Kim Dupree Jones PhD, FNP-BC, FAAN

Yoga and Mindful Movement

Disclosure Information

Treating & Preventing Chronic Pain Conference October 8-10, 2015

Kim Dupree Jones, FNP, PhD

I have no financial relationships to disclose

I will not discuss off-label use or investigational use or investigational use in my presentation

Identify why movement (exercise) is critical for people with fibromyalgia and myofascial pain

 List physiologic problems that make exercise more challenging in this population

 Discuss how to safely modify the exercise prescription in this population, with a special focus on yoga and mindful movement

Objectives

Poor Strength Linked to Mortality

Women with FM spend more time in sedentary behaviors and are less physically active than age-matched controls. Only 20.6% of women with FM (n=413) met standard physical activity and steps recommendations1.

Muscle strength with FM has been reported to be reduced by an average of 39 % compared to healthy women2

Physical inactivity and poor muscle strength are linked to all -cause mortality 3,4

1 Sequra-Jimenez, V et al, 2015 Arthritis Rheumatol2 Maquet D, et al,.Joint Bone Spine. 2002;69(3):293-9.

3 Katzmarzyk PT, et al. Obes Rev. 2003;4:257–90.4 FitzGerald SJ, et al. 2015 J Phys Activity Health. 1:7–18.

Identify why movement (exercise) is critical for people with fibromyalgia and myofascial pain

 List physiologic problems that make exercise more challenging in this population

 Discuss how to safely modify the exercise prescription in this population, with a special focus on yoga and mindful movement

Objectives

Impaired sleep is associated with reduced activation of the inhibitory pain pathway

There is a bi-directional relationship between

sleep and pain

Blood Flow is Reduced After Dynamic and During Static Contractions of Infraspinatus Muscle (ISM)

Control (n=11) FM Patient (n=10)

• Standard Doppler evaluation of ISM typically shows no/small vessel perfusion. Administration of ultrasound contrast media (Levovist) allows visualization of muscle vascularity

• No differences in resting vascularity of ISM between FM and control subjects• During static contraction - no detectable vascularity in FM most patients

(<0.002)• After dynamic contractions - reduced vascularity in FM patients (<0.001)• Normal vascularity in the non-contracting deltoid muscle of FM patients

Elvin et al. Eur J Pain. 2006;10:137-144

Resistance Training improves FM Severity and Strength

Keep Movements Near the Body’s Midline to Minimize Eccentric Loading

Smaller movements, especially during warm-up, may reduce immediate or delayed onset muscle pain

Bjersing, 2012, Arth Rsch TherJones, 2015, Arthritis Rheumatism

Limit Time Spent with Arms OverheadWeight training work done with arms overhead is discouraged – instead find exercises that will keep arms at shoulder level or below. Gentle overhead stretching OK. Aim for exercising less-painful muscle to evoke EA?

Nijs, 2012, Pain Physician

Alternate between the right and left arm or leg during exercise.

Avoid multiple repetitions on the same side of the body.

When using resistance tools, completely unload the muscle group being worked frequently during repetitions.

Let Muscles Rest by Alternating Sides

Elvin et al. Eur J Pain. 2006;10:137-144

Objective Neurosensory Analyses Testing

All Balance Control Systems Compromised

Balance Conclusions cont.

The average 40 y/o with FM has balance scores predicted for an 80 y/o

Particularly striking is FM subjects’ inability to:

• Use somatosensory information to identify stability limits (forward/backward leaning)

• Use anticipatory postural adjustments

• Maintain gait speed with divided attention

Jones et al, 2011, Arth Rsch & Ther & Jones et al, 2009, J of Clin Rheum

Balance Training is Effective in Fibromyalgia

Identify why movement (exercise) is critical for people with fibromyalgia and myofascial pain

 List physiologic problems that make exercise more challenging in this population

 Discuss how to safely modify the exercise prescription in this population, with a special focus on yoga and mindful movement

Objectives

Modify for Dizziness, Poor Balance and Fall Risk

Use a cane, pole, chair, wall or ballet bar.

Quick turns or pivots are not recommended.

Slowly challenge balance systems and train for improvement.

• Chin back• Crown of head lifts• Shoulders relax downward• Breathing may become deeper

Regularly stretch the chest area and strengthen the upper back to promote good body alignment.

Reverse Pain Postures

Jones & Hoffman, 2009, Fibromyalgia

What Improves in Fibromyalgia During Land-based Aerobic Trials?

Physical function/fitness

effect size=0.65 (sustained at follow up)

What doesn’t improve?

Sleep effect size=0.01 NS (NS at follow up)

What isn’t sustained?

Pain effect size=0.31 (0.13 NS at follow up)

Hauser, 2010, Arthritis Rsch & Ther

Mindful movement interventions:

What is Emerging in FM for Pain & Sleep?

Tai chi (land or water)

Qigong

Yoga w/ mindfulness

Mist, Firestone & Jones, 2013,J of Pain Rsch

Yoga + Mindfulness improves symptoms, function, acceptance, strength & balance

Yoga of Awareness Poses• two series

• 1st chair-based, 2nd standing + floor-based

OHSU Yoga Study

based on traditional schools (Kripalu, Siddha)

1. asana / gentle yoga poses

2. dhyana / meditation

3. pranayama / breathing exercises

4. satsanga / group discussions (experience of home

practice, changes in symptoms during week)

5. swadhyaya / study of topics (literally, “self-study”) such as the mind-body connection, and foundational principles

Look for hypermobility syndromeDo not overstretch

Balance Flexibility with Strength in Yoga

Ting et al., 2012, Ped Rheum On J

Practice Expansive Breathing & Relaxation

Anticipate Challenges of Restorative Yoga

Mindfulness Hypothesis

• Mindfulness entails meditation and other strategies for developing greater

• presence of mind

• acceptance of symptoms

• willingness to learn from pain and other challenging experiences

• When exercise is combined with mindfulness, can people with chronic pain learn to move mindfully and better accept disagreeable sensations arising during movement?

• Moreover does improved acceptance modulate pain by psycho-physiological mechanisms such as activation of the PAG?

Yoga DVD for fibromyalgia

www.myalgia.com/VIDEOS

The End Q & A