International Journal of Yoga Therapy — No. 26 (2016) 93 Research Mindful Yoga Pilot Study Shows Modulation of Abnormal Pain Processing in Fibromyalgia Patients James W. Carson, PhD,1 Kimberly M. Carson MPH, eRYT,1 Kim D. Jones, PhD, FNP-BC, FAAN,1,2 Lindsay Lancaster, PhD, RN,3 Scott D. Mist, PhD1,2 1. Oregon Health & Science University, Department of Anesthesiology and Perioperative Medicine, Portland, OR 2. Oregon Health & Science University, School of Nursing, Portland, OR 3. University of Portland, School of Nursing, Portland, OR Correspondence: [email protected] Abstract the average 40-year-old with fibromyalgia has fitness find- ings expected for a healthy 80-year-old (Jones, Rutledge, Published findings from a randomized controlled trial have Jones, Matallana, & Rooks, 2008; Jones, King, Mist, shown that Mindful Yoga training improves symptoms, Bennett, & Horak, 2011). Fibromyalgia has also been asso- functional deficits, and coping abilities in individuals with ciated with increased mortality (McBeth et al., 2009) and is fibromyalgia and that these benefits are replicable and can likely due in part to altered pain processing in the central be maintained 3 months post-treatment. The aim of this and peripheral nervous system (Jensen et al., 2009; Staud, study was to collect pilot data in female fibromyalgia Bovee, Robinson, & Price, 2008). Additional pathophysio- patients (n = 7) to determine if initial evidence indicates logic factors include genetic predispositions, autonomic that Mindful Yoga also modulates the abnormal pain pro- dysfunction, and emotional, physical, and environmental cessing that characterizes fibromyalgia. Pre- and post-treat- s t ressors (Clauw, Arnold, McCarberg, & Fi b r o ment data were obtained on quantitative sensory tests and Collaborative, 2011). measures of symptoms, functional deficits, and coping abil- The successful management of fibromyalgia patients is ities. Separation test analyses indicated significant improve- still a work in progress. FDA-indicated drug therapies are ments in heat pain tolerance, pressure pain threshold, and generally only 30% effective in relieving symptoms and heat pain after-sensations at post-treatment. Fibromyalgia 20% effective in improving function (Russell et al., 2008). symptoms and functional deficits also improved significant- Most clinicians and researchers recommend non-pharmaco- ly, including physical tests of strength and balance, and pain logical modalities such as exercise and cognitive-behavioral coping strategies. These findings indicate that further inves- therapy in addition to pharmacotherapy (Hauser, Thieme, tigation is warranted into the effect of Mindful Yoga on & Turk, 2010). However, recently there has been a growing neurobiological pain processing. interest in incorporating age-old Asian mind/body practices such as yoga, tai chi, and qigong (da Silva, Lorenzi-Filho, & Keywords: mindfulness, yoga, fibromyalgia, chronic pain, Lage, 2007; Haak & Scott, 2008; Mist, Firestone, & Jones, quantitative sensory test 2013; Wang et al., 2010). In a recently published study, we randomized 53 fibromyalgia patients to an 8-week Mindful Yoga interven- Fibromyalgia afflicts up to 15 million persons in the US, tion (previously published as “Yoga of Awareness”) or to primarily women, and carries an annual US direct care cost wait-listed usual care (Carson et al., 2010). Mindful Yoga as of greater than $20 billion (Spaeth, 2009). Fibromyalgia we teach it is distinct from many current Hatha yoga styles results in profound suffering, including widespread muscu- in that (1) it intensively emphasizes moment-to-moment loskeletal pain and stiffness, fatigue, disturbed sleep, mind/body awareness during asana practice rather than the dyscognition, affective distress, and very poor quality of life precise execution of postural alignments; and (2) substantial (Jones & Hoffman, 2009). Diminished aerobic fitness has practice of meditation, breathing exercises, study of yoga been documented for decades, but recent studies report that philosophy, practitioner meetings, and informal application www.IAYT.org 94 International Journal of Yoga Therapy — No. 26 (2016) of mindful awareness in daily life are highlighted along with changes in pain processing following an intervention. A gentle asana practice. handful of intervention studies have focused on the effects At post-treatment, women assigned to the Mindful of yoga. One study used QST to investigate the effects of Yoga program showed significantly greater improvements eight weeks of “relaxing yoga” on pain processing in individ- on standardized measures of fibromyalgia symptoms and uals with fibromyalgia, finding a small but non-significant functioning, including pain, fatigue, stiffness, poor sleep, reduction in pressure pain thresholds (da Silva et al., 2007). depression, and anxiety, as well as improvements in meas- Another study tested the effect of slow yogic breathing among ures of relaxation, acceptance, and vigor. Physical tests women with fibromyalgia and reported reduced ratings of showed improvements in strength and balance. A majority pain intensity and unpleasantness compared to matched of these improvements qualified as “clinically significant healthy controls (Zautra, Fasman, Davis, & Craig, 2010). changes” (Dworkin et al., 2008). Adverse effects were limit- Several other studies have used QST to quantify the ed to anticipated experiences such as transitory increases in effects of yoga and/or mindfulness on pain in other popula- mild muscle soreness and minor non-intervention-related tions. Improvement in pressure pain thresholds was report- events such as developing the common cold. Subsequent ed among patients with chronic nonspecific neck pain after analyses showed sustained significant improvements on a 9-week Iyengar Yoga intervention, compared with stan- most measures at 3-month follow-up. When the wait-list dard exercise (Cramer et al., 2013). A brief 3-day mindful- group was crossed over into the Mindful Yoga intervention, ness meditation intervention demonstrated a decrease in results largely replicated the post-treatment improvements pain sensitivity in healthy normals (Zeidan, Go rd o n , seen in the original Mindful Yoga group (Carson, Carson, Me rchant, & Goolkasian, 2010). In another study, Jones, Mist, & Bennett, 2012). Villemure and team found that yoga practitioners tolerated Given these replicated findings, we were interested in cold pain more than twice as long as matched controls the possibility that such improvements might be accompa- (Villemure, Ceko, Cotton, & Bushnell, 2014). In addition nied by changes in abnormal pain processing that are found to QST, a series of recent experimental studies have focused in fibromyalgia. Research in the past decade has significant- on brain imaging techniques such as functional magnetic ly increased our understanding of the pathophysiological resonance imaging (fMRI) to elucidate the impact of med- mechanisms of fibromyalgia, due in large part to the itation techniques on pain (see Grant, 2014 for a review). expanding use of quantitative sensory testing (QST) to These studies reveal findings demonstrating that mindful- characterize the pain processing abnormalities of this disor- ness reliably decreases pain scores. Moreover, mindfulness- der. QST modalities assess and quantify the detection related improvements in pain are consistently accompanied threshold of accurately calibrated sensory stimuli, such as by a neural pattern characterized by reduced affective and thermal, pressure, or other stimuli (Kindler et al., 2011). cognitive processing of pain but increased sensory process- Varying QST modalities capture unique aspects of the pain ing of pain. This pattern suggests that meditators may learn processing continuum including mechanisms of peripheral to view painful stimuli more neutrally (Grant, 2014). and central sensitization and the central integration of pain While prior QST studies have provided important (Arendt-Nielsen & Yarnitsky, 2009). Most relevant to the objective data regarding yoga and mindfulness effects on p resent study are QST studies demonstrating that pain, most have assessed only single measures of pain sensi- fibromyalgia is characterized by (1) generalized neurobio- tivity (threshold or tolerance). Multi-modal QST assess- logical amplification of sensory stimuli, as evidenced by ment is advantageous because of the ability of each QST hyperalgesia in terms of lower sensory thresholds and toler- modality to assess a different aspect of the pain pathway ance (e.g., decreased heat pain threshold and tolerance) (Arendt-Nielsen & Yarnitsky, 2009) and hence provides the (Geisser et al., 2003); (2) sensitization of ascending path- opportunity to elucidate a variety of exact mechanisms by ways as a component of central sensitization as measured by which yoga exerts pain-reducing effects. Our intention with temporal summation, or hyper-excitability of dorsal horn the current study was to conduct an uncontrolled pilot neurons in response to repetitive C fiber input (e.g., study of Mindful Yoga using a multi-modal QST protocol increased ratings of prolonged heat pain) (Gracely, Grant, in a small sample of fibromyalgia patients to determine if & Giesecke, 2003) and more intense and prolonged after- initial evidence indicates that further investigation is merit- sensations of painful stimuli) (Price & Staud, 2005); and ed. If the Mindful Yoga pilot data demonstrate that signifi- (3) mechanical hyperalgesia and allodynia as