Kim Jones - (TAP) Chronic Pain Conference

Yoga and Mindful Movement
Kim Dupree Jones PhD, FNP-BC, FAAN
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
Objectives
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
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 Rheumatol
2 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.
Objectives
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
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 Ther
Jones, 2015, Arthritis Rheumatism
Limit Time Spent with Arms Overhead
Weight 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
Let Muscles Rest by Alternating Sides
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.
Elvin et al. Eur J Pain. 2006;10:137144
All Balance Control Systems Compromised
Objective Neurosensory Analyses Testing
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
Objectives
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
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.
Reverse Pain Postures
• 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.
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
What is Emerging in FM
for Pain & Sleep?
Mindful movement interventions:
Qigong
Yoga w/ mindfulness
Tai chi (land or water)
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 syndrome
Do 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

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