Lit Review: IBS And YOGA
This is a pretty comprehensive overview of the published literature looking at IBS and yoga. Yes, this is a LONG post Hopefully it’s broken up into palatable sections so that you can see what’s out there. And when you get to a pic of a lovely flower, stop, take a few breaths, maybe even close your eyes, and then proceed. With any medical condition having a great team of providers is key, and more importantly if they can coordinate care, that’s even better. Ok, here we go!
What is IBS?
IBS is determined by the Rome III criterion which is the current gold standard of diagnosing IBS. Symptoms:
recurrent abdominal pain or discomfort for at least 3 months
Onset at least 6 months previously and with at least 2 of the following:
Improvement with defecation
Onset associated with a change in frequency of stool
Onset associated with a change in appearance of stool
Symptoms include abdominal pain, altered bowel habits, bloating and flatulence.
Under the umbrella of IBS there are four subgroups of IBS: diarrhea prominent (IBS-D), constipation dominant (IBS-C), mused (IBS-mixed) and unspecified IBS.
The enteric nervous system (ENS) influences gut motility based on serotonergic and cholinergic nerve innervation. Sensitivity of visceral afferent pathways, that send information from the abdominal viscera to the brain, or central application of visceral input is thought to be related to enhanced perception of visceral stimuli which may lead to increased autonomic arousal. Autonomic nervous system imbalances may only be present in 25% of patients with IBS and could vary as a function of severity and type of IBS.
How Common is It?
IBS is the most common functional GI disorder. It accounts for 12% of primary care visits and 70% of diagnoses from GI specialists.
5-20% Worldwide
12% in Canada
10-15% in North America. Before late adolescences, girls and boys have equal prevalence, which shifts after sex differences emerge, when women are 2x as likely to be affected as men.
IBS occurs in 51% of patients with chronic fatigue syndrome patients and 49% in patients with fibromyalgia patients.
What Makes IBS Worse?
One of the primary influencers for IBS appears to be stress, anxiety, lifestyle choices and visceral hypersensitivity. Lifestyle choices include intake of alcohol, nicotine, caffeine, dietary choices, physical activity practices and sleep quality. Mayer found activation in pain amplification regions in the brain on MRI with no activation of inhibitory pain areas leading to visceral hypersensitivity.
Consequences of IBS include:
Missed school
Decreased physical activities
Anxiety/Depression
Disruptions of social relationships
Mood disorders
Neuroticism
Perceived academic competence moderates the relationship between symptoms and disability in adolescents with IBS (esp if low)
Work absenteeism
Does Yoga Work?
Yoga may be able to help reduce GI symptoms, illness perception, pain frequency and anxiety and increase general well being. Participants in yoga groups often state plans to continue yoga as part of their management strategy. Issues include time management around other commitments and accessibility. While literature reviews conclude that due to significant limitations in study design and dramatic differences in study intervention, it is not possible to make any firm recommendations about the use of yoga for treatment of IBS, it is valuable to keep in mind that matching the right student to the right teacher and to the right style, could benefit a multi-faceted management style.
Yoga may improve functioning in IBS patients through a variety of mechanisms, including improved psychospiritual functioning and reduced visceral sensitivity, in addition to more regulated ANS reactivity for those patients with ANS imbalance. It is thought that yoga quiets the body as well as the mind through attention, vascular and muscular relaxation. Yoga improves physiologic responses for ANS functioning including reduced blood pressure, decreased heart rate, and increased heart rate variability. Yoga has been confirmed to induce a preponderance of parasympathetic effects. It is possible that yoga helped alleviate abdominal pain despite intraluminal volume causing abdominal distention through increase PNS activation and decreased colonic hypersensitivity, suggesting that the decrease in nociceptive reactivity, not the volume based distention could be helpful in managing discomfort overall. It is also possible that breath awareness during yoga produces a high level of autonomic control. Davydov found that patients that demonstrated differences in cardiovascular phenotypes in IBS responded differently to walking versus yoga, and therefore customization of exercise prescription may be able to be identified through baroreceptor sensitivity.
Taneja found that yoga lead to decrease bowel symptoms and anxiety, while increasing parasympathetic reactivity. Taneja compared yoga to loperamide which also decreased bowel symptoms and anxiety, but not parasympathetic reactivity17. Parasympathetic activity, in regards to traditional view points improves restoration, improved digestion and health optimization when not paired with a threat response that may lead to dissociation or freeze as described by the Porges’ polyvagal theory.
Research methodology in studying yoga is always challenging due to the variety of styles, teacher trainings, teaching choices, etc. The most specific yoga research methods was through Evan’s team utilizing the Iyengar methodology. Participants reported improved physical functioning that was maintained 2 months later. Evans noted that most teens do respond to yoga, however some respond quicker than others, and a significant factor is the characteristics of the parents in how well the teens respond.
Pranayama, a series of breathing techniques was shown to possibly help increase sympathetic tone for those with IBS-D. Alternate nostril breathing may be an interesting and accessible mode for balancing the nervous system. Telles describes that right nostril breathing increase oxygen consummation which indicates increased metabolism and sympathetic activity, while left nostril breathing leads to parasympathetic shift69. Slow, deep breathing for 6 weeks improved cognition and general well being. It also increased parasympathetic activity compared to controls.
Kavuri recommended practice of savasana, pranayama, and Sudarshan kriya. Sudarshan kriya has been shown to alleviate symptoms of anxiety, depression and stress related ailment. Laughter yoga was found to decrease IBS symptom severity and anxiety more than anti anxiety meds or normal care.
D’Silva proposed possible mechanisms that yoga works through that may influence IBS symptom severity89:
relaxation techniques to reduce stress via reduced mRNA expression of pro inflammatory genes
reduced cortisol levels
regulation of the sympathetic nervous system and the HPA axis
In other domains, literature reviews have found beneficial effects of yoga for depression, anxiety, as well as coping skills and self efficacy. Yoga has been shown to reduce stress and psychological distress in varied patient populations.
Shahabi found that both walking and yoga are beneficial for patients. Walking may be more feasible due to easier access90. If yoga isn’t attractive to a patient, studies have shown benefits from multiple forms of movement practice from aerobic to qigong.
What Else?
Due to the nature of IBS as a functional condition rather than a pathologen based condition, there is a wide range of use of complementary alternative medical management systems. Alternative methods include dietary changes, supplements, hypnotherapy and CBT, yoga, massage, acupuncture, etc. Essentially anything that is not traditional western medically given was assessed in this category. In Mexico 50.9% of those suffering from IBS reported using alternative methods. In a Canadian review of literature investigating complementary alternative medical treatments, peppermint oil and probiotics had the most evidence to suggest benefit. They also looked at hypnotherapy and CBT, but not exercise/physical therapy.
Fortunately, due to the wide use, there was an investigation to see if physicians were referring to alternative medical providers and how that was received by patients. Van Tilburg found that referrals from physicians to psychologists, naturopaths and dietitians were well received, and followed by patients. Physicians appeared to not recommend yoga, massage, physical therapy or acupuncture. Thirty-five percent of all participants in this study utilized at least one type of complementary treatment, mostly ginger based supplements, massage and yoga. Harris et al found that physicians recommendations are a significant contributor to if patients accept a CAM treatment. Those treatments that are most closely related to conventional medicine (taking a pill) or lifestyle adjustments were the most attractive to patients 55 or younger. Ernst found patients most likely to utilize CAM services identified as female, were well educated, and middle aged.
Positive data was found regarding hypnosis for IBS which maybe more widely available and accessible with less variation than a community yoga class. Slightly different from a yoga practice that was investigated was John Kabat-Zinn’s MBSR program. Zernicke found a clinically meaningful reduction in IBS symptom severity after an 8 week MBSR program, with maintained improvements at 6 months. In a prospective non-randomized program, 93 patients with IBS used MBSR and found improvement in quality of life and GI specific anxiety. They did not find a reduction in IBS specific symptom severity. In a randomized study, 75 female patients went through an 8 week intervention comparing mindfulness and social support. The mindfulness group reported clinically significant reductions in IBS symptom severity after 3 months of follow up. In an 8 week intervention of mindfulness meditation participants had high activation in left-sided frontal lobe, which is associated with positive feelings (joy, happiness, compassion) and lower levels of anxiety.
The placebo effect could be a significant component in the management of IBS, indicating a significant mind-body component of symptom severity. Antidepressants and serotonin reuptake inhibitors have shown improvements in IBS symptoms even if no psychiatric disorder is present.
How can we track it?
Outcome measures for determining effectiveness of practices vary. A frequently used measure was the IBS Severity Scoring System. Additional measures included a quality of life measure for those with IBS, a stress inventory, a mood state inventory, a spiritual well being scale5, and a pain coping questionnaire.