ArticlePDF Available

Abstract and Figures

Background: Fibromyalgia (FM) is a chronic widespread pain disorder characterized by negative affect, sleep disturbance, and fatigue. This uncontrolled pilot study investigated the efficacy of daily yoga-based exercise to improve FM symptoms and explored baseline phenotypic characteristics associated with the greatest benefit. Methods: FM patients (n=46, with 36 completers) reported psychosocial functioning and a range of FM symptoms using validated instruments before and after participation in Satyananda yoga, which included weekly in-person pain-tailored group classes for 6 weeks and daily home yoga video practice. Results: Changes in FM symptoms from pre- to post-yoga were variable amongst participants. Group means for pain decreased, as reported by average daily diary and Brief Pain Inventory, with greater home practice minutes associated with a greater decrease in pain. Average daily ratings of sleep and fatigue improved. Pain catastrophizing was decreased overall, with greater change correlated to a decrease in FM symptoms. We did not observe any group mean changes in actigraphy sleep efficiency, Patient-Reported Outcomes Measurement Information System-anxiety and the Revised Fibromyalgia Impact Questionnaire. Multilevel Modeling analysis revealed a significant interaction between anxiety and catastrophizing for end-study sleep efficiency, fatigue, and pain, such that patients with higher baseline catastrophizing and lower baseline anxiety reported less pain and fatigue, and higher sleep efficiency after the sixth week of yoga practice. Conclusion: This pilot study suggests that yoga may reduce pain and catastrophizing, as well as improve sleep, but these changes were modest across study participants. Greater uptake of home yoga practice as well as a phenotype of higher baseline catastrophizing combined with lower baseline anxiety were associated with greater impact. Future randomized, controlled trials comparing different types of yoga or exercise will allow determination of the most effective treatments for FM and allow closer targeting to the patients who will benefit most from them.
Content may be subject to copyright.
Impact of daily yoga-based exercise on pain,
catastrophizing, and sleep amongst individuals
with bromyalgia
This article was published in the following Dove Press journal:
Journal of Pain Research
Asimina Lazaridou
Alexandra Koulouris
Jaime K Devine
Monika Haack
Robert N Jamison
Robert R Edwards
Kristin L Schreiber
Department of Anesthesiology,
Perioperative, and Pain Medicine,
Brigham and Womens Hospital, Harvard
Medical School, Chestnut Hill, MA 02467,
Department of Neurology,
Harvard Medical School, Beth Israel
Deaconess Medical Center, Boston, MA
02215, USA
Background: Fibromyalgia (FM) is a chronic widespread pain disorder characterized by
negative affect, sleep disturbance, and fatigue. This uncontrolled pilot study investigated the
efcacy of daily yoga-based exercise to improve FM symptoms and explored baseline
phenotypic characteristics associated with the greatest benet.
Methods: FM patients (n=46, with 36 completers) reported psychosocial functioning and a
range of FM symptoms using validated instruments before and after participation in
Satyananda yoga, which included weekly in-person pain-tailored group classes for 6 weeks
and daily home yoga video practice.
Results: Changes in FM symptoms from pre- to post-yoga were variable amongst partici-
pants. Group means for pain decreased, as reported by average daily diary and Brief Pain
Inventory, with greater home practice minutes associated with a greater decrease in pain.
Average daily ratings of sleep and fatigue improved. Pain catastrophizing was decreased
overall, with greater change correlated to a decrease in FM symptoms. We did not observe
any group mean changes in actigraphy sleep efciency, Patient-Reported Outcomes
Measurement Information System-anxiety and the Revised Fibromyalgia Impact
Questionnaire. Multilevel Modeling analysis revealed a signicant interaction between
anxiety and catastrophizing for end-study sleep efciency, fatigue, and pain, such that
patients with higher baseline catastrophizing and lower baseline anxiety reported less pain
and fatigue, and higher sleep efciency after the sixth week of yoga practice.
Conclusion: This pilot study suggests that yoga may reduce pain and catastrophizing, as
well as improve sleep, but these changes were modest across study participants. Greater
uptake of home yoga practice as well as a phenotype of higher baseline catastrophizing
combined with lower baseline anxiety were associated with greater impact. Future rando-
mized, controlled trials comparing different types of yoga or exercise will allow determina-
tion of the most effective treatments for FM and allow closer targeting to the patients who
will benet most from them.
Keywords: yoga, pain, bromyalgia, sleep, catastrophizing
Fibromyalgia (FM), characterized by persistent, widespread pain, myofascial tender-
ness, negative affect, and dysregulated sleep, affects an estimated 5 million adults in the
US (2% prevalence in 2005), though recent population-based surveys have estimated
higher rates.
FM involves a complex and diverse set of symptoms and proposed
biopsychosocial mechanisms including 1) alterations in central pain-modulatory pro-
cesses in the spinal cord and brain, 2) a prominent role of negative affective factors in
Correspondence: Kristin L Schreiber
Department of Anesthesiology,
Perioperative, and Pain Medicine, Brigham
and Womens Hospital, Harvard Medical
School, 75 Francis Street, Boston, MA
02115, USA
Tel +1 617 732 8218
Journal of Pain Research Dovepress
open access to scientic and medical research
Open Access Full Text Article
submit your manuscript | Journal of Pain Research 2019:12 29152923 2915
DovePress © 2019 Lazaridou et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at
terms.php and incorporate the Creative Commons Attribution Non Commercial (unported, v3.0) License ( By accessing
the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (
maintaining pain and disability, 3) disrupted sleep and circa-
dian rhythms and related fatigue, and 4) a relative lack of
efcacy of many pharmacologic treatments.
Psychosocial functioning plays a key role in shap-
ing individual differences in pain. Negative affect and
catastrophizing amplify pain sensitivity and inuence
pain modulation in many chronic pain conditions,
including FM, as well as low back pain, osteoarthritis,
and rheumatoid arthritis.
Interestingly, exercise has
been shown to impact a broad array of FM symptoms,
with collective evidence suggesting that moderately
intense, relatively frequent (at least 3×/week) and sus-
tained (46 weeks) exercise may reduce not only pain
and fatigue, but also depression symptoms.
nding an exercise routine that is 1) gentle enough not
to trigger the new onset of pain, soreness, and thereby,
catastrophizing about pain, 2) adaptable to the indivi-
dual, and 3) habitually sustainable over the long term,
is a substantial challenge. Yoga, with its holistic
approach, may be well-adapted to meet these criteria,
and has shown promise in reducing pain and functional
outcomes in both low back and FM pain.
patients with FM also suffer from signicant distur-
bances initiating or maintaining sleep,
and robust
relationships are observed between pain severity and
sleep disturbance in FM patients,
suggesting this to
be an important aim for treatment strategy success.
The aim of this uncontrolled pilot study was to assess
the effectiveness daily yoga-based exercise, consisting of a
specially designed gentle 6-week program to reduce FM
symptoms, including pain and sleep disturbance, and with
a focus on the role of negative cognitions about pain such
as catastrophizing.
Materials and methods
Setting, participants, and study design
The Partners Institutional Review Board approved this
study, which was a pilot uncontrolled trial without a
control comparison group. Participants were recruited
using physical yers and a centralized clinical data reg-
istry. Inclusion criteria included; 1) 1875 years of age,
2) chronic pain with a diagnosis of FM (Wolfe et al 2011
criteria) for>6 monthsduration, 3) stable medications
prior to entering the study, 4) average pain score 4/10,
5) sleep disturbance, dened as Pittsburgh Sleep Quality
Index (PSQI) score 5, 6) able to speak and understand
English, 7) access to a computer/tablet/smartphone at
home, 8) and willing and physically able to participate
in yoga-based exercise. Exclusion criteria included; 1)
ongoing cancer treatment, 2) acute osteomyelitis/bone
disease, 3) chronic systemic inammatory disease, 4)
schizophrenia, delusional disorder, psychotic disorder, or
dissociative disorder judged to interfere with study parti-
cipation, 5) pregnancy, 6) unstable systemic illness or
injury requiring urgent surgery or treatment, 7) active
addiction disorder, 8) current rigorous daily exercise rou-
tine (>20 mins/day and >5×/week), and 9) current regular
meditative practice (e.g tai-chi, meditative form of yoga
or contemplative prayer) for >20 min/week. Informed
consent procedures were performed in accordance with
the Declaration of Helsinki for all participants. Patients
who dropped out before week 6 or attended <4/6 weekly
yoga classes were not included in the analysis.
Yoga study procedures
Participants underwent initial telephone screening, and eligi-
ble participants who gave consent were invited for a baseline
research visit followed by a 6-week yoga program. Once a
sufcient number of participants to ll a class were enrolled
(group sizes of n~10), time of day and day of the week for
classes was determined based on participantsand instruc-
tors collective schedules. The study included 5 separate
consecutive yoga cycles/groups, with 610 participants com-
pleting the yoga program per cycle, which took place at a
satellite outpatient clinical and research center connected to a
large tertiary referral academic hospital.
Satyananda Yoga program
Subjects participated in a yoga program specically adjusted
for chronic pain patients, led by a certied yoga instructor and
doctoral-level psychologist. Each week, there was an in-per-
son session that lasted 1.5 hrs and included asanas, meditation,
and other mindfulness-based practices (see Appendix).
Satyananda Yoga is a traditional form of yoga which includes
asanas (physical exercises), pranayama (breathing exercises),
pratyahara (mind focusing practices), and meditation (breath-
ing awareness, awareness of senses, awareness of thoughts,
and yoga nidra); it is gentle and may be adapted to be less
physically demanding,
integrating development of physi-
cal, mental, emotional, psychic, and spiritual aspects of ones
being. In order to encourage the integration of these practices
into everyday life, participants were also instructed to follow a
daily 30-min yoga video while at home in between in-person
classes with the instructor. These videos featured the same
instructor as in-person and consisted of a condensed
Lazaridou et al Dovepress
submit your manuscript |
Journal of Pain Research 2019:12
combination of meditation, breathing exercises, and asanas,
which had been introduced in the class that week (i.e., 6
different videos sent throughout the program, a new one for
each week).
Sociodemographic data and psychosocial
Sociodemographic information was collected including age,
race, education, and current occupational status. Only female
participants responded to study advertisements. Data were
collected during the baseline assessment week and the 6th
week of yoga intervention (end of study intervention), via the
secure REDCap survey system email link.
Pain Catastrophizing
The Pain Catastrophizing Scale (PCS),
which has been
widely used in chronic pain patients and controls,
used to measure catastrophic thinking (rumination, magni-
cation, and helplessness) about pain.
Emotional Distress-Anxiety and Depression
The Patient-Reported Outcomes Measurement Information
System (PROMIS) anxiety (7 items) and depression
(8 items) short forms, which are widely used and exten-
sively validated,
were used.
Fibromyalgia symptoms
In order to measure general FM symptomatology, the
Revised Fibromyalgia Impact Questionnaire (FIQR),
21-item assessment of functioning and overall impact of
FM symptoms, was completed.
Self-Reported Sleep Assessment
The Pittsburgh Sleep Quality Inventory (PSQI), which
includes questions regarding sleep quality, latency, dura-
tion, disturbances, habitual sleep efciency, daytime func-
tionality due to sleep, and the use of sleep medications,
was used, with score 5 considered poor sleep quality.
Sleep Actigraphy
A wrist actigraph (Actiwatch 2) was worn by participants
during the baseline assessment week and during the 6th
week of the yoga program in order to estimate sleep ef-
ciency. Activity count data was downloaded and habitual
sleep parameters determined using Philips Actiware default
settings for sleepwake determination. Average sleep ef-
ciency for a week was calculated as: (sleep time/in bed
time)×100, averaged over 6 nights.
Participants completed the Brief Pain Inventory (BPI),
including 4 pain intensity questions (pain now, average
pain, worst pain, least pain) rated on a 0 to 10 scale.
Ecological momentary assessment (daily diaries)
During the baseline assessment week and the 6th week of
yoga intervention, patients completed 7 days of electronic
diary entries at home, sent via the secure REDCAP survey
system email link each morning and evening. This
included pain ratings, anxiety, fatigue, stress, and subjec-
tive sleep quality.
Yoga practice
At the end of each week of the yoga program (i.e., on the day
before each yoga class), participants completed a weekly
check-insurvey, reporting the number of days and amount
of time/number of days that they practiced yoga at home
since the last yoga class (over a 5-day period).
Data analysis
A total of 46 participants were enrolled, with 36 participants
completing the study (Appendix-studyow diagram). Those
who dropped out before week 6 or attended <4/6 weekly
yoga classes were not included in the analysis. All analyses
were conducted using IBM-SPSS v.25. Individual changes in
pain and other symptoms were assessed using Students
paired samples t-test or Wilcoxon signed-ranks tests and
Pearson or Spearman correlations were calculated to assess
relationships between variables, as appropriate. In the group
of participants who completed the study, the amount of
missing data was relatively low for daily diary collection
(5%), with no missing preintervention and postintervention
assessment data. Multilevel modeling was used in order to
assess patient characteristics that were associated with better
outcomes at the end of the yoga program (sixth week).
Baseline to post-treatment percentage change was calculated
as follows: {[Post/Pre×100]100}. Repeated measures of
daily pain, fatigue, and sleep efciency (Level 1 units)
were nested within participants, and related to patientsbase-
line psychosocial characteristics (Level 2 units), including
baseline anxiety (PROMIS-anxiety short form) and catastro-
phizing (PCS). Given that multilevel modeling can account
for an unbalanced data structure and/or random missing
no data imputation procedure was used. Two-way
(e.g., Level 2 baseline catastrophizing × Level 2 baseline
PROMIS-anxiety) interaction terms were also specied and
included in the model, and baseline sleep efciency, fatigue,
Dovepress Lazaridou et al
Journal of Pain Research 2019:12 submit your manuscript |
DovePress 2917
and pain were included as covariates. We examined the
amount of missing data for each of the main outcome vari-
ables (e.g. pain catastrophizing, pain intensity, daily fatigue,
daily pain, FM symptoms, sleep quality). For the primary
variables sleep quality, daily fatigue, pain severity, pain cat-
astrophizing, and FM symptoms, there were no missing data.
Non-completers were not included in the analysis, due to a
lack of endpoint comparator for pre-post comparisons, and
lack of 6-week data for multilevel modeling.
Forty-six participants initially enrolled, and 36 participants
completed the study. Participants who dropped out of the
study (n=10; 5 at week 1, 1 at week 2, 1 at week 4, and 3 at
week 5) (see ow diagram, Appendix), most commonly cited
lack of time to attend classes as the reason for noncontinuance.
Demographic and baseline characteristics
of sample (Table 1)
The average age of participants was 48.5±13.9, all parti-
cipants were women, and 83% were identied as
Caucasian. The reported average pain severity, sleep dis-
turbance, and psychosocial variables were similar to pre-
vious studies among patients with FM.
Of those who
initially agreed to participate, 74% (N=36) participated to
a meaningful extent (attending 46 classes and reporting
minutes of at home practice/day).
Changes in pain
Pain, as measured by the BPI, decreased from baseline to 6
weeks amongst the participants (5.0±2.1 vs 4.5±2.3,
p=0.041) and the highest reported daily pain (measured
by daily diaries during baseline and week 6) decreased as
well (67±16 vs 60±18, p=0.007) although substantial
variability in pain scores was reported across participants
(Figure 1A). Similarly, participants reported a variable
amount of daily home practice, with more average home
practice time associated with reduction in average pain
(Spearman Rho: 0.428, p=0.009, Figure 1B). The great-
est benet was observed in those who practiced 25 mins/
day or more (28% of subjects), compared to those who
practiced less than 25 mins/day (p=0.023).
Changes in FM symptoms: FIQR, fatigue,
and sleep efciency
In contrast to the decrease in BPI, we did not observe a
decrease in Revised FIQR group means (57.20±20.52 vs
53.18±18.12, p=0.44; 7% change). Because sleep disturbance
is a prominent facet of FM symptomatology, we examined
whether yoga-based exercise impacted sleep. Similar to pain,
we observed a small overall decrease in sleep disturbance
groupmeanonthePSQI(Figure 2A, 11.3±4.5 vs 10.0±4.40
p=0.027, 12% change) as well as fatigue (Figure 2B,60.7
±17.5 vs 54.0±17.8, p=0.003; 11% change), although this was
quite variable between individuals. No signicant change in
sleep efciency was detected as measured by actigraphy
(Figure 2C, 87.1±7.6 vs 85.5±9.9, p=0.59, Wilcoxon signed
rank), again with variability between individuals. However, a
higher sleep efciency at the end of the study (week 6 average
sleep efciency) was correlated with greater decreases in sleep
disturbance over the course of the study (PSQI) (Rho: 0.40,
p=0.03), greater decreases in fatigue (rho: 0.395, p=0.034),
and greater increases in overall self-reported physical activity
(Rho: 0.395, p=0.034).
Table 1 Demographics and baseline clinical characteristics
Age 48.5±13.9
BMI 28.2±7.1
Caucasian 83%
African American 8%
Non-college graduate 26%
College graduate 49%
Master's degree 20%
Doctoral degree 6%
Full-time 15%
Part-time 18%
Homemaker 23%
Retired 15%
Daily average pain (0100) 51.6±18.1
Fybromyalgia symptoms (FIQR) 57.2±20.5
Pain (BPI) 5.0±2.1
Sleep disturbance (Pittsburgh Sleep Quality Index) 11.3±4.5
Daily fatigue (0100) 60.7±17.5
Catastrophizing (PCS) 21.5±14.0
Anxiety (PROMIS t-score) 59.4±8.7
Abbreviations: BMI, body mass index; FIQR, Fibromyalgia Impact Questionnaire;
BPI, Brief Pain Inventory; PCS, Pain Catastrophizing Scale; PROMIS, patient-
reported outcomes measurement system.
Lazaridou et al Dovepress
submit your manuscript |
Journal of Pain Research 2019:12
Changes in pyschosocial functioning: pain
Changes in pain catastrophizing were also variable
amongst participants, with an overall decrease over the
course of the program (21.5±14 vs 18.1±15, p=0.039,
16% change Wilcoxon signed rank; Figure 3A). On the
other hand, general anxiety, as measured by the PROMIS-
anxiety short form, did not change (59.38±8.7 vs 60.19
±10.14 p<0.001).
Interestingly, those who showed a greater decrease in pain
catastrophizing over the course of the program also reported a
greater decrease in FM symptoms (FIQR) (Rho: 0.450,
p=0.006, Figure 3B) as well as lower reported daily worst
pain (Rho: 0.351, p=0.036). There was a trend toward a
negative correlation between decreased catastrophizing and
improved sleep efciency (Rho: 0.31, p=0.102), but not
between decreased anxiety and improved sleep efciency
(Rho: 0.09, p=0.649).
Baseline characteristics predicting
symptoms at the end of yoga intervention
In order to understand whether individual differences in
psychosocial characteristics, such as catastrophizing and
anxiety, could help explain variation in the degree of
yogas effect between individuals, we conducted multi-
level modeling (MLM) analysis of pain and sleep.
Figure 1 Changes in pain: association with amount of yoga practiced. (A) Pain intensity scores as measured using the brief pain inventory, either at baseline before (left) or
after (right) yoga program; (B) correlation of decrease in average daily pain from baseline to 6th week of program with average reported minutes of home yoga practice over
a 5-day period.
Figure 2 Changes in sleep and fatigue. (A) Sleep quality as measured by the pittsburgh sleep quality index, either at baseline before (left) or after (right) yoga program; (B)
average fatigue (0100) measured by daily diaries, either at baseline (left) or during the 6th week of the yoga program (right); (C) sleep efciency as measured using
actigraphy, at baseline (left), and at end (right) of yoga program.
Dovepress Lazaridou et al
Journal of Pain Research 2019:12 submit your manuscript |
DovePress 2919
Specically, we used this method to investigate the inu-
ence of baseline catastrophizing and anxiety on the daily
diary-rated pain and fatigue, as well as on actigraphy-
measured sleep efciency, during the nal week of the
yoga program, because FM symptoms (such as pain and
sleep disturbance) vary considerably from day to day.
The results from the MLM analyses did not reveal a
signicant main effect of baseline pain catastrophizing score
(PCS) on sleep efciency (B=0.041 SE=0.16, p=0.80), fatigue
(B=0.059 SE=0.28, p=0.83), or pain (B=0.17 SE=0.29,
p=0.55). Similarly, there was no signicant main effect of
PROMIS-anxiety scores on sleep efciency (B=0.077
SE=0.26, p=0.77), fatigue (B=0.41, SE=0.43, p=0.34), or
pain (B=0.399, SE=0.40, p=0.33). However, we observed a
signicant interaction between baseline PROMIS-anxiety and
catastrophizing on post-study sleep efciency (B=0.40,
Figure 3 Changes in pain catastrophizing: association with changes in bromyalgia symptoms. (A) Pain catastrophizing scores as measured using the pain catastrophizing
scale (PCS), either at baseline before (left) or after (right) yoga program. (B) Correlation of decrease in bromyalgia symptoms, as measured by change in pre- and post-
scores on the Revised Fibromyalgia Impact Questionnaire (FIQR), with decrease in pain catastrophizing.
Figure 4 Pain, fatigue, and sleep efciency at study end: association with baseline psychosocial characteristics. (A) Daily diary pain severity, (B) daily diary fatigue, and (C)
nightly sleep efciency (actigraphy) during the last week of yoga (week 6) was investigated using multilevel modeling to understand the impact of patientsbaseline
psychosocial characteristics. An interaction between baseline anxiety, as measured using PROMIS-anxiety, and baseline catastrophizing, as measured using the pain
catastrophizing scale, was observed for all three outcomes.
Lazaridou et al Dovepress
submit your manuscript |
Journal of Pain Research 2019:12
SE=0.01, p=0.016), fatigue (B=0.06 SE=0.022, p=0.011), and
pain (B=0.055 SE=0.02, p=0.011), such that patients who
scored high in catastrophizing and low in anxiety demon-
strated signicantly less fatigue, and pain, and higher sleep
efciency (Figure 4), after controlling for baseline fatigue,
sleep efciency and pain severity. In addition, sensitivity
analyses indicated that the interaction was not moderated by
any other demographic (i.e., age, sex, ethnicity) or psycholo-
gical (i.e., anxiety, depression) variables (all ps>0.05).
This pilot study in FM patients suggests that an exercise-
based Satyananda yoga intervention may modulate some
of the core symptoms of FM, including pain, sleep dis-
turbance, and catastrophizing, but that this benet is quite
variable amongst individuals, resulting in meaningful ben-
et only to some. Exploratory analysis demonstrated that
benet was more pronounced for individuals who prac-
ticed more consistently, and who reported higher baseline
catastrophizing, but low anxiety, in terms of sleep ef-
ciency, fatigue, and pain at the end of the program.
The present nding that pain modestly decreased from
baseline to postintervention for the overall group parallels
results from previous yoga and meditation-based research
interventions in chronic pain populations.
These stu-
dies have shown a modest effect on reducing pain and
disability, pain catastrophizing and acceptance, as well as
cortisol, proinammatory cytokines, and endorphin
Further analysis revealed the degree of benettobe
unequally distributed among participants, with some parti-
cipants reporting more marked pain reduction.
Specically, pain reduction was inversely correlated with
a greater amount of home practice, and most pronounced
in those reporting greater than 25 mins of home practice
on average. This suggests that greater engagement and
participation may yield benets in terms of pain reduction,
which is in agreement with prior studies.
Use of daily
yoga videos at home, which featured the same instructor,
may have assisted with practice adherence and engage-
ment, but further investigation is required to determine
barriers and facilitators to self-practice.
Laboratory-based, clinical, and epidemiological studies
have suggested that sleep duration and quality inuence
subsequent pain report. Sleep deprivation in healthy sub-
jects results in enhanced pain, and poor sleep is correlated
with elevated pain severity and disability in individuals
with chronic pain.
Patients with sleep disturbance are
more likely to develop chronic pain, and degree of sleep
disturbance predicts severity of FM symptoms.
Epidemiologic surveys consistently report that the vast
majority of patients with FM suffer from signicant dis-
turbances initiating or maintaining sleep,
and robust
relationships are observed between pain severity and
sleep disturbance in FM patients.
Our study indicated
benecial effects of yoga practice on sleep quality and
subjective fatigue in patients with FM, similar to earlier
Yoga appears to decrease autonomic reac-
tivity, suggesting a fundamental normalization of physical
which may favor a transition to more normal
sleep. More efcient sleep at the end of the study (based
on wrist actigraphy) mirrored subjective sleep quality
improvement and was associated with greater physical
Patients with high catastrophizing and low anxiety at
the beginning of the study had the most favorable sleep
efciency, reported better sleep, and less pain during the
nal week of Satyananda yoga. This interaction between
catastrophizing and anxiety with respect to pain and sleep
quality may indicate that participants who engage in nega-
tive thinking about symptoms (i.e. catastrophizing) might
stand the most to gain from both the physical exercises and
meditative practices inherent in yoga, but only if they have
relatively low generalized anxiety. Previous studies have
indicated that yoga allows patients to overcome the fear of
which is similar conceptually to catastrophiz-
ing about pain. Catastrophizing, which is higher amongst
individuals with FM, was modestly decreased overall in
the group during this study. Interestingly, we did also
observe that decreases in reported FM symptoms (FIQR)
during the course of the yoga program were associated
with decreases in catastrophizing, perhaps indicating that
FM symptom reduction may be connected to decreased
catastrophizing in FM patients.
However, a higher level
of general anxiety might preclude effective engagement
with yoga practice. Although prior studies have demon-
strated that yoga helps decrease anxiety, this might be only
the case in individuals with mild-moderate levels of anxi-
ety at preintervention.
The most important limitation of this pilot study was a
relatively small sample size without a control group, mak-
ing the generalizability of positive ndings, as well as the
denitiveness of negative ndings, unclear. While we
observed trends toward change in many variables, some
did not reach statistical signicance, raising the possibility
that the study was underpowered for these outcomes.
Dovepress Lazaridou et al
Journal of Pain Research 2019:12 submit your manuscript |
DovePress 2921
Second, as is apparent in the gures, the between subject
variability was high, also limiting statistical power. We
were able to partially mitigate the impact of variability
by using paired tests and MLM analysis of daily diary and
actigraphy data. However, it is likely that the degree of
variation between individuals reects a true variability in
the experience of symptoms between individuals with FM,
with some people gaining more benet (or less) from the
practice of yoga. Third, because of the voluntary nature of
the intervention, substantial selection bias may exist, limit-
ing the application of ndings to individuals who are
willing and able to engage in yoga. Fourth, approximately
a quarter of initially interested individuals dropped out of
meaningful participation, suggesting that this type of inter-
vention may be too cumbersome for a signicant subset of
FM patients, and precluding our ability to assess its benet
to FM patients more generally. Fifth, this particular yoga
intervention included gentle postures, anchored by a short
meditation, and included daily at home video-led practice.
It is unclear which of these elements was helpful/not help-
ful, and to what degree this may generalize to other yoga,
exercise, or meditation practices. Further evaluation in a
larger sample of patients, with a time-and-attention
matched control would allow conrmation of the efcacy
and tolerability of group-based yoga therapy for this chal-
lenging condition. The selection of meaningful active and
passive control conditions will be important to understand
whether and for whom yoga may be more useful.
This pilot study suggests that yoga-based exercise can be
effective in decreasing pain, catastrophizing, and sleep
disturbance in some FM patients, particularly those who
are willing to engage in a more consistent home self-paced
practice. As uptake of Satyananda yoga in FM can be
variable, future research should potentially explore the
efcacy of other yoga styles and protocols. Additionally,
individual phenotypic characteristics that may predict the
better clinical effect of yoga on fatigue, sleep efciency,
and pain include high catastrophizing, but relatively low
general anxiety, although this should be investigated in a
larger sample before being applied to clinical recommen-
dation. Overall, yoga, as a safe, gentle, and adaptable
exercise option, could be a benecial tool to complement
the conventional therapies currently used to manage FM
The authors would like to sincerely thank all the partici-
pants who gave their time and energy to making this study
possible. This study was supported by a grant to KLS from
the Osher Center for Integrative Medicine/Harvard Medical
The authors report no conicts of interest in this work.
1. Ward L, Stebbings S, Cherkin D, Baxter GD. Yoga for functional
ability, pain and psychosocial outcomes in musculoskeletal condi-
tions: a systematic review and meta-analysis. Musculoskeletal Care.
2013;11(4):203217. doi:10.1002/msc.1042
2. Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiol-
ogy to therapy. Nat Rev Rheumatol.2011;7(9):518. doi:10.1038/
3. Edwards RR, Cahalan C, Mensing G, Smith M, Haythornthwaite JA.
Pain, catastrophizing, and depression in the rheumatic diseases. Nat
Rev Rheumatol.2011;7(4):216224. doi:10.1038/nrrheum.2011.2
4. Schreiber KL, Campbell C, Martel MO, et al. Distraction analgesia in
chronic pain patientsthe impact of catastrophizing. Anesthesiology.
2014;121(6):12921301. doi:10.1097/ALN.0000000000000465
5. Hauser W, Klose P, Langhorst J, et al. Efcacy of different types of
aerobic exercise in bromyalgia syndrome: a systematic review and
meta-analysis of randomised controlled trials. Arthritis Res Ther.
2010;12(3):R79. doi:10.1186/ar3002
6. Busch AJ, Webber SC, Richards RS, et al. Resistance exercise training
for bromyalgia. Cochrane Database Syst Rev.2013;12:Cd010884.
7. Carson JW, Carson KM, Jones KD, Bennett RM, Wright CL, Mist
SD. A pilot randomized controlled trial of the yoga of awareness
program in the management of bromyalgia. Pain.2010;151(2):530
539. doi:10.1016/j.pain.2010.08.020
8. Carson JW, Carson KM, Jones KD, Mist SD, Bennett RM. Follow-up
of yoga of awareness for bromyalgia: results at 3 months and
replication in the wait-list group. Clin J Pain.2012;28(9):804813.
9. Tilbrook HE, Cox H, Hewitt CE, et al. Yoga for chronic low back
pain: a randomized trial. Ann Intern Med.2011;155(9):569578.
10. Sherman KJ, Cherkin DC, Wellman RD, et al. A randomized trial
comparing yoga, stretching, and a self-care book for chronic low
back pain. Arch Intern Med.2011;171(22):20192026. doi:10.1001/
11. Fabian LA, McGuire L, Page GG, Goodin BR, Edwards RR,
Haythornthwaite J. The association of the cortisol awakening
response with experimental pain ratings. Psychoneuroendocrinology.
2009;34(8):12471251. doi:10.1016/j.psyneuen.2009.03.008
12. Ablin JN, Buskila D. Predicting bromyalgia, a narrative review: are
we better than fools and children? Eur J Pain.2014;18(8):1060
1066. doi:10.1002/j.1532-2149.2014.00481.x
13. Finan PH, Goodin BR, Smith MT. The association of sleep and pain:
an update and a path forward. J Pain.2013;14(12):15391552.
14. Schreiber K, Loggia M, Cahalan C, Napadow V, Edwards R. (211)
Modulation of experimental and clinical pain by distraction in bro-
myalgia patients and controls. J Pain.2015;16(4):S28. doi:10.1016/j.
15. Clauw DJ. Fibromyalgia: a clinical review. Jama.2014;311
(15):15471555. doi:10.1001/jama.2014.3266
Lazaridou et al Dovepress
submit your manuscript |
Journal of Pain Research 2019:12
16. Diaz-Piedra C, Di Stasi LL, Baldwin CM, Buela-Casal G, Catena A.
Sleep disturbances of adult women suffering from bromyalgia: a
systematic review of observational studies. Sleep Med Rev.
2015;21:8699. doi:10.1016/j.smrv.2014.09.001
17. Saraswati SS. Yoga Nidra. Yoga Publications Trust; 2009.
18. Saraswati SS. Asana Pranayama Mudra Bandha. Yoga Publications
Trust; 2008.
19. Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale:
development and validation. Psychol Assess.1995;7(4):524532.
20. Pavlin DJ, Sullivan MJ, Freund PR, Roesen K. Catastrophizing: a
risk factor for postsurgical pain. Clin J Pain.2005;21(1):8390.
21. Osman A, Barrios FX, Kopper BA, Hauptmann W, Jones J, ONeill
E. Factor structure, reliability, and validity of the pain catastrophizing
scale. J Behav Med.1997;20(6):589605.
22. Pilkonis PA, Choi SW, Salsman JM, et al. Assessment of self-
reported negative affect in the NIH toolbox. Psychiatry Res.
2013;206(1):8897. doi:10.1016/j.psychres.2012.09.034
23. Cella D, Riley W, Stone A, et al. The Patient-Reported Outcomes
Measurement Information System (PROMIS) developed and tested
its rst wave of adult self-reported health outcome item banks: 2005
2008. J Clin Epidemiol.2010;63(11):11791194. doi:10.1016/j.
24. Bennett RM, Friend R, Jones KD, Ward R, Han BK, Ross RL. The
revised Fibromyalgia Impact Questionnaire (FIQR): validation and
psychometric properties. Arthritis Res Ther.2009;11(4):R120.
25. Buysse DJ, Reynolds III CF, Monk TH, Berman SR, Kupfer DJ. The
pittsburgh sleep quality index: a new instrument for psychiatric
practice and research. Psychiatry Res.1989;28(2):193213.
26. Cleeland C, Ryan K. Pain assessment: global use of the brief pain
inventory. Ann Acad Med.1994;23(2):129138.
27. Peugh JL. A practical guide to multilevel modeling. J Sch Psychol.
2010;48(1):85112. doi:10.1016/j.jsp.2009.09.002
28. Singer JD, Willett JB. Applied Longitudinal Data Analysis: Modeling
Change and Event Occurrence. Oxford;New York: Oxford University
Press; 2003:xx, 644.
29. Brummett CM, Clauw DJ. Fibromyalgia: a primer for the anesthesia
community. Curr Opin Anaesthesiol.2011;24(5):532. doi:10.1097/
30. Clauw DJ, Arnold LM, McCarberg BH, editors. The science of
bromyalgia. In: Mayo Clinic Proceedings. Elsevier; 2011;86
31. Hawkins RA. Fibromyalgia: a clinical update. J Am Osteopath Assoc.
2013;113(9):680689. doi:10.7556/jaoa.2013.034
32. Williams K, Abildso C, Steinberg L, et al. Evaluation of the effec-
tiveness and efcacy of Iyengar yoga therapy on chronic low back
pain. Spine (Phila Pa 1976).2009;34(19):20662076. doi:10.1097/
33. Tiedemann A, ORourke S, Sherrington C. Is a yoga-based program
with potential to decrease falls perceived to be acceptable to com-
munity-dwelling people older than 60? Public Health Res Pract.
2018;28(2):e28011801. doi:10.17061/phrp28011801
34. Curtis K, Osadchuk A, Katz J. An eight-week yoga intervention
is associated with improvements in pain, psychological function-
ing and mindfulness, and changes in cortisol levels in women
with bromyalgia. JPainRes.2011;4:189201. doi:10.2147/JPR.
35. Michalsen A, Grossman P, Acil A, et al. Rapid stress reduction and
anxiolysis among distressed women as a consequence of a three-
month intensive yoga program. Med Sci Monit.2005;11(12):Cr555
36. Yadav RK, Magan D, Mehta N, Sharma R, Mahapatra SC. Efcacy
of a short-term yoga-based lifestyle intervention in reducing stress
and inammation: preliminary results. J Altern Complement Med.
2012;18(7):662667. doi:10.1089/acm.2011.0265
37. Santana MJ, SP J, Mirus J, Loadman M, Lien DC, Feeny D. An
assessment of the effects of Iyengar yoga practice on the health-
related quality of life of patients with chronic respiratory diseases:
a pilot study. Can Respir J.2013;20(2):e17e23. doi:10.1155/2013/
38. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived
stress. J Health Soc Behav.1983;24(4):385396.
39. Wang YY, Chang HY, Lin CY. [Systematic review of yoga for
depression and quality of sleep in the elderly]. Hu Li Za Zhi.
40. Wang F, Eun-Kyoung Lee O, Feng F, et al. The effect of meditative
movement on sleep quality: a systematic review. Sleep Med Rev.
2016;30:4352. doi:10.1016/j.smrv.2015.12.001
41. Carson JW, Carson KM, Jones KD, Lancaster L, Mist SD. Mindful
yoga pilot study shows modulation of abnormal pain processing in
bromyalgia patients. Int J Yoga Therap.2016;26(1):93100.
42. Kanojia S, Sharma VK, Gandhi A, Kapoor R, Kukreja A,
Subramanian SK. Effect of yoga on autonomic functions and psy-
chological status during both phases of menstrual cycle in young
healthy females. J Clin Diagn Res.2013;7(10):2133.
43. Combs MA, Thorn BE. Yoga attitudes in chronic low back pain:
roles of catastrophizing and fear of movement. Complement Ther
Clin Pract.2015;21(3):160165. doi:10.1016/j.ctcp.2015.06.006
44. Campbell CM, McCauley L, Bounds SC, et al. Changes in pain
catastrophizing predict later changes in bromyalgia clinical and
experimental pain report: cross-lagged panel analyses of dispositional
and situational catastrophizing. Arthritis Res Ther.2012;14(5):R231.
45. Wieland LS, Santesso N. A summary of a cochrane review: yoga
treatment for chronic non-specic low back pain. Eur J Integr Med.
2017;11:3940. doi:10.1016/j.eujim.2017.03.003
Journal of Pain Research Dovepress
Publish your work in this journal
The Journal of Pain Research is an international, peer reviewed, open
access, online journal that welcomes laboratory and clinical ndings in
the elds of pain research and the prevention and management of pain.
Original research, reviews, symposium reports, hypothesis formation
and commentaries are all considered for publication. The manuscript
management system is completely online and includes a very quick
and fair peer-review system, which is all easy to use. Visit http:// to read real quotes from pub-
lished authors.
Submit your manuscript here:
Dovepress Lazaridou et al
Journal of Pain Research 2019:12 submit your manuscript |
DovePress 2923
... Moreover, PA and exercise (aerobic exercise, strength training, aquatic exercise, and yoga, among others) have proved to be effective in people with FM when measured with tools such as the Fibromyalgia Impact Questionnaire (FIQ) [75,76]. Thus, PA benefits included positive effects on pain [77][78][79][80], depressive symptoms [30], and sleep issues [80,81]. Despite the mentioned benefits, pain, fatigue, psychological discomfort, or lack of time appear as major barriers that limit adherence to exercise programs, representing a major challenge [82][83][84] and being one of the reasons for the researchers to continue their research investigating innovative, more motivating, and less time-consuming PA programs using new technologies and other exercise-based activities for people with FM [32,39,73,85]. ...
... Moreover, PA and exercise (aerobic exercise, strength training, aquatic exercise, and yoga, among others) have proved to be effective in people with FM when measured with tools such as the Fibromyalgia Impact Questionnaire (FIQ) [75,76]. Thus, PA benefits included positive effects on pain [77][78][79][80], depressive symptoms [30], and sleep issues [80,81]. Despite the mentioned benefits, pain, fatigue, psychological discomfort, or lack of time appear as major barriers that limit adherence to exercise programs, representing a major challenge [82][83][84] and being one of the reasons for the researchers to continue their research investigating innovative, more motivating, and less time-consuming PA programs using new technologies and other exercise-based activities for people with FM [32,39,73,85]. ...
Full-text available
Fibromyalgia (FM) is a rheumatic disease characterized by pain, fatigue, low-quality sleep, depression, anxiety, stiffness, fall risk, mood disturbance, cognitive impairment, poor physical condition, and other symptoms leading to a worse quality of life. Physical activity (PA) and exercise are effective methods to reduce FM symptoms, including pain. This study presents the first bibliometric study on FM, pain, and PA. An advanced search of the Web of Science (WoS) Core Collection database performed on this topic using was carried out traditional bibliometric laws. A total of 737 documents were found. Annual publications presented an exponentially growing trend (R2 = 85.3%). Rheumatology International, Kaisa Mannerkorpi, and the USA were the journal, co-author, and country most productive, respectively. The exponential growth of annual publications on FM, PA, and pain shows the high interest of researchers and publishers in this topic. The document “Fibromyalgia A Clinical Review” was the most cited. Moreover, Kaisa Mannerkorpi was the most prolific co-author, Rheumatology International was the most prolific journal, “Fibromyalgia: a clinical review” was the most highly cited document, and Daniel Clauw was the most cited co-author.
... 29,30 In prior research, a PCS score ≥ 16 has been used to represent clinically relevant levels of catastrophizing. 31,32 Depression The 8-item depression short form from the Patient Reported Outcome Measurement Information System (PROMIS) 33 was used to measure depressive symptoms at T2. All items (eg, "I felt unhappy"; "I felt worthless") were rated on a scale from 1 (never) to 5 (always), and items were summed for a total score (α=0.96). ...
... 42,43 The mean score of pain catastrophizing after living in the pandemic for 1 year in the present study was higher than pain catastrophizing reported in some samples of individuals with chronic pain pre-pandemic, 44 but lower than pain catastrophizing scores among other chronic pain samples pre-and during the pandemic. 8,31 Importantly, we did not assess pre-pandemic levels of loneliness, depression, or pain catastrophizing, and therefore we are unable to attribute scores on these variables to the COVID-19 pandemic. ...
Full-text available
Purpose: Loneliness increased during the COVID-19 pandemic and social distancing guidelines, potentially exacerbating negative cognitions about pain. The present study investigated the longitudinal relationship between loneliness, assessed during the early weeks of the pandemic, and pain catastrophizing, assessed after living in the pandemic for approximately 1 year, among chronic pain patients. We also examined whether severity of depressive symptoms mediated this association. Methods: This prospective longitudinal study recruited individuals with chronic pain (N=93) from Massachusetts using an online convenience sampling method via the platform Rally. Participants completed an initial survey early after the onset of social distancing (4/28/20-6/17/20; Time 1) and a follow-up survey 1 year later (5/21/21-6/7/21; Time 2). Participants completed validated assessments of loneliness (T1), pain catastrophizing (T2), and depression (T2). Spearman correlations and Mann-Whitney U-tests were used to explore associations among psychosocial, pain, and participant characteristics. A mediation analysis was conducted to test whether the association between loneliness and pain catastrophizing was mediated by depression. Results: Participants had a mean age of 40.6 years and were majority female (80%) and White (82%). Greater loneliness was associated with subsequent higher pain catastrophizing (b=1.23, 95% CI [0.03, 2.44]). Mediation analysis showed a significant indirect effect (b=0.57, 95% CI [0.10, 1.18) of loneliness (T1) on catastrophizing (T2) through depression (T2) while accounting for several important covariates. The direct effect of loneliness on catastrophizing was no longer significant when depression was included in the model (b=0.66, 95% CI [-0.54, 1.87]). Conclusion: Findings suggest that greater loneliness during the pandemic was associated with higher pain catastrophizing 1 year later, and severity of depression after living in the pandemic mediated this association. As loneliness, depression, and catastrophizing can all be modified with behavioral interventions, understanding the temporal associations among these variables is important for the employment of future empirically supported treatments.
... 13 Intervention studies reported reductions in pain outcomes, functional disability, pain medication usage, depression, and fatigue in yoga group participants. 15,16,33,34 Research in the field corroborated our findings that yoga programming is valuable in creating positive outcomes in persons living with chronic pain. Of note, 9 participants reported the importance of routine yoga practice in their health improvements. ...
Full-text available
Background Yoga integrates all aspects of self, with biological, mental, intellectual, and spiritual elements. The practice of yoga aligns with the biopsychosocial model of health and, as such, it can be instrumental in pain treatment. Aims The purpose of this qualitative study was to explore perceptions regarding the yoga sessions for chronic pain through thematic content analysis with comparison of gender, veteran or civilian status, and delivery methods. Methods Patients with chronic pain attended a 5-week intensive interdisciplinary chronic pain management program at the Michael G. DeGroote Pain Clinic. Participants were asked to complete six open-ended questions following four weekly 1-h yoga classes, through in-person or virtual delivery. Survey responses were thematically and separately analyzed by reviewers. Results Forty-one (N = 41) participants (56% males, 71% veterans) with an average age of 50.87 (SD 10.10) years provided comments. Nine themes emerged: (1) mind and body are one through yoga practices; (2) meaningful practice of yoga basics is productive for range of motion/movement, tension in joints, and chronic pain; (3) yoga classes provide an enjoyable process of learning; (4) yoga reminds patients of their physical capabilities; (5) routine practices lead to improvements; (6) yoga improved on strategies for chronic pain; (7) yoga can be adapted for each patient; (8) mindset improves to include positive thinking, better focus, and willingness to try new things; and (9) improvements exist for the current yoga programming. Conclusion Findings of the current study were nine qualitative themes that present the experience of patients with chronic pain in the yoga sessions.
... On contrary, Curtis and colleagues subjectively studied the effect of an eight-week Mindfulness Based Stress Reduction (MBSR) in 173 bromyalgia patients; authors claim no improvement in pain and psychological symptoms like sleep problems, quality of life and cognition after intervening patients with 2.5 hours MBSR session (once a week) and 45 minutes home practice (5 sessions/week) [35]. Reductions in pain catastrophizing behaviour and pain inventory along with sleeplessness were noticed after six weeks of weekly 210 minutes yoga session (5 days home video practice) by another group too [36]. Twice a week gentle Hatha yoga was also found to reduce FM related symptoms [37]. ...
... Tai Chi, yoga and meditation exercises as monotherapy or adjunctive therapy have been shown to reduce anxiety, depression or sleep disorders (Saeed et al., 2019). For example, yoga has shown interesting results in reducing pain, anxiety and catastrophizing among individuals with FMS, thereby increasing their functional capacity and QoL (Lazaridou et al., 2019). PEBT led to a 9-7-point increase and a 10.43-point increase in physical and mental SF-36 scores, respectively. ...
Full-text available
The aim of our meta-analysis was to compile the available evidence to evaluate the effect of physical exercise-based therapy (PEBT) on pain, impact of the disease, quality of life (QoL) and anxiety in patients with fibromyalgia syndrome (FMS), to determine the effect of different modes of physical exercise-based therapy, and the most effective dose of physical exercise-based therapy for improving each outcome. A systematic review and meta-analysis was carried out. The PubMed (MEDLINE), SCOPUS, Web of Science, CINAHL Complete and Physiotherapy Evidence Database (PEDro) databases were searched up to November 2022. Randomized controlled trials (RCTs) comparing the effects of physical exercise-based therapy and other treatments on pain, the impact of the disease, QoL and/or anxiety in patients with FMS were included. The standardized mean difference (SMD) and a 95% CI were estimated for all the outcome measures using random effect models. Three reviewers independently extracted data and assessed the risk of bias using the PEDro scale. Sixty-eight RCTs involving 5,474 participants were included. Selection, detection and performance biases were the most identified. In comparison to other therapies, at immediate assessment, physical exercise-based therapy was effective at improving pain [SMD-0.62 (95%CI, -0.78 to -0.46)], the impact of the disease [SMD-0.52 (95%CI, -0.67 to -0.36)], the physical [SMD 0.51 (95%CI, 0.33 to 0.69)] and mental dimensions of QoL [SMD 0.48 (95%CI, 0.29 to 0.67)], and the anxiety [SMD-0.36 (95%CI, -0.49 to -0.25)]. The most effective dose of physical exercise-based therapy for reducing pain was 21-40 sessions [SMD-0.83 (95%CI, 1.1--0.56)], 3 sessions/week [SMD-0.82 (95%CI, -1.2--0.48)] and 61-90 min per session [SMD-1.08 (95%CI, -1.55--0.62)]. The effect of PEBT on pain reduction was maintained up to 12 weeks [SMD-0.74 (95%CI, -1.03--0.45)]. Among patients with FMS, PEBT (including circuit-based exercises or exercise movement techniques) is effective at reducing pain, the impact of the disease and anxiety as well as increasing QoL. Systematic Review Registration: PROSPERO, identifier CRD42021232013.
... 17,18 For much of this research, she has adapted simple, validated psychometric measures, including objective quantitative sensory testing in the preoperative clinic, to "phenotype" patients preoperatively, and predict patients at risk for acute and chronic postsurgical pain and opioid use, including the development of bedside adaptations of these tests. 19 She has also examined the impact of alternative therapies on pain modulation, including the impact of yoga-based exercise on pain in fibromyalgia patients, [20][21][22] distraction in chronic pain patients, 23 music in emergency medicine patients, 24 and a randomized controlled trial of open-label placebo in spine surgery patients, 17 which was featured in press releases after its publication in PAIN. During the pandemic, she aptly pivoted to investigate the impact of social isolation on chronic pain and reported differential impact among individuals, with certain chronic pain patients being more impacted (minority and female). ...
... Yoga was shown to decrease pain catastrophizing by 16% on the Pain Catastrophizing Scale (PCS). The greatest pain reduction was observed in those practicing yoga for 25 min or more a day, over the 6-week period of the study [66]. Long-term studies with larger sample sizes, and further research on specific yoga asanas are still warranted for more evidence for the utility of yoga in fibromyalgia. ...
Full-text available
The recent global increase in popularity of home-based yoga, an ancient Indian technique practiced for thousands of years, has translated into its use as a complementary therapy for a multitude of ailments. This review aims to examine the published literature regarding the effects of yoga therapy on systemic chronic diseases; in particular on the inflammatory myopathies (IMs) and other muscle disorders. Despite the fact that the evidence base for yoga in inflammatory myositis is in its infancy, collateral results in other disorders such as muscular dystrophies are promising. A beneficial effect of yoga in chronic pain has been shown alongside an improvement in motor function and muscle strength. Patients with Duchenne muscular dystrophy with respiratory involvement may find improvement in lung function. Elderly patients may experience reduction in falls secondary to an improvement in balance while practicing long-term yoga therapy. Further benefits are improving disorders of mental health such as depression and anxiety. A reported improvement in overall quality of life further suggests its efficacy in reducing morbidity in patients with chronic diseases, who often suffer co-existent psychological comorbidities.
Endometriosis is a common chronic pain condition with no known cure and limited treatment options. Digital technologies, ranging from smartphone apps to wearable sensors, have shown potential toward facilitating chronic pain assessment and management; however, to date, many of these tools have not been specifically deployed or evaluated in patients with endometriosis-associated pain. Informed by previous studies in related chronic pain conditions, we discuss how digital technologies may be used in endometriosis to facilitate objective, continuous, and holistic symptom tracking. We postulate that these pervasive and increasingly affordable technologies present promising opportunities toward developing decision-support tools assisting healthcare professionals and empowering patients with endometriosis to make better-informed choices about symptom management.
Pain is common and variable in its severity among hospitalized patients with cancer. Although biopsychosocial factors are well established as modulators of chronic pain, less is known about what patient-level factors are associated with worse pain outcomes among hospitalized cancer patients. This prospective cohort study included patients with active cancer presenting to the emergency department (ED) with pain severity of ≥4/10 and followed pain outcomes longitudinally throughout hospital admission. Baseline demographic, clinical, and psychological factors were assessed on ED presentation, and daily average clinical pain ratings and opioid consumption during hospitalization were abstracted. Univariable and multivariable generalized estimating equation analyses examined associations of candidate biopsychosocial, demographic, and clinical predictors with average daily pain and opioid administration. Among 113 hospitalized patients, 73% reported pain as the primary reason for presenting to the ED, 43% took outpatient opioids, and 27% had chronic pain that predated their cancer. Higher pain catastrophizing (B = 0.1, P ≤ 0.001), more recent surgery (B = -0.2, P ≤ 0.05), outpatient opioid use (B = 1.4, P ≤ 0.001), and history of chronic pain before cancer diagnosis (B = 0.8, P ≤ 0.05) were independently associated with greater average daily pain while admitted to the hospital. Higher pain catastrophizing (B = 1.6, P ≤ 0.05), higher anxiety (B = 3.7, P ≤ 0.05), lower depression (B = -4.9, P ≤ 0.05), metastatic disease (B = 16.2, P ≤ 0.05), and outpatient opioid use (B = 32.8, P ≤ 0.001) were independently associated with higher daily opioid administration. Greater psychological distress, especially pain catastrophizing, as well as pain and opioid use history, predicted greater difficulty with pain management among hospitalized cancer patients, suggesting that early assessment of patient-level characteristics may help direct consultation for more intensive pharmacologic and nonpharmacologic interventions.
Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) condition treated by GI and primary care physicians. Although IBS symptoms (abdominal pain, bowel problems) are generally refractory to medical therapies, consistent research has shown that they improve following cognitive-behavioral therapy (CBT). Notwithstanding empirical support for CBT, there is less research explicating the reasons for why or how it works. Like other pain disorders, the focus on change mechanisms for behavioral pain treatments has focused on pain-specific cognitive-affective processes that modulate pain experience, few of which are more important than pain catastrophizing (PC). The fact that PC changes are seen across treatments of differing theoretical and technical orientation, including CBT, yoga, and physical therapy, suggests that it may be a nonspecific (vs. theory-based) change mechanism akin to therapeutic alliance and treatment expectancy. Therefore, the current study examined change in PC as a concurrent mediator of IBS symptoms severity, global GI symptom improvement, and quality of life among 436 Rome III-diagnosed IBS patients enrolled in a clinical trial undergoing two dosages of CBT versus a nonspecific comparator emphasizing education and support. Results from structural equation modeling parallel process mediation analyses suggest that reduction in PC during treatment are significantly associated with improvement in IBS clinical outcomes through 3-month follow-up. Results from the current study provide evidence that PC may be an important, albeit nonspecific change mechanism, during CBT for IBS. Overall, reducing the emotional unpleasantness of pain through cognitive processes is associated with improved outcomes for IBS.
Full-text available
Objectives and importance of study: Yoga improves balance and mobility, and therefore has potential as a fall prevention strategy, yet its validity for preventing falls has not been established. The Otago Exercise Programme (OEP) and tai chi are proven to prevent falls. This study aimed to evaluate the perceptions and preferences of older people towards a yoga-based program with potential to decrease falls, to compare these perceptions to the views expressed about the OEP and tai chi, and to identify participant characteristics associated with a preference for the yoga program. Study type: Survey. Methods: Participants were 235 community-dwellers aged 60 years or older who were not participating or had not previously participated (within the past 10 years) in yoga-based exercise. Participants completed a self-report survey measuring demographics, physical activity level and attitude. They then viewed explanations of the yoga-based program, the OEP and tai chi. Participants completed the Attitudes to Falls-Related Interventions Scale (AFRIS) to measure program acceptability and identified their preferred program. Acceptability scores and preference were compared between the programs, and factors associated with yoga preference were identified with analysis of variance. Results: The mean age of participants (69% female) was 69.4 years (standard deviation 7.4). All programs were rated as equally acceptable (p = 0.17), with AFRIS scores ranging from 28.1 to 29.4. Eighty-two people (35%) preferred yoga, 32% chose the OEP and 33% chose tai chi. Overall, people who preferred yoga were significantly younger, healthier, less fearful of falling, and perceived exercise more positively than people who preferred the OEP (p values ranged from 0.03 to
Full-text available
The purpose of this systematic review was to identify and assess evidence related to the efficacy of meditative movement (MM) on sleep quality. We conducted a comprehensive review of relevant studies drawn from English and Chinese databases. Only randomized controlled trials (RCTs) reporting outcomes of the effects of MM (tai chi, qi gong, and yoga) on sleep quality were taken into consideration. Twenty-seven RCTs fulfilled our inclusion criteria and formed the basis for this review. Due to clinical heterogeneity, no meta-analysis was performed. Seventeen studies received a Jadad score of ≥ 3 and were considered high-quality studies. Findings of the 17 studies showed that MM has beneficial effects for various populations on a range of sleep measures. Improvement in sleep quality was reported in the majority of studies and was often accompanied by improvements in quality of life, physical performance, and depression. However, studies to date generally have significant methodological limitations. Additional RCTs with rigorous research designs focusing on sleep quality or insomnia and testing specific hypotheses are needed to clearly establish the efficacy of MM in improving sleep quality and its potential use as an intervention for various populations.
Full-text available
The Fibromyalgia Impact Questionnaire (FIQ) is a commonly used instrument in the evaluation of fibromyalgia (FM) patients. Over the last 18 years, since the publication of the original FIQ, several deficiencies have become apparent and the cumbersome scoring algorithm has been a barrier to widespread clinical use. The aim of this paper is to describe and validate a revised version of the FIQ: the FIQR. The FIQR was developed in response to known deficiencies of the FIQ with the help of a patient focus group. The FIQR has the same 3 domains as the FIQ (that is, function, overall impact and symptoms). It differs from the FIQ in having modified function questions and the inclusion of questions on memory, tenderness, balance and environmental sensitivity. All questions are graded on a 0–10 numeric scale. The FIQR was administered online and the results were compared to the same patient's online responses to the 36-Item Short Form Health Survey (SF-36) and the original FIQ. The FIQR was completed online by 202 FM patients, 51 rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) patients (31 RA and 20 SLE), 11 patients with major depressive disorder (MDD) and 213 healthy controls (HC). The mean total FIQR score was 56.6 ± 19.9 compared to a total FIQ score of 60.6 ± 17.8 (P < 0.03). The total scores of the FIQR and FIQ were closely correlated (r = 0.88, P < 0.001). Each of the 3 domains of the FIQR correlated well with the 3 related FIQ domains (r = 0.69 to 0.88, P < 0.01). The FIQR showed good correlation with comparable domains in the SF-36, with a multiple regression analysis showing that the three FIQR domain scores predicted the 8 SF-36 subscale scores. The FIQR had good discriminant ability between FM and the 3 other groups; total FIQR scores were HC (12.1 ± 11.6), RA/SLE (28.6 ± 21.2) and MDD (17.3 ± 11.8). The patient completion time was 1.3 minutes; scoring took about 1 minute. The FIQR is an updated version of the FIQ that has good psychometric properties, can be completed in less than 2 minutes and is easy to score. It has scoring characteristics comparable to the original FIQ, making it possible to compare past FIQ results with future FIQR results.
Full-text available
Background: Previous studies indicate that yoga may be an effective treatment for chronic or recurrent low back pain. Objective: To compare the effectiveness of yoga and usual care for chronic or recurrent low back pain. Design: Parallel-group, randomized, controlled trial using computer-generated randomization conducted from April 2007 to March 2010. Outcomes were assessed by postal questionnaire. (International Standard Randomised Controlled Trial Number Register: ISRCTN 81079604) Setting: 13 non-National Health Service premises in the United Kingdom. Patients: 313 adults with chronic or recurrent low back pain. Intervention: Yoga (n = 156) or usual care (n = 157). All participants received a back pain education booklet. The intervention group was offered a 12-class, gradually progressing yoga program delivered by 12 teachers over 3 months. Measurements: Scores on the Roland-Morris Disability Questionnaire (RMDQ) at 3 (primary outcome), 6, and 12 (secondary outcomes) months; pain, pain self-efficacy, and general health measures at 3, 6, and 12 months (secondary outcomes). Results: 93 (60%) patients offered yoga attended at least 3 of the first 6 sessions and at least 3 other sessions. The yoga group had better back function at 3, 6, and 12 months than the usual care group. The adjusted mean RMDQ score was 2.17 points (95% CI, 1.03 to 3.31 points) lower in the yoga group at 3 months, 1.48 points (CI, 0.33 to 2.62 points) lower at 6 months, and 1.57 points (CI, 0.42 to 2.71 points) lower at 12 months. The yoga and usual care groups had similar back pain and general health scores at 3, 6, and 12 months, and the yoga group had higher pain self-efficacy scores at 3 and 6 months but not at 12 months. Two of the 157 usual care participants and 12 of the 156 yoga participants reported adverse events, mostly increased pain. Limitation: There were missing data for the primary outcome (yoga group, n = 21; usual care group, n = 18) and differential missing data (more in the yoga group) for secondary outcomes. Conclusion: Offering a 12-week yoga program to adults with chronic or recurrent low back pain led to greater improvements in back function than did usual care. Primary funding source: Arthritis Research UK.
Published findings from a randomized controlled trial have shown that Mindful Yoga training improves symptoms, functional deficits, and coping abilities in individuals with fibromyalgia and that these benefits are replicable and can be maintained 3 months post-treatment. The aim of this study was to collect pilot data in female fibromyalgia patients (n = 7) to determine if initial evidence indicates that Mindful Yoga also modulates the abnormal pain processing that characterizes fibromyalgia. Pre- and post-treatment data were obtained on quantitative sensory tests and measures of symptoms, functional deficits, and coping abilities. Separation test analyses indicated significant improvements in heat pain tolerance, pressure pain threshold, and heat pain after-sensations at post-treatment. Fibromyalgia symptoms and functional deficits also improved significantly, including physical tests of strength and balance, and pain coping strategies. These findings indicate that further investigation is warranted into the effect of Mindful Yoga on neurobiological pain processing.
Background: Diverting attention away from noxious stimulation (i.e., distraction) is a common pain-coping strategy. Its effects are variable across individuals, however, and the authors hypothesized that chronic pain patients who reported higher levels of pain catastrophizing would derive less pain-reducing benefit from distraction. Methods: Chronic pain patients (n = 149) underwent psychometric and quantitative sensory testing, including assessment of the temporal summation of pain in the presence and absence of a distracting motor task. Results: A simple distraction task decreased temporal summation of pain overall, but, surprisingly, a greater distraction analgesia was observed in high catastrophizers. This enhanced distraction analgesia in high catastrophizers was not altered when controlling for current pain scores, depression, anxiety, or opioid use (analysis of covariance [ANCOVA]: F = 8.7, P < 0.005). Interestingly, the magnitude of distraction analgesia was inversely correlated with conditioned pain modulation (Pearson R = -0.23, P = 0.005). Conclusion: Distraction produced greater analgesia among chronic pain patients with higher catastrophizing, suggesting that catastrophizing's pain-amplifying effects may be due in part to greater attention to pain, and these patients may benefit from distraction-based pain management approaches. Furthermore, these data suggest that distraction analgesia and conditioned pain modulation may involve separate underlying mechanisms.