exercise and had the same level of adherence as exercise.
A more recent pilot study conducted at a neuro-rehabilitation center in Germany evaluated the impact of a 3-week program of Integrated Yoga and Physical Therapy (IYP) on 11 patients. Participants received an intervention consisting of yogic physical postures, pranayama and meditations along with physical therapy (PT) techniques 5 days a week, for 5 hours each day. Researchers noted a significant improvement in visual reaction time as well as mental health outcomes such as depression and anxiety. Unfortunately, this study did not assess the effects of yoga and physical therapy separately and was limited by a small sample size and the lack of long-term follow-up data. Another study published in 2016 reported on the effects of a six-month yoga program developed at the College of Physical Education in Campinas, Brazil. A total of 12 women who had no prior experience with yoga were assigned to either a control or a yoga training group where they received weekly 60-min yoga classes. The researchers reported significant improvement in measures of postural balance only in the yoga group. Importantly, improvements with the yoga intervention were especially apparent in patients with a higher score on the disability status scale highlighting its feasibility for this population.
In summary, studies to date have demonstrated strong short-term and moderate long-term efficacy of yoga in alleviating symptoms in MS patients without significant adverse side-effects. Future research should evaluate changes in immune parameters and investigate which components of yoga practice might be providing the greatest efficacy for improving patient outcome. In addition, cost-effectiveness analyses are needed to assist in justifying the practical clinical implementation of yoga for MS and future research should also address the limitations of small sample size and risk of bias. Such future research efforts would improve our knowledge of the underlying mechanisms of yoga in MS treatment and allow yoga therapists to devise more effective interventions.