Research Article: Isometric yoga improves the fatigue and pain of patients with chronic fatigue syndrome who are resistant to conventional therapy: a randomized, controlled trial.
Takakazu Oka*¹, Tokusei Tanahashi¹, Takeharu Chijiwa¹, Battuvshin Lkhagvasuren¹, Nobuyuki Sudo¹ and Kae Oka². “Isometric yoga improves the fatigue and pain of patients with chronic fatigue syndrome who are resistant to conventional therapy: a randomized, controlled trial.” Biopsychosoc Med, 2014, 8(1): 27.
* Correspondence: firstname.lastname@example.org
1. Department of Psychosomatic Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.
2. Department of Pediatrics and Child Health, School of Medicine, Kurume University, Asahi-machi 67, Kurume 830-0011, Japan.
Background: Patients with chronic fatigue syndrome (CFS) often complain of persistent fatigue even after conventional therapies such as pharmacotherapy, cognitive behavioral therapy, or graded exercise therapy. The aim of this study was to investigate in a randomized, controlled trial the feasibility and efficacy of isometric yoga in patients with CFS who are resistant to conventional treatments.
Methods: This trial enrolled 30 patients with CFS who did not have satisfactory improvement after receiving conventional therapy for at least six months. They were randomly divided into two groups and were treated with either conventional pharmacotherapy (control group, n = 15) or conventional therapy together with isometric yoga practice that consisted of biweekly, 20-minute sessions with a yoga instructor and daily in-home sessions (yoga group, n = 15) for approximately two months. The short-term effect of isometric yoga on fatigue was assessed by administration of the Profile of Mood Status (POMS) questionnaire immediately before and after the final 20-minute session with the instructor. The long-term effect of isometric yoga on fatigue was assessed by administration of the Chalder’s Fatigue Scale (FS) questionnaire to both groups before and after the intervention. Adverse events and changes in subjective symptoms were recorded for subjects in the yoga group.
Results: All subjects completed the intervention. The mean POMS fatigue score decreased significantly (from 21.9 ± 7.7 to 13.8 ± 6.7, P < 0.001) after a yoga session. The Chalder’s FS score decreased significantly (from 25.9 ± 6.1 to 19.2 ± 7.5, P = 0.002) in the yoga group, but not in the control group. In addition to the improvement of fatigue, two patients with CFS and fibromyalgia syndrome in the yoga group also reported pain relief. Furthermore, many subjects reported that their bodies became warmer and lighter after practicing isometric yoga. Although there were no serious adverse events in the yoga group, two patients complained of tiredness and one of dizziness after the first yoga session with the instructor.
Conclusions: Isometric yoga as an add-on therapy is both feasible and successful at relieving the fatigue and pain of a subset of therapy-resistant patients with CFS.
Firstly, “What is Isometric Yoga”? Isometric exercises or isometrics are defined as a type of strength training in which the joint angle and muscle length do not change during contraction. Isometrics are done in static positions, rather than being dynamic through a range of motion. So it follows that Isometric Yoga is a type of Yoga that is done in a static position (in this instance in a seated position on a stool).
Yoga, the body/mind practice of poses and meditation has been used worldwide for decades and in India for millennia where it originated around the sixth and fifth centuries BCE.
The authors’ aim of this study was to determine whether a mild form of yoga, here isometric yoga – selected so as to cause the least exacerbation of post-exertional malaise (PEM) of ME/CFS patients’ – could alleviate the symptoms of fatigue in ME/CFS patients. They aimed to assess the effect of isometric yoga on fatigue and related psychological and physical symptoms of people with ME/CFS who did not respond to the conventional therapies of pharmacotherapy, cognitive behavioral therapy (CBT), or graded exercise therapy (GET).
The Study and Subjects
Unfortunately, this study suffers from something a lot of ME/CFS research suffers from – a very small sample size. A total of 81 people were assessed for eligibility, and 51 were excluded (35 “improved satisfactorily”, 12 were younger than 20, 2 were too severe to participate and 2 declined to participate). Of the remaining, total number of participants was 30 (diagnosed with CFS according to the 1994 Fukuda diagnostic criteria), with 15 being randomly assigned to the yoga group with conventional pharmacotherapy and the other 15 assigned to a conventional pharmacotherapy only group – the “control group”, where n=15 is an extremely sample size.
The subjects of the study had been outpatients of the Department of Psychosomatic Medicine of Kyushu University Hospital. Subjects were included on the basis that (1): their fatigue did not improve sufficiently after having been given standard treatment within that department. This treatment included pharmacotherapy (for example, antidepressants, Japanese traditional herbal medicine and/or coenzyme Q10), psychotherapy, and/or GET; in some cases, a four-week inpatient treatment program was also included for at least six months. The 2nd criterion was the subject was between 20 and 70 years old. Thirdly, the subject’s fatigue was serious enough to cause absences from school or work of at least several days per month but not serious enough to require assistance with daily activities. Fourthly, the subject was able to fill in the questionnaire without assistance. Fifthly, the subject could sit for at least 30 minutes and finally the sixth criterion was the subject could visit Kyushu University Hospital regularly every two or three weeks.
The latter part of the third criterion may cause some disquiet among some readers as a lot of ME/CFS sufferers need assistance with daily activities, be it shopping or housework. So it follows these study participants were not even moderately affected ME/CFS patients.
Subjects were excluded from the study if their fatigue was due to some other cause such as, for example, liver disease, and if they had previously practiced yoga.
So the study comprised 30 subjects, with 15 in the yoga group (age range: 24–60 years; mean age (mean ± SD): 38.0 ± 11.1 years; 3 men) and 15 in the control group (age range: 20–59 years; mean age: 39.1 ± 14.2 years; 3 men). All patients completed the study.
The Yoga Program
The Yoga program developed for this study differed significantly from traditional yoga in several ways. For instance it was aimed at at patients with ME/CFS and must not exacerbate their symptoms or lead to post-exertional malaise. So it would not be nearly as vigorous as normal yoga. Tellingly, the authors state that “because the patients are deconditioned, however, it should also act as an exercise therapy”. I will come back to this point later. They also wanted a yoga practice that would be easy to remember and follow because most of their patients’ “short-term memory and concentration are impaired”. Lastly, the setting for the yoga is a more cramped hospital and not a traditional yoga studio. So the poses should be able to be done in an out-patient setting.
Isometric yoga was developed by Dr. Keishin Kimura. The authors included these isometric yoga poses in a 20 minute seated program that consists of three parts. First, patients are asked to be aware of their spontaneous breathing for one minute. Next, they practice six poses. These poses are very slow movements that are coordinated with the timing of breathing, with or without sounds, and isometric exercise at 50% of the patient’s maximal physical strength. Lastly, the patients practice abdominal breathing for one minute (Figure 1).
Figure 1. The Yoga Program
The patients practice in a quiet room one-on-one with an experienced instructor. The patients were also asked to practice at home with a video and a booklet. The authors report all patients practiced the yoga program at least four times with a mean of ± SD = 5.6 ± 1.7 with the instructor during the period of the trial. The authors report that the program was further modified on a case-by-case basis for each subject depending on their level of fatigue and pain.
The trial period was two months.
Assessment, Adverse Effects And Adherence
The acute and chronic effects of the yoga practice were assessed in each case by questionnaires of various kinds (see the article above). Adverse effects were monitored by each visit to hospital and by each participant keeping a “yoga diary” of each yoga practice. Adherence was monitored by analysis of this diary.
Results And Discussion
Short term effects were assessed on mean fatigue F and vigour V based on scores of the Profile of Mood States (POMS) questionnaire before and after the final session of isometric yoga with the instructor. Mean F significantly decreased and mean V significantly increased comparing pre- and post-session. However, both post- figures were within one or two standard deviations of their pre-session figures.
Long term effects of the isometric yoga on fatigue were assessed by comparing the Chalder’s FS total score and the subscale scores for physical and mental symptoms of the control group to those of the yoga group before and approximately two months after the trial period.
The authors found that the patients who did the yoga found a greater improvement in fatigue than the control group.
The authors also assessed whether the regular isometric yoga practice has an effect on health related Quality Of Life (QOL). They compared the SF-8(TM) scores pre- and post-yoga trial. Before the trial all the baseline subscale scores were below 50, indicated the QOL was much lower than the general Japanese population. After the trial, the authors found that of the 10 subscale scores, three increased significantly (bodily pain, general health and physical component summary). However, each pre- and post-trial value was within one standard deviation of the other.
Of the 15 yoga participants only one indicated that they did not want to continue with isometric yoga beyond the trial period. The reason given by the authors is a co-morbid psychiatric illness that led the participant to finding the meditative aspect of the yoga disturbing.
None of the yoga participants experienced disabling post-exertional malaise.
The authors conclude that this study demonstrates the feasibility of isometric yoga being used as a treatment to relieve fatigue for ME/CFS patients who are resistant to conventional therapy. Interestingly, two participants who had also been diagnosed with Fibromyalgia (FM) also reported pain relief. So isometric yoga might be used to treat both ME/CFS and FM.
The mechanism behind the beneficial effects of yoga programs is not understood. Some are proposed. Previous studies have shown yoga improves the fatigue of cancer patients.
Yoga has been reported to reduce serum levels of cortisol (a hormone produced by the body in response to stress) and proinflammatory cytokines (messenger/communication molecules) such as interleukin-6. It also increases heart rate variability and shifts the autonomic nervous system from a state predominated by sympathetic activity to one predominated by parasympathetic activity [1,2]. All of these changes may contribute to the beneficial effects of isometric yoga, one of which is reduced fatigue.
One thing the authors did not comment on any further than their rather offhand statement that one of the criteria for the yoga program should be that it also act as an “exercise therapy”. Could some of the beneficial effects of this isometric yoga trial be that it is itself a form of Graded Exercise Therapy (GET)?
There were, some weaknesses and limitations to this trial. First among them being the very small sample size of 15 that actually underwent the yoga trial. The RCT itself was not blind, neither could it be so there might have been some expectation among the 15 participants that the yoga program should be beneficial and that might have influenced their questionnaire responses.
Another problem was that patients were excluded if they needed assistance with daily living so the participants here must have been mildly to only just moderately affected. The length (two months) of the trial might not be sufficient to truly assess the long-term effects of yoga on fatigue and pain levels.
Further studies are needed to see if this trial can be generalised to all ME/CFS patients and/or any type of yoga program.
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