Fibromyalgia Syndrome and Yoga

Abstract

Fibromyalgia syndrome (FMS) is a chronic condition characterized by widespread pain and tenderness at specific points in the body, sleep disturbances, fatigue, depression, and anxiety. Current management for FMS focuses on a multidisciplinary approach to symptom management. Among the complementary and alternative therapies used for symptom management, yoga holds a significant position. Yoga, which aims to achieve balance in physical, mental, emotional, and spiritual aspects, is suggested to have potential benefits in managing the symptoms of fibromyalgia. These potential benefits include pain and stress management, reduction in sleep disturbances and chronic fatigue, increased body awareness, and improved quality of life. However, despite the expanding research on the relationship between yoga and fibromyalgia, definitive conclusions regarding a clear clinical effect have not yet been established. Nonetheless, the positive effects of practices such as yoga, which integrate physical postures, mindfulness, and breathwork, on overall health, functional capacity, and quality of life should be considered. People with fibromyalgia should consult their healthcare provider before trying therapeutic practices such as yoga.

Introduction

Fibromyalgia syndrome (FMS) is a chronic condition characterized by fatigue, depression, anxiety, sleep disturbances, and widespread pain and tenderness at designated points in the body. These complex symptoms are associated with reduced functional capacity and quality of life.[1,2] FMS predominantly affects women aged 20–55.[3] The diagnostic criteria for FMS have evolved and vary across classification systems. According to the American College of Rheumatology, while a certain number of tender and painful points was previously important, new criteria emphasize the significance of widespread pain areas.[4] The prevalence of fibromyalgia in the general population is estimated to range between 2% and 7%, depending on the study and diagnostic criteria used.[5] The etiology of FMS is unknown, but evidence suggests that patients experience autonomic dysfunction, such as altered hypothalamic–pituitary–adrenal (HPA) axis, impaired pain processing, decreased levels of serotonin, dopamine, and norepinephrine, and potential contributions from muscle microtrauma, which may lead to localized inflammation and chronic pain through repetitive stress injuries. Muscle microtrauma has been proposed as a contributing factor in FMS, with studies indicating that repeated or sustained stress on muscle fibers may induce inflammation, sensitizing nociceptive pathways, and exacerbating chronic pain symptoms. This mechanism is thought to further interact with neurochemical imbalances, such as reduced levels of serotonin and norepinephrine, commonly observed in FMS patients.[5,6,7]

There is no definitive cure for FMS, but current treatment approaches focus on multidisciplinary symptom management. Symptom management includes both pharmacological and nonpharmacological complementary and alternative therapies. Among complementary and alternative therapies are cognitive–behavioral therapy, heat applications, nutritional supplements, diet, acupuncture, massage, body awareness therapy, video games, dance, pilates, exercise, tai chi, and yoga.[7,8,9,10] According to a report published by the Germans, the complementary and alternative therapies used at least once in the management of FMS are as follows: heat-based applications (67.0%), dietary and vitamin supplements (35.2%), physical therapy methods involving a tool such as acupuncture (28.5%), and meditative practices such as yoga (18.4%).[11]

Yoga, an ancient discipline practiced for approximately 5000 years, aims to balance an individual’s physical, mental, emotional, and spiritual aspects and is widely practiced worldwide due to its benefits.[12,13] Various types of yoga, such as Hatha, Vinyasa, Iyengar, Yin, Bikram, and Restorative, focus on the balance of mind and body, with the content varying based on the practices, environment, and materials used.[14] Originating in India with a long history, Yoga is metaphorically depicted as a tree and includes eight different branches: universal ethics (yama), individual ethics (niyama), bodily postures (asana), breathing techniques (pranayama), sensory control (pratyahara), concentration (dharana), meditation (dhyana), and bliss (samadhi).[15] Over time, it has become popular in Western societies and is mainly associated with the three elements of bodily postures (asana), breathing techniques (pranayama), and meditation (dhyana).[16] The breathing techniques and meditation practices included in yoga aim to increase awareness while also enhancing parasympathetic activity.[45] Awareness is one of the components of mindfulness. Mindfulness, first introduced by American physician Jon Kabat-Zinn, is the process of openly participating in one’s present moment experience with awareness. Definitions of this concept commonly include components such as the focus on the present, acceptance, and openness.[17] It is known that mindfulness significantly reduces stress which is an important factor for FMS.[18]

In the United States Physical Activity Guidelines, yoga is considered both aerobic and muscle-strengthening due to its variations. This physical activity can be done both lightly and moderately according to personal preference, with the guidelines recommending 150–300 min of moderate-intensity physical activity per week for adults.[19] It is used as a complementary and integrative medical therapy in North America, Australia, and Europe, with most practitioners being young, female, having higher education levels, higher income, and better health status. Despite the different types of yoga, the positive outcomes are predominant, suggesting that the choice of yoga depends on personal preference and suitability.[16,20]

The popularity of yoga as a therapeutic practice is increasing. It is often practiced for musculoskeletal problems and stress management.[21] However, it is also known to play a significant role in combating chronic diseases such as cancer, rheumatoid arthritis, cardiac disorders, chronic back pain, and hypertension.[20] It is known that the serum levels of cytokines interferon-γ and interleukin-12, which play an active role in both innate and adaptive immunity, prevent viral infections and tumor formation, and activate macrophages, increase with yoga. This proves the anticancer, anti-inflammatory, and immune-strengthening effects of yoga.[22] In addition, it activates the parasympathetic nervous system by stimulating the vagus nerve through breathing practices. Numerous studies have shown that yoga reduces salivary cortisol, blood glucose, plasma renin levels, and 24-h urinary norepinephrine and epinephrine levels.[15] It is also known that yoga increases serotonin release and decreases adrenaline release. Due to its effects on these hormone levels, yoga is also mentioned to play an important role in improving psychological problems such as depression, anxiety, and chronic fatigue.[23] In addition to all these effects, yoga is effective in improving posture, increasing strength and endurance, weight control, sleep quality, pain reduction, enhancing lymph circulation, and improving mental focus and concentration.[12]

Yoga is widely used by patients suffering from various rheumatic diseases. Rheumatic diseases typically present with joint stiffness, degeneration, wear of cartilage, connective tissues, and bones, as well as pain and inflammation that restrict daily living activities. In addition to pharmacological treatment, yoga or other types of exercise provide benefits to patients with rheumatic diseases due to their positive effects on strength, flexibility, balance-coordination, and endurance.[24] Systematic reviews indicate that yoga is a safe and effective adjunctive method for coping with rheumatic diseases such as FMS, rheumatoid arthritis, or osteoarthritis, although the level of evidence is still weak.[25,26] Yoga’s effectiveness in improving the core symptoms of FMS, such as pain, dysfunction, fatigue, and mood disorders, is well-known. Although many studies support this, further research is needed.[24,27,28]

The aim of this review is to synthesize the current evidence, identify research gaps, and guide future studies. The variability in findings across different studies and the need for a comprehensive perspective on clinical applications in this field make this approach particularly important.

Effects of Yoga on Fibromyalgia Syndrome

Pain and stress

FMS, a chronic pain disorder that can affect children and adolescents but is more common in adult women, contributes significantly to the prevalence of chronic pain.[29] Clinical studies have reported that many FMS patients adopt yoga.[30] Yoga is used in the treatment of various chronic conditions where pain is a dominant feature.[31] It is known that yoga improves measures of pain, fatigue, mood, anxiety, acceptance, and coping in FMS patients, with favorable pain scores.[32] In their study, Lazaridou et al. reported a reduction in pain and stress symptoms among participants, as well as positive effects on mood, sleep, and self-confidence. Yoga is increasingly used in clinical settings for stress-related diseases and anxieties and is considered promising.[33] The autonomic nervous system function in FMS syndrome is affected by stress.[34] Low resting heart rate variability, an indicator of dysfunction, is associated with vagus nerve activity.[35] Lower levels of cardiac vagal tone have been measured in FMS patients.[36] Yoga, which includes diaphragmatic breathing, has been reported to directly affect neurological activity mediated by the vagal tone in cardiopulmonary vagal nerve stimulation.[37] Meditation-based breathing techniques show positive analgesic effects for acute pain conditions.[38]

Yoga can also demonstrate its effects through physiological mechanisms on the HPA axis.[39] Studies in the literature show that yoga reduces cortisol levels. In a study conducted in 2013 on 54 people using antidepressants, yoga or both, training was given at a yoga center for 10 days, and after the first 10 days, yoga was practiced 1 h a day for a total of 12 weeks, 5 days a week. In the last measurement of the participants after 12 weeks, it was reported that yoga reduced serum cortisol levels afterwards.[40] In a study examining the effects of yoga on the HPA axis, 114 people with an average age of 62.2 years were subjected to an 8-week Hatha yoga intervention, while the control group performed stretching exercises. A significant decrease in salivary cortisol levels was reported after the exercise intervention of 1 h three times a week for 8 weeks. This effect is thought to be effective in reducing stress and preventing cognitive decline.[41] In the study conducted by Kumar et al., fibromyalgia patients participated in yoga sessions three times a week, each lasting 60 min. The sessions focused on physical postures and relaxation techniques, leading to improvements in pain levels, flexibility, and corticomotor excitability. The results highlight the potential benefits of yoga therapy in managing fibromyalgia symptoms and support its role in pain management and flexibility enhancement in musculoskeletal conditions.[42]

Sleep

Besides the known physiological effects of yoga on rheumatic diseases, its impact on mental problems has also been researched, with positive results found. In a systematic review of 27 studies investigating the effects of yoga on depression, anxiety, mood, and sleep quality in rheumatic diseases such as FMS, osteoarthritis, rheumatoid arthritis, and chronic fatigue syndrome, positive effects were observed on all parameters.[43] Considering that FMS is a painful rheumatic disease involving sleep disturbances and chronic fatigue, there are also studies investigating the effects of yoga on sleep in FMS. In a study completed with 36 patients with FMS, participants were given 6 weeks of private Satyananda Yoga practice and home practice. The program was designed as a face-to-face session each week and included asanas (postures, Pawanmuktasanas I and II) (50 min), pranayama (breathing techniques) (5 min), Yoga Nidra (deep relaxation) (15 min) and meditation techniques (10 min) to facilitate the process of reconnecting body, mind, and emotions and to improve self-acceptance and confidence. Participants were also sent daily 30-min yoga videos to practice at home. An increase in sleep efficiency and a decrease in sleep disturbance were reported in patients and were associated with an increase in physical activity.[33] In a case study, it was reported that practicing yoga for 1 h each in the morning and evening, 6 days a week for 9 months, resulted in improved sleep quality, reduced sleep latency, and decreased daytime sleep duration in an FMS patient.[44] In the study conducted by Lazaridou et al., fibromyalgia patients participated in yoga-based exercises for 8 weeks, with sessions lasting 30–45 min each, conducted daily for a total of 56 sessions. The results demonstrated a significant improvement in sleep quality among the participants, along with reductions in pain and catastrophizing.[45] These findings suggest that yoga can be an effective intervention for improving sleep quality in fibromyalgia patients, in addition to offering other benefits such as pain relief and enhanced psychological well-being.

Yoga is thought to reduce the activation of the sympathetic system, which is effective in daily or strenuous activities while increasing the activation of the parasympathetic system, which plays a role in sleep and rest. Therefore, yoga can be a good method for addressing sleep disturbances, a significant symptom of FMS.

Quality of life

Patients with FMS experience a decrease in functional capacity due to multiple symptoms, such as widespread musculoskeletal pain, sleep disturbances, fatigue, and mood abnormalities, resulting in a reduction in their quality of life.[46] There is evidence in the literature that yoga, one of the mind-body exercises, has a positive effect on quality of life. In a study published by Carson et al.[28] in 2010, a comprehensive yoga intervention was aimed at evaluating the impact of FMS symptoms. Fifty-three patients with FMS participated in group yoga sessions once a week for 120 min over 8 weeks. The intervention significantly improved pain, fatigue, mood, and quality of life.[26] A 2019 meta-analysis examining the effects of yoga on quality of life in rheumatic diseases, including FMS, incorporated 23 randomized controlled trials with 1430 participants. Yoga was found to positively influence overall quality of life, functional capacity, and physical and emotional well-being. Interventions typically involved sessions conducted 1–2 times per week, lasting 60–90 min each, over a duration of 6–12 weeks. These practices focused on physical postures, breathing exercises, and mindfulness techniques, contributing to significant improvements in both physical and emotional health.[47] In a 2022 meta-analysis by Zhang et al., which included 57 randomized controlled trials with 3319 participants, mind-body exercises like yoga were found to significantly improve health-related quality of life compared to usual care. Yoga interventions typically involved sessions lasting 60–90 min, conducted 1–3 times per week over 6–12 weeks. These practices showed notable benefits for quality of life, functional capacity, and emotional well-being, making yoga a highly effective option for managing FMS symptoms.[48]

Irritable bowel syndrome-Fibromyalgia syndrome relationship

Patients with irritable bowel syndrome (IBS) exhibit symptoms such as constipation, abdominal pain, changes in bowel habits, anxiety, depression, sleep difficulties, chronic headaches, and fatigue.[49,50] Gastrointestinal symptoms such as bloating, fecal incontinence, diarrhea, and constipation are quite common in FMS patients. Both FMS and IBS are more common in women and psychiatric disorders are prevalent in both.[51] FMS and IBS frequently coexist, and considering these overlapping symptoms, it is thought that the two syndromes may share a common etiology. While FMS and IBS are commonly defined as having impaired pain perception, hypotheses such as dysbiosis and small intestinal bacterial overgrowth related to changes in the gut microbiota have been proposed in the etiology, but no conclusive evidence has been found.[52] Given the proposed common etiology hypotheses and overlapping symptoms, similar outcomes are likely in treatment management as well.[53] There is evidence that yoga, among the complementary and alternative therapies used in the treatment of FMS, is effective in managing IBS symptoms. Schumann et al. (2016) conducted a systematic review to evaluate the effectiveness of yoga in treating IBS, analyzing six randomized controlled trials with 273 patients. The yoga interventions varied across studies but typically involved sessions lasting 60–90 min, performed 1–3 times per week, over a duration of 6–12 weeks. Styles such as Iyengar and Hatha yoga, emphasizing physical postures, breathing exercises, and relaxation techniques, were employed. The findings indicated significant improvements in IBS severity, anxiety, and quality of life.[54]

Conclusion

The positive physical, biological, physiological, and psycho-emotional effects of yoga on the human body are undeniable. It is also known to be an effective and safe physical activity for managing rheumatological diseases. Considering all these factors, yoga is thought to play an important role in the symptom management of fibromyalgia. Although existing studies are present, more definitive results and further research are needed. It is recommended that future studies conduct longitudinal research to explore the sustained benefits of yoga and compare different yoga styles through randomized controlled trials.

Limitations

This review highlights yoga’s potential benefits in managing FMS; however, it also has some limitations. The findings discussed are based on studies with relatively small sample sizes and short intervention durations, which may partially limit their generalizability. Furthermore, a more detailed exploration of the effects of different yoga styles on fibromyalgia symptoms could enrich the literature in this field. While the review primarily focuses on key symptoms such as pain and sleep disturbances, further investigation into the impacts of yoga on emotional well-being and functional capacity is warranted. Future studies could address these areas with more comprehensive and long-term research, contributing to the advancement of the field.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.