Yoga Therapy for Irritable Bowel Syndrome Continued (pg. 2)


Yoga Therapy for Digestive Disorders

From a Yoga Therapy perspective, digestive problems are related to improper ingestion (food enters the body), digestion (food is broken down into usable nutrients), absorption (nutrients are absorbed into the body), assimilation (nutrients are prepared for direct use by the body) or elimination (waste products are removed). Problems can be related to diet, organ or systemic dysfunction, stress and/or a variety of other causes.  Often these conditions are complex and the best way to heal them is through a combination of lifestyle changes, allopathic medicinal remedies, and complementary alternative medicine. In yoga therapy, we can divide disgestive system disorders into conditions of hyperactivity and conditions of hypoactivity.

Digestive Conditions of Hyperactivity

One condition of hyperactivity is stress-based excessive secretion of gastric acid, which leads to heartburn and or gastric ulcers. This condition is also associated with gastro-esophageal acid reflux. Although many people take antacids to combat this excess, the true cure is to relax the stress response. Focusing the mind on the positive through mantra japa or relaxing the mind through visualization and meditation are ways to reduce our stress response. Once our stress response is lowered, the stress-based over-secretion of gastric acid subsides.

Inflammatory Bowel Disease

The three most common inflammatory bowel diseases are Crohn's disease, diverticulitis and colitis.

Crohn’s disease is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract.  The disease is characterized by abdominal pain, diarrhea (which may be bloody when inflammation is at its worst), vomiting, or weight loss, but may also cause complications outside the gastrointestinal tract such as skin rashes, arthritis, inflammation of the eye, tiredness, and lack of concentration.  Multifactorial condition caused by interactions between environmental, immunological and bacterial factors in genetically susceptible individuals.  Current thinking is that microorganisms are taking advantage of their host's weakened mucosal layer and inability to clear bacteria from the intestinal walls.  Crohn's disease affects between 400,000 and 600,000 people in North America, men and women equally. There is no cure for Crohn’s disease.

Diverticulitis is characterized by pouches (diverticula) in the intestinal tract that become inflamed.  The most common symptom of diverticulitis is abdominal pain. If an infection is present, then symptoms may include nausea, vomiting, fever, cramping, and constipation can occur as well. This condition is treated conservatively with antibiotics and bowel rest, however, more acute cases involving fistula may require surgery.

Colitis is literally “inflammation of the colon” and is characterizes by abdominal pain, visceral cramping, bloating and diarrhea and, possibly, blood in the stool. There are a number of causes, including infection andischemia (lack of blood flow).  The treatment depends on the underlying cause.

Irritable Bowel Syndrome

IBS is a chronic condition characterized by abdominal pain, dysfunction of bowel habits, abdominal bloating, the sensation of incomplete evacuation and often accompanied by diarrhea. It is a multifactorial condition that involves compromised gut motility, intestinal inflammation and visceral hypersensitivity due to both genetic and environmental factors. Thought to result from the dysregulation of brain–gut neuroenteric systems, emotional stress and anxiety can exacerbate a person's symptoms. From a yogic perspective, diarrhea-predominant IBS fits the hyperactive digestive system model.

Yoga Therapy for Irritable Bowel Syndrome

The symptoms of IBS are thought to occur due to disturbed brain–gut interactions at many levels: the central nervous system, autonomic nervous system, enteric nervous system, and gut musculature. Yoga could be acting at any of these levels. Certain postures, such as the ones used in the following studies described, may be acting at a peripheral level by massaging the gut smooth muscle. Holding these postures may create pressure changes in visceral organs, which stimulate visceral afferents, and thus affect neural and visceral activity.

Yoga may also act more globally by influencing psychological stress and well-being. It is not clear whether stress is a causal factor in IBS, but it can certainly exacerbate symptoms in patients with IBS. Yoga is well-documented to reduce feelings of stress and anxiety and increase feelings of well-being. It is possible that these changes in stress and mood modulate the autonomic nervous system, endocrine system, enteric nervous system, and their interactions. More specifically, both sympathetic and parasympathetic autonomic nervous system (ANS) function may be dysregulated in individuals with IBS. Stress hormone levels, such as adrenaline or cortisol, may be raised in IBS patients as a result of dysregulation in the hypothalamic-pituitary-adrenal (HPA) axis. Yoga can influence both the ANS and HPA. For example, slow deep Yogic breathing is thought to reset the autonomic nervous system in favor of parasympathetic activation.

Yoga practice is also associated with decreased levels of the stress hormone cortisol and increased levels of GABA, a neurotransmitter associated with inhibiting anxiety and stress. Other chemical changes may also contribute to the beneficial effects of Yoga. Recent treatments for IBS have aimed at modifying the effects of serotonin (5-hydroxytryptamine or 5-HT) on the gut, and Yoga practice has been shown to increase levels of serotonin, which is a neurotransmitter associated with both mood and the function of the digestive system. Administration of the hormone melatonin has also been shown to improve abdominal pain in IBS patients with sleep disturbances, and Yoga is associated with increased levels of melatonin.

The effects of Yoga on all of these neurochemical systems may provide a further explanation for its benefits. The proposed physiological mechanisms through which Yoga may be acting are summarized in the Figure 1 below. Other aspects of the Yogic lifestyle, including dietary factors and meditation, are also likely to be valuable. Further research is needed to determine which specific Yoga practices are the most helpful, as well as the mechanisms through which they improve symptoms of IBS.

Figure 1: Yoga Therapy may affect Irritable Bowel Syndrome via several pathways.

Several research studies have been conducted to report on the effectiveness of Yoga Therapy for Irritable Bowel Syndrome. One study was conducted to evaluate Yoga Therapy versus conventional treatment in diarrhea-predominant irritable bowel syndrome (IBS) in a randomized controlled trial.(17) The patients were 22 males, aged 20-50 years, with confirmed diagnosis of diarrhea-predominant IBS. The conventional group (n = 12, 1 dropout) was given symptomatic treatment with loperamide 2-6 mg/day for 2 months, and the Yoga Therapy intervention group (n = 9) consisted of a set of 12 asanas (yogic poses, i.e., Vajrasana, Shashankasana, Ushtrasana, Marjariasana, Padhastasana, Dhanurasana, Trikonasana in two variations, Pawanmuktasana, and Paschimottanasana) along with Surya Nadi pranayama (right-nostril breathing) two times a day for 2 months. All participants were tested at three regular intervals, at the start of study--0 month, 1 month, and 2 months of receiving the intervention--and were investigated for bowel symptoms, autonomic symptoms, autonomic reactivity (battery of five standard tests), surface electrogastrography, anxiety profile by Spielberger's Self Evaluation Questionnaire, which evaluated trait and state anxiety. Two months of both conventional and Yoga Therapy intervention showed a significant decrease of bowel symptoms and state anxiety. This was accompanied by an increase in electrophysiologically recorded gastric activity in the conventional intervention group and enhanced parasympathetic activity, as measured by heart rate parameters, in the Yoga Therapy intervention group. The study indicates a beneficial effect of Yoga Therapy intervention over conventional treatment in diarrhea-predominant IBS. (17)

Another study evaluated the effect of yoga therapeutic exercises on pain frequency and intensity and on quality of life in children with functional abdominal pain. (18) In this study, 20 children, aged 8-18 years, with irritable bowel syndrome or functional abdominal pain (FAP) were enrolled and received 10 yoga lessons. Pain intensity and pain frequency were scored in a pain diary and quality of life was measured with the Kidscreen Quality of Life questionnaire (KQoL). In the 8-11 year old group, and the 11-18 year old group pain frequency was significantly decreased at the end of therapy (p=0.031 and p=0.004) compared to baseline. In the 8-11 year group, pain intensity was also significantly decreased at this time point (p=0.015). After 3 months there still was a significant decrease in pain frequency in the younger patient group (p=0.04) and a borderline significant decrease in pain frequency in the total group (p=0.052). Parents reported a significantly higher KQoL-score after yoga treatment. This pilot study suggests that yoga exercises are effective for children aged 8-18 years with FAP, resulting in significant reduction of pain intensity and frequency, especially in children of 8-11 years old. (18)

Irritable bowel syndrome affects as many as 14% of high school-aged students. Symptoms include
discomfort in the abdomen, along with diarrhea and/or constipation and other gastroenterological symptoms that can significantly impact quality of life and daily functioning. Emotional stress appears to exacerbate irritable bowel syndrome symptoms suggesting that mind-body interventions reducing arousal may prove beneficial. For many sufferers, symptoms can be traced to childhood and adolescence, making the early manifestation of irritable bowel syndrome important to understand. A recent study focused on young people aged 14-26 years with irritable bowel syndrome. The study tested the potential benefits of an Iyengar Yoga Therapy program on clinical symptoms, psychospiritual functioning and visceral sensitivity. Yoga is thought to bring physical, psychological and spiritual benefits to practitioners and has been associated with reduced stress and pain. Sixty irritable bowel syndrome patients aged 14-26 will be randomly assigned to a standardized 6-week twice weekly Iyengar yoga group-based program or a wait-list usual care control group. The groups will be compared on the primary clinical outcomes of irritable bowel syndrome symptoms, quality of life and global improvement at post-treatment and 2-month follow-up. Secondary outcomes will include visceral pain sensitivity assessed with a standardized laboratory task (water load task), functional disability and psychospiritual variables including catastrophizing, self-efficacy, mood, acceptance and mindfulness. Mechanisms of action involved in the proposed beneficial effects of yoga upon clinical outcomes will be explored, and include the mediating effects of visceral sensitivity, increased psychospiritual resources, regulated autonomic nervous system responses and regulated hormonal stress response assessed via salivary cortisol. The yoga therapy group demonstrated significant improvements in IBS symptoms, QOL, visceral pain sensitivity and salivary cortisol. (21)

Yoga Therapy Practices Beneficial for IBS

Pranayama (Breathing): A simple practice to begin with is to gently place the hands on the abdomen and breathe deeply, observing the movement of the abdomen. Alternate nostril breathing can also be practiced to balance the autonomic nervous system.

Warm-Ups on Hands and Knees: Head-to-knee pose (alternating sides) helps to relieve abdominal bloating. Cat/cow, followed by balasana (child’s pose), can help relieve constipation and bloating.
Inversion: A gentle inversion, viparita karani (legs-up-the-wall pose), can be very relaxing both at the start of the session and again before final relaxation. It may be helpful in relieving symptoms of diarrhea.

Forward bends: Paschimottonasana (seated forward bend) and padahastasana (standing hands-to-feet pose) can help calm the nerves and relax the mind.

Back bends: Setu bandhasana (bridge pose) can help relieve abdominal cramps and diarrhea. Bhujangasana (cobra pose), shalabhasana (locust pose), and dhanurasana (bow pose) may encourage the circulation of blood to the abdominal organs and massage the abdominal organs. This can help relieve digestive complaints and constipation.

Twists and side bends: Twisting postures and side bends, including trikonasana (triangle pose), improve circulation to the abdominal organs. They help to improve digestion and can relieve constipation.

Relaxation: In savasana (corpse pose), a focus on deep abdominal breaths relaxes the whole body and mind. Observing the natural rise and fall of the abdomen with each breath and becoming aware of the abdominal organs enhances the relaxation effect. With each exhalation, the Yogi may mentally repeat, “I relax my abdominal organs; my abdominal organs are relaxed.”

Conclusion

Irritable Bowel Syndrome is a challenging condition to manage, and current pharmacological treatments do not provide adequate relief for the majority of patients. The addition of Complementary Alternative therapies is needed to offer additional symptom relief. We have highlighted promising evidence regarding the use of Yoga Therarpy for IBS. Yoga acts holistically to promote physical, psychological, and spiritual well-being, and its practices can be easily adopted by most patients. Yoga has great potential to be used alongside conventional medical therapy in the management of IBS.

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