INTERNATIONAL JOURNAL OF YOGA THERAPY No. 22 (2012) 53. Gentle Hatha Yoga and Reduction of Fibromyalgia- Related Symptoms: A Preliminary Report

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1 INTERNATIONAL JOURNAL OF YOGA THERAPY No. 22 (2012) 53 Research Gentle Hatha Yoga and Reduction of Fibromyalgia- Related Symptoms: A Preliminary Report Lisa Rudrud, EdD Saint Mary's University of Minnesota Abstract Objectives and Methods: This study examined whether gentle Hatha yoga reduced fibromyalgia-related symptoms for a convenience sample of 10 participants ranging in age from 39 to 64 years who received yoga instruction 2 times per week for 8 weeks. Methods: Respondents completed the Fibromyalgia Impact Questionnaire 1 time per week and provided weekly journal reports regarding their health status. Pre- and postintervention manual tender point evaluations were also conducted. Results: Findings provide evidence of association between participating in gentle Hatha yoga classes and reduced fibro m y a l g i a - related symptoms. Conclusions: Ad d i t i o n a l r a n d o m i zed controlled trials with larger sample sizes and greater empirical rigor are needed to more fully understand this re l a t i o n s h i p. Key Words: yoga, fibromyalgia Introduction Fibromyalgia (FM) has been recognized in the medical lexicon for nearly 2 decades. 1 Individuals with FM commonly experience diffuse pain, sleep disturbance, anxiety, migraines, irritable bladder and bowel, and other conditions. There is a high degree of variability in its presentation, however. Two to 4 percent of the American population are affected by FM, the majority of whom are women. 2 Loss of physical mobility, concentration, memory, and motivation and the presence of depressive symptoms are most frequently endorsed as challenges related to living with FM. 3 A global survey of the impact of FM featured in United Business Media, June 2011, noted that FM poses a considerable financial burden on society as a result of inability to work and lost income. 3 This study evaluated whether participation in gentle Hatha yoga classes was associated with FM-symptom reduction. It takes an average of 1.9 to 2.7 years and multiple physicians to accurately detect and diagnose FM. One factor contributing to the length of time to diagnose FM is the lack of specific measurement strategies to diagnose the condition. 2 Historically, diagnosis of FM involved an assessment of pain on 18 specific sites called tender points. A patient received a diagnosis of FM if he or she endorsed tenderness of 11 of 18 points following palpation. This strategy yielded a considerable number of false diagnoses, however, and was replaced in May 2010 by a more standardized strategy that involved use of the widespread pain index (WPI) and the symptom severity (SS) scale. Using the WPI, patients rate whether they have experienced pain during the past week in 19 regions of the body. Using the SS, individuals rate the presence of symptoms, including fatigue, lack of mental clarity, and lack of restful sleep. 4 Patients receive a positive FM diagnosis if they endorse pain in 7 or more areas in combination with fatigue, cognitive impairments, and poor sleep for at least 3 months in the absence of any other disorder that could account for such symptoms or functional disturbances. Presently there is no cure for FM. Treatment includes both medication and nonpharmaceutical modalities. Complementary and alternative therapies, such as yoga,

2 54 INTERNATIONAL JOURNAL OF YOGA THERAPY No. 22 (2012) therapeutic massage, acupuncture, and other mind body therapies, may be useful; however, there is insufficient data to support their effectiveness. 2 This study explored whether gentle Hatha yoga was associated with reduction of symptoms and functional deficits for people with FM. Yoga and Fibromyalgia Several studies have examined the functional utility of regular yoga practice for reducing symptoms of FM. Curtis and colleagues reported an association between participating in yoga classes and reductions in pain and catastrophizing, increases in acceptance and mindfulness, and alterations in total cortisol levels in women with FM. 5 In a recent pilot study that used a yoga awareness program that included gentle poses, meditation, breathing exe rc i s e s, yoga-based coping instructions, and group discussions, Carson et al. found a trend toward improvement on stand a rd i zed measures of FM symptoms and functioning, including pain, fatigue, and mood, and in pain catastrophizing, acceptance, and other coping strategies. 6 Mindfulness-based stress reduction (MBSR) includes mindfulness meditation and mindfulness-based yoga. A total of 177 women with FM were randomly assigned to either an 8-week, structured MBSR program, an active control procedure controlling for nonspecific effects of MBSR, or a wait-list control group. Health-related quality of life was assessed at baseline and 2 months posttreatment, as were depression, pain, anxiety, somatic complaints, and a proposed index of mindfulness. Analyses did not support the efficacy of MBSR for individuals with FM; however, some modest benefits were detected for participants in the MBSR group. 7 Though a number of studies have examined the impact of yoga relative to changes in symptoms related to FM, there is a pressing need to better understand the relationship between yoga practice and improved health outcomes for individuals with FM. Given the modest evidence linking yoga with improved reductions in sleep disturbance, anxiety, and various types of chronic pain, it was hypothesized that individuals with FM who engaged in gentle Hatha yoga would evidence reductions in FM-related symptoms. Participants Methods Participants were required to have physician-diagnosed FM based on the criteria established by the American College of Rheumatology. Data collection for this study occurred prior to the adoption of the WPI and SS index for diagnosing FM. Participants ranged in age from 39 to 64 years and included women only. Participants did not have other health conditions that limited their ability to participate in yoga, such as chronic back pain from herniated or bulging discs, pregnancy, or hip or knee replacements. All shared symptoms of pain, sleep deprivation, and fatigue. Individuals were asked to continue their daily routines and current treatments but were instructed not to begin any new regimens during the study. If the participants began new treatments or changed their typical routine, they were asked to note these changes in their journals. Participants were required to have not practiced yoga or other regular stretching routines, including tai chi, for at least 1 month prior to study onset. They were required to commit to 2 yoga sessions per week, miss no more than 20% of the sessions, and complete weekly assessments consisting of a questionnaire and journal entries. Of the 10 participants who met inclusion criteria, 2 withdrew and 2 did not complete the required number of sessions. Procedures Baseline data were collected one week prior to treatment onset, with participants completing the Fibromyalgia Impact Questionnaire (FIQ) and writing their first journal entry. A physician performed a manual tender point evaluation before the yoga intervention. At the end of eight weeks, the participating physician administered another tender point evaluation. Measures The Fibromyalgia Impact Questionnaire (FIQ). The FIQ measures the number of days an individual felt well, was unable to work (including household chores), and experienced pain, fatigue, morning tiredness, anxiety, and depression in the past week. Higher scores reflect greater symptomatology. The maximum score is 100 and the average score is approximately 50. People who are severely affected by FM usually score 70 or more on the FIQ. The FIQ has been tested for reliability and validity and has been translated into numerous languages. Tender point eva l u a t i o n s. A physician experienced in t reating people with FM conducted the tender point eva l u a- tions. These evaluations occurred prior to the interve n t i o n and within 1 week after intervention completion. Pa rticipants rated their pain as 0 (no pain), 1 (some pain), or 2 (much pain). This study was conducted prior to the change of evaluation methods in May 2010, when the tender point e valuation was changed to a widespread-pain index. Weekly journal entries. Participants completed weekly journal entries beginning 1 week prior to intervention and

3 GENTLE HATHA YOGA AND FIBROMYALGIA 55 continuing weekly for the duration of the study. Individuals were asked to write about how they felt physically and mentally and if anything had changed throughout the study, such as their treatments or life circumstances. Themes from the journals were identified weekly and a table was created to display the common themes. Intervention In preparation for the study, the first author, a health and wellness professional, discussed yoga as treatment for FM with medical providers, who expressed that some patients report feeling worse after trying yoga, with some experiencing pain for days following exercise. These concerns were taken into careful consideration when designing the yoga sequence for this study. The intent was to use an eclectic blend of yoga styles, including Vinyasa, Kundalini, and Iyengar yoga. Hatha yoga uses flowing postures that link breath and movement for the purposes of reducing stress, gaining energy, and increasing flexibility and overall mobility. In our study, postures that require great strength and flexibility or those that are held for long periods were not used, with the exception of several restorative postures that are held for a longer duration at the end of class. Participants were frequently reminded to perform only those postures they were comfortable with and that did not cause pain. The class design involved nostril breathing for generating heat and calming the mind, gentle standing poses that flowed with breath, seated postures, and guided imagery. Participants always began standing in mountain pose while practicing breath work solely through their nostrils (Ujjayi breath) unless this type of breath was uncomfortable or unnatural. In such cases, any type of breathing was acceptable. Ujjayi breath was chosen for its calming effects on the mind during the exhale and its energizing and heating effects. After about 5 minutes of breath work involving centering exe rcises to bring participants into the pre s e n t moment and to encourage body awareness, participants began to perform a series of postures in which inhalation and exhalation were linked with movement. All participants were given modifications to poses when needed. One participant did the practices seated in a chair because of knee pain. (A description of the sequence of poses is available from the first author). Data Analysis Paired t-tests and Wilcoxon's signed-rank test were used for the study. These statistical methods were chosen because of the sample size. The paired t-test was used to compare baseline FIQ to postintervention FIQ scores, and Wilcoxon's signed-rank test was used to identify pre- to postchange in the tender point evaluations. For the qualitative data, participants' journals were analyzed to identify common themes throughout the 9 weeks of data collection. Table 1. Pre- to Postintervention Tender Point Evaluation Scores and Change Scores Participant After Before After Before A B C D F J K L M N Quantitative Analyses Results A paired t-test of the mean of FIQ scores revealed a significant trend toward an overall decrease in FM-related symptoms from baseline to postintervention (p =.0029). The 14.1-point pre- to posttreatment difference represents a 28% reduction in FIQ scores. Table 1 illustrates pre- to postintervention tender point evaluation scores and change values by participant. A higher score indicates more reported pain. As such, 7 of 10 participants reported declines in pain, 2 indicated increases, and 1 reported no change. McNemar's Exact Test was used to evaluate change. No significant pre- to postintervention reductions in pain ratings were detected after each participant's different tender point ratings (18 total locations) were compared individually on both right and left sides. Qualitative Analyses Themes from the journal entries were identified and are shown in Tables 2 and 3. Table 2 lists negative themes identified in participant journals. Participants endorsed more pain symptoms at the beginning of the intervention than in

4 56 INTERNATIONAL JOURNAL OF YOGA THERAPY No. 22 (2012) the following consecutive weeks. Although neck and back pain were indicated throughout the study, fewer people endorsed focal pain over time. In Week 2, 7 people reported back pain, whereas in Week 7, only 1 person indicated experiencing back pain. As illustrated in Table 2, negative comments about symptoms either decreased or were no longer mentioned in the journals after the initial weeks. Table 2. Endorsement of Negative Journal Themes Across Time Themes Baseline Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 Stressed 2* 1 1 Depressed Pain Back pain Neck pain Leg pain 2 1 Arm pain 2 Shoulder 2 1 pain Weather affects pain Fatigue Headache Feeling stiff Yoga is not 1 1 helping Yoga hurts 1 Note. *Values represent number of individuals who endorsed this theme on a given week. Blank fields indicate no response was provided for that item. Table 3. Participant Endorsement of Positive Journal Themes Across Time Baseline Themes Wk 1 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 Looking 4* forward to yoga Feeling good Yoga is helping Doing yoga at home Not 2 1 feeling as stiff More 2 energy Sleeping 1 better Note. *Values represent number of individuals who endorsed this theme on a given week. Blank fields indicate no response was provided for that item. Table 3 reveals the positive themes identified. Very few positive comments were offered during the first few weeks of journal writing, but positive comments were more frequently indicated over time. Discussion Mean-level analyses provided evidence of diminished self-reported FIQ symptoms from preintervention baseline to postintervention assessment. Likewise, tender point evaluations indicated a reduction in the endorsement of pain over time. With respect to the journal themes, the negative content decreased over time, whereas positive experiences were more frequently endorsed as the weeks progressed. Although pain was always present from start to finish, the frequency of pain-related journal entries declined over time. Overall, our quantitative findings are consistent with those from earlier studies in which benefits of yoga practice for individuals with FM were detected. 5-7 Limitations and Future Directions Examination of FIQ change scores, participant journals, and combined tender point scores suggests that participants reported experiencing fewer FM-related symptoms during and immediately after participating in an 8-week yoga intervention. Nevertheless, findings are preliminary and should be cautiously interpreted. Participants selfselected into the program and findings relied exclusively on self-report data, offering the potential for reporting biases. The lack of a randomized control group prohibited our ability to detect whether reductions in pain were an artifact of the intervention or the result of other factors, including group social support and attention from instructors, among others. The very small sample precluded a comprehensive analysis of longitudinal effects of the intervention, and the lack of additional postintervention follow-up data collection prevented us from understanding whether or not reductions in FM symptoms persisted over time. Last, the lack of standardization of the yoga invention made it impossible to examine which, if any, components of the program were most beneficial for persons with FM. It would have been useful to have gathered tender point data t h roughout the course of the study concurrent with FIQ and journal re p o rts to cross-check for re p o rting accuracy. This was neither convenient nor feasible, howe ve r, because tender point data collection re q u i red participation by a physician and would h a ve added to the weekly assessment demand. Fu t u re studies would benefit from more frequent tender point eva l u a t i o n. Participant feedback suggested that weekly journal entries were not sufficient to capture the richness and variability of their experience. Further, many expressed the need

5 GENTLE HATHA YOGA AND FIBROMYALGIA 57 for increased frequency of classes, and several reported attempting a home yoga practice to alleviate symptoms. As such, it is important for future re s e a rch to examine dose response factors relative to pain relief. Preliminary evidence supports yoga as a cost-effective, accessible option for pain relief for persons with FM. Further studies that use greater methodological rigor are required to better understand these findings. References 1.Wolfe F, Clauw D, Fitzcharkes M, et al. The American College of Rheumatology preliminary diagnostic criteria for FM and measurement of symptom severity. Arthrit Care Res. 2010;65: FM, American College of Rheumatology. practice/clinical/patients/diseases_and_conditions/fm. Accessed March 8, New global survey exposes considerable burden of FM, including potential economic impact. PR Newswire, United Business Media. June 13, Exposure 4. New criteria proposed for diagnosing FM suggests no longer focusing on tender points. Rush University Medical Center, May 24, Accessed June 22, Curtis K, Osadchuk A, Katz J. An eight-week yoga intervention is associated with improvements in pain, psychological functioning and mindfulness, and changes in cortisol levels in women with FM. J Pain Res. 2011;(4): Accessed July 25, Carson J, Carson K, Jones K, Bennett R, Wright C, Mist S. A pilot randomized controlled trial of the Yoga of Awareness program in the management of FM. Pain. 2010;151(2): Schmidt S, Grossman P, Schwarzer B, Jena S, Naumann J, Walach H. Treating FM with mindfulness-based stress reduction: results from a 3-armed randomized control trial. Pain. 2011;152(2): Accessed December16, Burckhardt CS, Clark SR, Bennett RM. The FM impact questionnaire (FIQ): development and validation. J Rheumatol. 1991;18: Acknowledgments This project was the product of a doctoral dissert a t i o n for Saint Ma ry's Un i versity of Minnesota, Mi n n e a p o l i s. Gratitude is given to my professors who guided me in the re s e a rch process and to my dissertation committee members Rustin Wolfe, PhD, Je r ry Ellis, Ed D, and Scott Hannon, EdD. Additional thanks to Brant Deppa, Ph D, of Winona State Un i ve r s i t y, who assisted me with the statistical analysis; to Ma rk Ma rtin, DOS, who assessed the patients with fibromyalgia; and to the patients who part i c- ipated in the study. Gratitude is also given to Da n y a Espinosa; Brandy Schillace, PhD, and Kelly Mc Go n i g a l PhD, for editing. Thank you to Dr. Scott Hannon, Dr. Rustin Wo l f e, and Dr. Je r ry Ellis for re s e a rch guidance. Thank you to Dr. Brandy Schillace and Danya Espinosa for assistance with e d i t i n g. Correspondence: Lisa Rudrud, EdD yogalisa@live.com

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