Abstract

Purpose: To examine an 18 month period of yoga therapy on a single subject suffering from chronic pain, specifically fibromyalgia, and to determine how and what measures are needed to report improvement. Improvements documented over a specific time period in a controlled setting can further underscore the case for using yoga as a sole means for managing fibromyalgia & chronic pain and also provide a background to establish a working dialogue with “western” medicine practitioners.

Study Design: Using case-study research methods, an 18-month period of gentle Iyengar based Yoga was implemented 1-2x/week in a woman suffering from fibromyalgia and chronic pain.

Findings: The findings showed that the student steadily improved in many measures, including pain, body awareness, medications dose/type, body weight, cholesterol, hypertension, bone density, and subjective quality of life measures (increased confidence, improved body image).

Conclusions: As yoga therapists, we have a professional obligation to document the changes & improvements our yoga students are experiencing during a controlled yoga studio environment. Collecting this information is vital to encourage an open dialogue between western & eastern medicine. The information collected during this study is positive evidence that could assist in the future development of chronic pain management with yoga therapy. Future case studies and research should include more diverse populations of chronic pain sufferers as well as the use of tools which quantify a student’s intangible concerns and complaints (i.e., pain, quality of life, psychological health, emotional health, ease of daily activity completion, etc.).

Chronic Pain & Yoga – Telling our Story

As yoga therapists we see many students come to yoga seeking relief from pain. Likewise, we may have sought the same end when we first came to yoga. For the 50 million Americans who suffer from pain every year, relief may be sought for mental, emotional, psychological, social, & spiritual hurt or pain, not simply the physical.(1)

Treatments can include painkillers, injections, anti-inflammatories, electrical stimulation, ultrasound, massage, physical therapy, manual therapy – all with varying levels of success. The emotional and mental stress can be as painful and debilitating as the physical condition. The existing chronic pain then becomes complicated with the additional distress, leading to the depletion of the immune and nervous system resources. Further compounding the problem with each exacerbation is the subsequent declining ability of the body to deal with neurological pain perception thus, leading to increased perception of and decreased tolerance of pain.(5)

Even more confusing and frustrating with the situation of chronic pain is that symptoms can widely vary, be diffuse, and can constantly change.(4) The signs & symptoms of fibromyalgia, a chronic pain condition characterized by inflammation of & tender points surrounding the joints and muscles of the body can begin with generalized, global pain, fatigue, muscle tender & trigger points, muscle twitching, & spasms.(15)

Some victims of this syndrome may experience localized pain in addition to the global pain. Starting with the head and working towards the feet, any or all joints can suffer from the following symptoms: headaches & sensitivity to light &/or sound, vision changes, numbness or burning in the face or extremities, chest & costal (rib) pain, neuropathies in the hands & feet causing weakness, & balance problems.(5)

Fibromyalgia can also affect other systems of the body. Oftentimes, osteoarthritis, rheumatoid arthritis, irritable bowel syndrome, &/or chronic fatigue syndrome can accompany fibromyalgia. Lastly, the classic symptom of fibromyalgia is lack of REM or deep sleep, which creates serotonin imbalance and can be responsible for depression, impaired memory, &/or anxiety. 5 The course of fibromyalgia ranges from mild & minimally involved to severe and completely debilitating. (4)

Unfortunately, our health care system does not allow for more than “acute” treatment of pain. 2 Once someone is deemed “chronic”, there is a burden put on patients to “prove” they are in pain.(2) This proved to be true for the woman in this case study, who over a 30 year time span, did not hear of yoga as a treatment method even one time. Yoga is one of the oldest pathways to holistic health and wellness; yet there are still few western health care practitioners who embrace yoga or are even familiar with its plethora of benefits.

Experienced yogis & yoga practitioners know that yoga can address problems in every system of the body to effectively manage pain, and for the case study that follows here, 18 months of documented evidence further strengthens the case for successfully managing chronic pain syndromes with yoga therapy.

As yoga therapists & professionals, we have an obligation to establish a successful dialogue with other health care professionals. This may seem like a daunting task, but by recording & sharing the following basic information with others, we can all work to make yoga more accessible. More than that, I encourage you to begin collaboration with a health care professional to determine what would be helpful for their patient population. In reality, this is not a difficult task.

There are many different types of health care practitioners whose patients would benefit from yoga. physical therapists, primary care physicians, neurologists, chronic pain treatment centers, ob/gyns, psychologists/psychiatrists, even your athletic trainers at local high schools & universities. Bringing yoga to as many people possible is our job, not theirs.

Her Story

61 year old ST (fictitious initials) has suffered from fibromyalgia since 1980, when at 38, she learned she had “fibrositis” (fibrositis was the early name given to fibromyalgia). At the time, she had no idea what fibromyalgia was, other than it was to blame for her daily pain and fatigue.

ST slowly retreated from the activities she once enjoyed as her pain worsened. She was gaining weight because while she was trying to “avoid pain”, she was “avoiding all activity”. Her medical history became increasingly more complicated as her daily activities were kept to a bare minimum.

ST’s family and ST herself began to notice the physical & emotional separation that began to occur as the pain & overwhelming fatigue consumed her. Her previous life was a very healthy & active one. Now, she was feeling it turn into a nightmarish twilight zone like medical history that included type II diabetes, polycystic ovarian disease, hyperlipedemia, hypertension, right rotator cuff tear & impingement syndrome, osteoarthritis of the hands, atherosclerosis of the right hand posing as carpel tunnel syndrome, costochondritis, and finally in 1990 a radical mastectomy from breast cancer.

ST suffered in every way imaginable. Some days, “I could not even get out of bed”. “I was scared to move, because I was scared of hurting. So I didn’t move, the pain would increase anyway, and I further retreated into a life of fear & confusion.” ST came into my office – for yoga – after 23 years of pain. She had a laundry list of medications, & repeated unsuccessful attempts at “pain management”. Fortunately, her motivation level was high.

Unfortunately, ST was angry, addicted to her pain & dependent on her ever growing list of medications. ST only decided to try yoga because she had finally gotten “mad” enough to do something about her debilitating pain & fatigue. ST’s doctors had never offered any detailed advice further than “get out & exercise, eat less, and relax”. Furthermore, yoga had never been offered as a treatment option. (the reason for establishing a rapport with other professionals, and for documenting the effects of yoga practice).

Hence, the purpose of this case study is to increase awareness of the importance of case documentation, to provide a possible framework for case study documentation, and to encourage the yoga community to become involved in this necessary work.

ST dedicated herself wholly to yoga study, determined to break out of the cycle of pain and her shell of separation from her family & her old life. For the next 18 months, 1-2 times a week, ST participated in 60 minute individual yoga sessions. “Yoga is the only exercise or treatment that has ever worked – I no longer fear movement, I lost weight and have maintained an ideal weight, and my doctors are amazed that my medical condition is continuing to improve, despite my age.”

Methods

61 year old white female was started in a 1-2 times/weekly, 60 minute Iyengar based yoga program. She began with fibromyalgia, chronic neck and low back pain, type II diabetes, and was a complete novice to yoga.

Data Collection & Analysis

An ongoing evaluation was initiated on 6/28/02, documentation was maintained for each visit, noting specific asanas, pranayama, or any other techniques used. Medical records including quantitative analysis were also obtained, covering a period of 18 months. The following measures were taken prior to, during, and at the conclusion of the program: body weight, height, cholesterol, pain reports from every affected area, medications and dosage, triglyceride levels, BP, bone density reports, & glucose levels.

Findings:

As the data was reviewed, the measure of ST’s success was directly proportional to her involvement in yoga. ST underwent no other type of exercise during the 18 month period.

Condition Before After
Weight 181 145
Height 5’4” 5’4 ½’
Blood Pressure 134/74
Body Mass Index 31.1 24.9
Less than 18.5 Underweight
18.5-24.9 Healthy Range
24.9-30 Overweight
> 30 Obesity

Medication:
Blood pressure (Avopro)
Ant-depressive for serotonin balance (Imiprimine)
Fibromyalgia (Trazadone)
Reflux (Ranitidine)
Cholesterol (Lipitor)
Depression (Prozac)
Diabetes (Metformin)
Anxiety (Clonipin)
Arthritis/Pain (NSAIDS) “MD’ s report: Diabetes now under excellent control, and her fibromyalgia is basically gone.”

Blood Pressure (Avopro)
Anti-depressive for serotonin balance (Imiprimine-25 mg)
Diabetes (Metformin)

Cholesterol: 226
HDL 39
LDL 154 170
HDL 48 (Normal 45-100)
LDL 99 (Normal 0-130)
Triglycerides 289.9 116
Bone Density Scan 2000/11 1.087 gm/cm2 (Osteopenia lumbar spine) 2002/12 (after 6 months of yoga)
1.137 gm/cm2 (within normal range, no evidence of osteopenia) 4.6% change
*Physical Pain Manifestation: Cervical Spine

Costochondritis

Lumbar Spine

Glenohumeral (shoulder) joint
Measured worst/least
6/10 constant
10/10 worst
4/10 least
10/10 worst
8/10 least
10/10 worst
5/10 least

10/10 constant, had an MRI which diagnosed a right rotator cuff tear. “I was a surgical candidate for rotator cuff repair.” Measures current 0/10

0/10 –the only time I have pain is when I fail to practice good body mechanics or posture

0/10 present – the only time I have shoulder pain is when the weather gets very cold, which flares up my arthritis, or when I use poor lifting mechanics.

Thenar (thumb) imminence, wrist 8/10 constant, unable to bear any weight on the wrists, especially the right side; she had a rare discovery of atherosclerosis in the arteries supplying the right hand, which required microsurgery; the symptoms masked themselves as carpal tunnel syndrome for so long that the thenar & hypothenar imminences (pad of the palm at the thumb and 5th digit) had completely flattened from severe atrophy; she could not write with her right hand on some days, and spent 2 years in intermittent casts and/or splints prior to her yoga work. 4/10 , persisting secondary to the severe nature of her condition resulting from remaining weakness & hypomobility, which is on a weekly basis, still showing improvement.

Treadmill Stress Test

Could not complete test. Could not complete shopping errands or yoga session without fatigue & exhaustion Completed, and MD reported she was in much better CV shape than 12/01 and stated “whatever you have been doing, keep doing it.”

No difficulty completing activities of daily living, recreational activities, or yoga program.

*6/28/02 – pain globally – bilateral wrists, bilateral shoulders, cervical spine, lumbar spine, fingers, ribs, sternum, chest
*2/17/03 - ST reports I have no pain when I do yoga, but if I have any break from it at all, the pain comes back.” “I must do yoga regularly”.

Progression of yoga therapy:

Months 1-4 Asana:

ST started with extremely gentle restorative asanas & breath awareness. At the start of treatment, the subject was unable to tolerate any weight-bearing through the upper extremities without 10/10 pain through the right shoulder and bilateral wrists and hands.

Supine, prone, 4 point posture, and chair modified asanas were introduce first such as apanasana (knees to chest), supta padangusthasana (hand to big toe) with strap, dvipada pitham (bridge), setu bandhasana (bridge), baby bhujangasana (cobra) , shalabasana (locust) with palms upturned secondary to severe forearm restriction, ardha dhanurasana (1/2 bow) with tactile assistance and strap, (full dhanurasana without strap was accomplished by end of month 4), balasana (childs pose) with head on blanket and arms at side, cat (chakravakasana)/cow with blocks under hands, adhomukha svasana (downward facing dog) at the wall or with a chair, and savasana (corpse) with bolster under knees.

ST continued to practice supine and prone asanas prior to warm up vinyasas for 4 months before her flexibility was increased enough to progress to traditional sun salutations. Shoulder openers were also introduced and included garudasana (eagle arms) and gombukanasa (cow arms) as well as 2 variations of openers I created.(3, 6, 8, 10, 13, 16, 22).

Months 5-8

Asana progression took place after 4 months to include standing and seated postures, in addition to those cited above: tadasana (mountain), uttanasana (forward standing bend), ardha chandrasana (standing ½ moon), utkatasana (chair), modified surya namaskar (which followed a modified vinyasa warm-up [chakravakasana/cow, adhomukha svanasana, astang pranam, bhujangasana, balasana] but preceded the above asanas.

Also included were virabhadrasana I and II (warrior I, II), trikonasana (triangle), utthita parsvakonasana (extended side angle), and vrkasana (tree). Seated asanas included suhkasana (easy seated pose), dandasana (staff), paschimotanasana (forward seated bend), chatushpada pitham (tabletop), janu sirsasana (head to knee), marichyasana (seated twist), ardha matsyendrasana (1/2 lord of the fishes) & navasana (boat). After 12 months - the existing postures were much improved. ST no longer needed blankets for asana practice. (6, 8, 10, 13, 14, 22)

Months 9-12

All postures progressed and only needed a single blanket as a prop for seated postures; no props were needed for shoulder openers; Hamstring length had normalized at 90 degrees of straight leg raise; Hip flexors were of normal length as well.

Asanas added:

Noose posture, pavritta uhttita parsvakonasana (prayer twist), extended leg stretch, static plank, chataranga from knees, ardha padmasana (½ lotus), adhomuhka svanasana (downdog) honoring normal spinal curves; forward bending asanas without props.(8, 10, 11) Months 13-18

10 surya namaskar (sun salutations) completed; setu bandhasana (balancing unilaterally), matsyasana (fish); initiation of halasana (plow)(8, 10, 11)

Pranayama, Mudras, & Bandhas:

Initial breath awareness work was practiced for 6 months and included abdomino-diaphragmatic breath (coulter). Jalandhara bandha was immediately introduced, as was uddiyanda bandha. After 6 months, ST was able to demonstrate thoraco-diaphragmatic breath without anxiety; however, she was unable to maintain the breath during asana & pranayama practice. After 4 months, nadi shodana (alternate nostril breath) was introduced, however, a deviated septum made practice very difficult and in early stages, elicited panic symptoms. Ujyaii breath was introduced most recently when valsalva was no longer observed in asana practice. Mula bandha was the last bandha introduced. Mudras introduced throughout were: anjali & jnana.(6, 9, 10, 11, 12, 14, 16, 17, 22)

Discussion

I know what I’m doing and what it’s done for me – People ask me all the time “I can’t believe what a turn around you have experienced, and with having diabetes, fibromyalgia….I can’t believe in doesn’t bother you?” I tell them “no, as long as I stick with yoga”. “It makes me feel so good when people notice how good I feel on the inside”. “my outer appearance has come in second compared to how I feel.”

Quality of life & Shifts in personality

“I am a lot happier, because I can get out and do something. I didn’t go out before, because everything affected my pain – it was either too cold, too hot, too damp, or too early, or too late for my body. Now I know I can go out and do anything I want because I have overcome only paying attention to the physical aspects of my body – now I look at myself as a whole person. In fact, I can honestly say yoga has taught me to look at the whole world differently now.”

Body Awareness

“After I had breast cancer, I wouldn’t stand up straight, I would kind of lean over to the side of the mastectomy, I would avoid mirrors – out of feeling vulnerable and disfigured. After these 18 months of yoga, I actually watch myself and my posture constantly. I wear fitted clothing year round with confidence and I no longer lean over and hide. Before, I wasn’t even aware of where I was in space, now I walk tall and with positive self worth.”

Motivators

“After 18 months of yoga practice, I know the word “boredom” does not exist in yoga, because yoga isn’t a simple exercise program. There is no repetition & mindless movement. Yoga is never work for me, it is totally relaxing & energizing, and always enlightening. I never know what we will be addressing in a yoga session, and I always look forward to the challenge. I reached a turning point in my life when I realized that saying yoga was just exercise was like saying a short term diet is the answer to proper lifelong nutrition. Just like you don’t “diet”, you change your eating habits, you don’t “just exercise” in yoga, you change your movement habits throughout every system of your body.”

Deepening relationships

In ST’s words, which many yoga patients can agree with, she says, “.this is the ONLY type of exercise I’ve ever stuck with (or enjoyed) in my life because it doesn’t hurt me. Most importantly, the practice gives me peace. I can focus more clearly and my friends and family clearly feel (and not just see) the difference when they are around me. Yoga teaches me the difference between pain & soreness, between injury & conditioning of the body.

Sometimes I used to think I was having a heart attack because of the severe chest, neck, and arm pain, and the anxiety & sheer panic that goes with it. Now I know the difference between pain, disuse soreness, and the occasional arthritic ache - because of the keen body awareness yoga has given me. I’m in tune with my body now, and what’s most important is - I listen to it. Mentally, physically, emotionally, socially, spiritually - yoga has transformed me and now I am a whole person.

Yoga nourishes my body & mind, teaches me to honor my limits and the same time challenge them. Coming from someone who suffered for 23 years and now is pain free, I want you to have hope, because yoga can work for you too. I used to have pain of no less than 5/10 on the pain scale everyday of my life, most days it was 8/10, and some days I couldn’t even get out of bed. ST’s exact words ring very true, “Yoga worked for me, and it can work for you, if you are studying under the direct guidance of an experienced instructor.”

The sheer numbers of chronic pain in Americans (1 out of every 3 suffer from a chronic joint problem or arthritis, according to the Centers for Disease Control, Atlanta, GA) underscores the important of spreading the word about yoga therapy. Geeta Iyengar in her textbook Yoga – A Gem for Women, states “yoga can be done by all at any age. It is particularly beneficial to those over 40 when the recuperative power of the body is declining and resistance to illness is weakened”.

Leon Chaitow, in his book Conquer Pain the Natural Way, states “yoga is more than simply an exercise system, it benefits the whole body in so many ways...the regular practice of yoga brings about improvements in every system of the body.”

The documented improvements seen in ST correlate with the benefits of yoga found in other cases & studies as well.(16, 18, 19 )

Conclusions

Findings from this study indicate a further need for research to underscore the potential positive impact for use of yoga in the management of chronic pain & fibromyalgia. The question remains then, How do we establish a more successful dialog with western health care practitioners?

First, consider the language that is used in yoga – it is very poetically powerful and all encompassing. However, from the “western practitioner’s” frame of reference, “yogic” language is not understood, and therefore is often shunned. Speaking on the eastern behalf, I prefer yogic language – you actually learn more about yourself. Speaking on the western behalf, there is great power of persuasion in being able to objectively measure improvement in a student’s progress. A yogi can “feel” the difference, but unless they can explain why & how, their knowledge cannot benefit the community.

There is a solution within the yoga realm for solving this western conundrum – journaling. Documentation, as it is in western medicine, is the method for proving how point A to point B was traversed. The yoga therapist’s journal can be that vehicle for arriving at destination B – consider these guidelines.

1. Note the duration of practice, date, and intensity. Also note any subjective feelings your student may have – joy, sorrow, pain, fear, frustration.

2. Note the asanas or vinyasas as well as pranayama or breath awareness you instruct.

3. Note your focus or intent for the session that day. You may not start out with a goal, but the student’s mental and physical condition reveal themselves to you during the course of a practice, which should guide your progression. Note that.

4. Note any chakras, bandhas, drishtis, or koshas you may be including as part of your therapy.

5. Note their reaction and tolerance to the practice. Did any pain arise or resolve? Were some asanas modified or discontinued? Was a chakra noted to be more in balance after practice?

6. Note what direction future sessions might take. Include your goals or your students' wishes. What specific limb of yoga should be addressed next time?

An example, from ST’s chart, is one you may use as a guide:

11/13/02
Prior to session: not sore at all, feel great, mentally strong & positive.

During: started with 2 warm up vinyasas (cat/cow/adhomukha svanasana/astang pranam/bhujangasana/balasana), progressed to shoulder openers (shoulder opener of my own creation using strap/gombhukanasan arms/garudasana arms), emphasizing prevention of elbow hyperextension, then hip openers in kneeling lunge; 2 surya namaskar A’s, modified using 4 point stance to transition in/out of adhomukha svanasana and utthanasana; flow virabadrasana I,II, prasarita paddotanasana, seated and standing, navasana 3 times, dhanurasana, ardha urdhva dhanurasana, dolphin prep. (only dropping to 1 forearm and pressing back up), ardha padmasana.

Post session: tolerated very well without complaints; client is almost ready for surya namaskar with full step back to adhomukha svanasana; focus on breath remaining calm and normal during all poses; no valsalva observed during 60 minute session.

Future: emphasize breath awareness

All of these considerations were part of my yoga therapy with ST. I carefully monitored all of her bony landmarks and soft tissue responses during pose/repose in order to prescribe asanas, pranayama, and mediation. ST now lives her life pain-free, and with daily determination not to return her previous life of chronic pain. She is a motivator for all those who currently suffer from a chronic pain condition, and offers hope for renewal. Every chronic pain sufferer is an individual and yoga programs must always reflect their individual deficits and pain manifestations.

However, common threads do emerge from the lives of chronic pain suffers. This study serves to identify some of those common threads which may serve to contribute to the tapestry of current chronic pain management. For those who suffer, body awareness & control of the breath is paramount. Only by nurturing body awareness, can a person understand & care for their body. The practice and study of yoga serves to cultivate that appreciation for the body, in its broken and whole forms, and to teach its students to embrace the entire experience.

Finally, a single case such as this would be in vain if it did not spur other therapists to follow in similar order. It is imperative that we establish and furthermore maintain, a rapport with the “western” medical community. Sacrifice a small portion of your time, weekly or monthly, in order to speak with physicians, their assistants, physical therapists, psychologists, and the like. Invite western practitioners into your studio, offer free class(es) for them &/or their employees, offer an open house, &/or send out a quarterly newsletter to enlighten them on yoga’s far stretching benefits, including any group therapies or specialty classes you offer.

Speaking on group therapies, western health care has become incredibly cost prohibitive, and group therapies can offer an inexpensive, safe, and extremely beneficial method for long term exercise programming. Lastly, you may look to write a local column in your newspaper on a monthly basis as I have done for several years now– outlining the many benefits of yoga and yoga therapies. Most importantly, you must be prepared to speak their language and to intelligently state the benefits of yoga, as well as potentially answer questions that will require you “navigate the sometimes hazardous waters between therapy and religion”, as Georg Feurstein states in his 1998 article titled “Yoga and Yoga Therapy.”

You may be ready to answer those difficult questions now, but what questions & concerns will you ask of western health care professionals? Consider these: 1.What kind of patients do you see? Are any of them (how many) considered chronic pain patients? How many low back and neck pain, shoulder pain, or arthritis patients do you see (this being an opportune time to review yoga’s benefits)? May I offer a free session to you or a free group session for your staff to show you some of the yoga therapies I use to manage these conditions? More often than not, the staff is who will send potential students your way, not the physicians themselves.

I offer these simple questions to gently nudge you to think outside of your own studio or facility. We must engage the western world of medicine professionally, intelligently, and with only the purest of intentions. It is my hope that we will all be spurred to take a definitive course of action, thus serving to shine the healing light of yoga the world over.