International Review of Psychiatry

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Yoga intervention and functional pain syndromes:

a selective review
Roshan Sutar, Suresh Yadav & Geetha Desai
To cite this article: Roshan Sutar, Suresh Yadav & Geetha Desai (2016) Yoga intervention
and functional pain syndromes: a selective review, International Review of Psychiatry, 28:3,
316-322, DOI: 10.1080/09540261.2016.1191448
To link to this article: http://dx.doi.org/10.1080/09540261.2016.1191448

Published online: 13 Jun 2016.

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Date: 03 October 2016, At: 00:54

INTERNATIONAL REVIEW OF PSYCHIATRY, 2016

VOL. 28, NO. 3, 316322
http://dx.doi.org/10.1080/09540261.2016.1191448

REVIEW ARTICLE

Yoga intervention and functional pain syndromes: a selective review

Roshan Sutar, Suresh Yadav and Geetha Desai
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India

ABSTRACT

ARTICLE HISTORY

The definition of functional pain syndromes is varied across literature. No effort has been made
to see all functional pain disorder groups under broad nomenclature which would exclude conditions for which pathophysiology is strongly known. Since these disorders are commonly treated
with alternative treatment modalities and impose significant burden on health utilization, an
effort to look into studies on yoga-based interventions on functional pain syndromes (FPS) was
made. This study defined FPS as Chronic relapsing remitting pain conditions, the origin of which
is difficult to trace with no definite physical pathology on clinical suspicion or available laboratory
measures and are valid based on subjective pain reporting, associated distress and socio-occupational dysfunction. Chronic headache, neck pain, back pain, fibromyalgia, pelvic pain, Irritable
Bowel Syndrome, Chronic Fatigue Syndrome, and somatoform pain disorders were included for
this review. The review found four meta-analyses on the selected topic both indicating modest
efficacy and benefit of yoga in these disorders. Future efforts should be directed to do a large
meta-analysis of functional pain syndromes.

Received 1 February 2016

Revised 8 May 2016
Accepted 16 May 2016
Published online 10 June
2016

Introduction
In ancient times yoga was considered as a medium to
connect the body with the mind, as described in
Upanishads and Patanjali yoga sutra. Today we know
that any disharmony between body and mind has the
potential to cause an adverse health effect. This imbalance can lead to multiple symptoms, which either take
a form of syndromal diagnosis of a disease or group of
symptoms that have no definite aetiological basis
according to modern science. The curiosity is about
learning to make a balance between mind and body so
as to prevent rather than curing these illnesses (Telles,
Kozasa, Bernard, & Cohen, 2013). This article focuses
on revisiting the role of yoga from ancient texts to
modern times, defining functional pain syndrome
(FPS) category and review of various yoga-based interventions in FPS.
There are various types of yoga described from the
Vedic times, and it reflects the art of life. However, this
art seemed to have worked effectively in gaining control
over ones psyche and contributing to the preventive
strategy for multiple psychological illnesses. Yoga has
been defined as the mechanism to gain control over
fluctuations of the mind (Yogahchittavrttinirodhah,
Patanjalis Yoga Sutras, Chapter 1, Verse 2; Patanjali
circa 900 BC). It has also been described as a synonym
for equilibrium or balance towards calmness of mind
CONTACT Geetha Desai
2016 Institute of Psychiatry

desaigeetha@gmail.com

KEYWORDS

Backache; fibromyalgia;
functional pain; yoga;
review

(Samatvam yoga uchayate, Bhagavad Gita, Chapter 2,

Verse 48, Bhagavad Gita compiled circa 500 BC).
Certain practices and a particular mental attitude in
yoga were developed in the last century by Swami
Vivekananda, Paramhamsa Yogananda, B. K. S.
Iyengar, and Bikram Choudhary which are diverse to
meet the needs of widely differing yoga aspirants
(Telles, 2010). As more and more research has been
undertaken, it is noteworthy that scientific research of
yoga therapy is getting a new accreditation. The underlying mechanism and effects on physiological parameters have been extensively studied with positive results
in many psychiatric disorders (Varambally &
Gangadhar, 2012). Depressive disorders and anxiety
disorders are widely studied, while schizophrenia and
pain disorders are equally gaining importance in modern times (Woolery, Myers, Sternleib, & Zeltzer, 2004).
This article focuses on yoga therapy in chronic pain disorders, which are functional in nature and are often
referred to a psychiatrist.
Pain classically has been considered as a physical
symptom of an illness. In surgery, pain is considered
as a window to underlying pathology; in medicine it
has special significance along with associated symptoms; in psychiatry pain is considered as repressed
emotions that gives way to psychological conflict resolution. Hence, symptoms of pain disorders like

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore

INTERNATIONAL REVIEW OF PSYCHIATRY

Fibromyalgia, Chronic headache, and Low back pain

may represent the expression of personal sufferings.
Pain symptoms can also be present in depression and
anxiety disorders (Haldavnekar, Tekur, Nagarathna, &
Nagendra, 2014). These pain symptoms are very frequent for a clinician to encounter in tertiary as well as
primary healthcare services, which do not meet the
diagnostic criteria for major depression or anxiety disorder either. They present significant challenges to
healthcare systems because affected individuals make
more frequent primary care visits, specialist visits,
emergency room visits and have more hospital admissions with higher inpatient and outpatient costs. The
importance of developing simple and feasible but
effective interventions has been emphasized. It is found
that one-third to two thirds of patients attending general medical clinics do not receive any biomedical
explanations for their pain symptoms (Fink, Srensen,
& Engberg, 1999).
Our understanding of chronic pain disorder was limited to differentiation between organic and functional
pain. A group of disorders called somatic symptom disorders are now well recognized in the general hospital
setting and are not merely a diagnosis of exclusion.
However, there still exists a population group who
experience a significant level of distress due to pain
symptoms which cannot be classified broadly under any
of the above headings. Various studies have been done
in the last decade on functional pain and we noted that
each study has defined functional pain disorders differently, including migraine, post-surgical pain, post-cancer pain, osteoarthritis, and rheumatoid arthritis (Ward,
Stebbings, Cherkin, & Baxter, 2014). There has been no
universal definition for functional pain syndrome until
now. Our study is an attempt to give a new direction to
existing literature in terms of defining functional pain
syndromes/disorder which would not include some of
the conditions mentioned above, and also to review the
effect of yoga intervention in these disorders.

Methodology
We defined functional pain syndrome for the article
as:
Chronic relapsing remitting pain conditions, the
origin of which is difficult to trace with no definite
physical pathology on clinical suspicion or available
laboratory measures and are valid based on
subjective pain reporting, associated distress and
socio-occupational dysfunction.

Inclusion criteria were:

(1) Age group more than or equal to 18 years;
(2) Both genders;

317

(3) Diagnosis of functional pain syndrome as per

definition in our study; and
(4) Somatoform pain or somatic symptom disorder
pain.
Exclusion criteria were:
(1) Organic pain syndromes like osteoarthritis,
migraine, etc.;
(2) Cancer-related pain;
(3) Post-surgical pain; and
(4) Neuropathic pain.
Then we conducted an online search on PUBMED
using the terms chronic pain, fibromyalgia, somatoform pain, chronic low back ache, chronic headache,
irritable bowel syndrome, chronic fatigue syndrome,
chronic neck pain, chronic pelvic pain, and Yoga. The
following results were obtained as depicted in Figure 1.

Results
The majority of studies on yoga intervention were for
chronic low back pain following fibromyalgia, chronic
headache, and chronic neck pain. The details of the
studies for fibromyalgia are presented in Table 1
(Carson, Carson, Jones, Bennett, Wright, & Mist, 2010;
Carson, Carson, Jones, Mist, & Bennett, 2012; Curtis,
Osadchuk, & Katz, 2011; da Silva, Lorenzi-Filho, &
Lage, 2007; Hennard 2011; Langhorst, Klose, Dobos,
Bernardy, & Hauser, 2013; Mist, Wright, Jones, &
Carson, 2011; Rudrud 2012). There were two meta
analyses which not only included RCT but also open
label trials with control groups. The number of participants across the studies varied and studies including
only women as participants were higher. The control
group had a variety of treatments provided which
include education, waitlist, and other CAM therapies.
The duration of intervention varied between 8 weeks
to 12 month follow-up with varying frequency and
type of yoga practice. Details about medication use
were missing. Yoga was found to be effective in reducing the pain intensity and also improving functioning.
Most studies did not mention the sampling methods.
The details of the studies for chronic low back pain
are given in Table 2 (Cox, Tilbrook, Aplin, Semlyen,
Torgerson, Trewhela, et al., 2010; Evans & Hadler, 2006;
Evans, Carter, Panico, Kimble, Morlock, & Spears, 2010;
Galantino, Bzdewka, Eissler-Russo, Holbrook, Mogck,
Geigle, et al., 2004; Groessl, Weingart, Aschbacher,
Pada, & Baxi, 2008; Haldavnekar et al., 2014; Holtzman
& Beggs, 2013; Lee, Moon, & Kim, 2014; Nambi,
Inbasekaran, Khuman, Devi, & Shanmugananth, 2014;
Saper, Sherman, Cullum-Dugan, Davis, Phillips, &
Culpepper, 2009; Saper et al., 2014; Sherman, Cherkin,
Erro, Miglioretti, & Deyo, 2005; Sherman et al., 2010;

318

R. SUTAR ET AL.

Figure 1. Flowchart depicting selection of studies for the review.

Table 1. Yoga intervention in fibromyalgia.

Study

Type of study

No of participants

Type of yoga

Findings

Mist et al. (2011)

16 studies; 3 studies on
yoga intervention

Langhorst et al. (2013)

Hatha Yoga
Yoga of awareness
Yoga with mindfulness
Yoga

Positive outcome for yoga for

pain symptoms

Meta-analysis of Qigong,
Tai chi, and Yoga
interventions
Meta-analysis of RCTs
including qigong, Tai
chi, yoga

Rudrud (2012)

Case series

10

Hatha yoga

Carson et al. (2012)

Wait list controlled study

21

Yoga of Awareness
intervention

Curtis et al. (2011)

Open label trial

22

Hatha yoga

Hennard (2011)

Open label trial

11

Yoga and meditation

Carson et al. (2010)

RCT

53

da Silva et al. (2007)

RCT

40

Yoga Awareness
programme
Relaxing Yoga (RY) and
Relaxing Yoga plus
Touch (RYT)

7 studies; 362 subjects

Yoga was found to be beneficial in sub-group analysis in

domains of pain, fatigue,
depression, and HRQoL
Reduced fibromyalgia-related
symptoms
Benefits of yoga of awareness
in fibromyalgia are
replicable
Alters cortisol level and
improves pain
Significant improvements in
the reported number of
days felt good
Improvement in fibromyalgia
symptoms
RY better than RYT in long run
to gain control over pain

INTERNATIONAL REVIEW OF PSYCHIATRY

319

Table 2. Yoga intervention in chronic low back pain.

Study

Type of study

Type of yoga

Findings

Stein et al. (2014)

Randomized dosing trial

No of participants
95

Hatha yoga

Lee et al. (2014)

Open label trial

14

Hatha Yoga

Haldavnekar et al. (2014)

RCT

40

4
5

Nambi et al. (2014)

Holtzman and Beggs (2013)

Open/Experimental
Meta-analysis of RCT

yogic colon cleansing

(Laghu
Sankhaprakshalana
Kriya)
Iyengar yoga
Hatha Yoga
Viniyoga
Iyengar Yoga

Participant characteristics namely,

Poor physical health at baseline
had good outcome with improvement in pain intensity
Pain scores reduced compared to controls and BDNF may be one of the
key factors mediating beneficial
effects of yoga on chronic low
back pain
Improvement in pain, anxiety, disability, and spinal flexibility in yoga
group

Saper et al. (2013)

RCT

95

Sherman et al. (2010)

RCT

228

Tilbrook et al. (2014)

RCT

313

Evans et al. (2010)

Descriptive open

53

10

Tekur et al. (2010)

RCT

80

11

Cox et al. (2010)

Open

20

12
13

Saper et al. (2009)

Williams et al. (2009)

RCT
RCT

30
90

British Wheel of Yoga

and Iyengar Yoga
Modified integral yoga
classes
short-term intensive yoga
programme
specialized yoga plus
written advice
Hatha yoga
Iyengar yoga

14
15

Groessl et al. (2008)

Tekur et al. (2008)

Open
RCT

33
80

Yoga
Hatha Yoga

16

Slade and Keating (2007)

17

Evans and Hadler (2006)

Systematic review and

meta-analysis
RCT

18

Sherman et al. (2005)

RCT

101

Viniyoga, relaxation, and

breathing exercises
Viniyoga

19

Williams et al. (2005)

RCT

60

Iyengar Yoga

20

Galantino et al. (2004)

Open label trial

22

Hatha Yoga

60
8 RCTs, 743 patients

yoga poses, breathing

techniques, and relaxation exercises
Viniyoga

6 RCTs
101

Slade & Keating 2007; Stein, Weinberg, Sherman,

Lemaster, & Saper, 2014; Tekur, Singphow, Nagendra, &
Raghuram, 2008; Tekur, Chametcha, Hongasandra, &
Raghuram, 2010; Tilbrook et al., 2014; Williams,
Petronis, Smith, Goodrich, Wu, Ravi, et al., 2005;
Williams, Abildso, Steinberg, Doyle, Epstein, Smith,
et al., 2009). Two meta- analysis reported yoga to have
an effect size of 0.6. The number of participants varied
across the studies along with the control group treatment conditions.
Tables 3 (Bhatia et al., 2009; B
ussing, Ostermann,
L
udtke, & Michalsen, 2012; Kiran, Girgla, Chalana, &
Singh, 2014; Sharan, Manjula, Urmi, & Ajeesh, 2014)
and 4 (Cramer, Lauche, Hohmann, L
udtke, et al.,

Improvement in pain and HRQoL

Yoga was reported as efficacious
adjunctive treatment. Five studies
measured pain as the outcome and
other three included only
functioning
Similar efficacy of once and twice
weekly yoga therapy
Yoga intervention was found to be
better than self care book, but was
as efficacious as stretching exercise
Greater improvement than usual care
Greater pain self-efficacy in Yoga
group
Yoga increases quality-of-life and spinal flexibility
Less pain reported in yoga group
More effective than usual care
Greater reductions in functional disability and pain intensity were
observed in the yoga group
Improved health
Reduced pain-related disability and
improved spinal flexibility
Improved pain and function.
Yoga improved function and reduced
symptoms in chronic low-back pain
Yoga intervention was found to be
better than self care book
Yoga intervention was found to be
efficacious than educational
inteventions
Benefit in individuals doing yoga

2013; Cramer, Lauche, Hohmann, Langhorst, &

Dobos, 2013; Crow, Jeannot, & Trewhela, 2015;
Dunleavy et al., 2015; Michalsen et al., 2012) present
studies on yoga intervention in chronic headache and
chronic neck pain. Evidence for yoga intervention in
Fibromyalgia and chronic low back ache from systematic reviews and meta analysis appeared promising.
There was only one randomized controlled trial in
Chronic Fatigue Syndrome (CFS) consisting of 30 subjects wherein isometric yoga intervention used as an
add-on therapy was found to be successful at relieving
the fatigue and pain of a sub-set of therapy-resistant
patients with CFS (Oka, Tanahashi, Chijiwa,
Lkhagvasuren, Sudo, & Oka, 2014). A pilot study

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R. SUTAR ET AL.

Table 3. Yoga intervention for headache.

Study reference

Type of study

Kiran et al. (2014)

Prospective study

2
3

Sharan et al. (2014)

B
ussing et al. (2012)

Pilot study
Meta analysis

Bhatia et al. (2007)

Prospective study

No of participants

Type of Yoga

Findings

50

Rajyoga meditation

8
In 6 studies, yoga was used to treat
patients with back pain; in 2 studies to treat rheumatoid arthritis; in
2 studies to treat patients with
headache/migraine; and 6 studies
enrolled individuals for other
indications
15 patients of Chronic Tension Type
Headache and 7 age-matched
controls

Hatha Yoga
Mixed yoga forms

Significant improvement in
headache
Improved significantly in pain
Moderate effect on pain and
associated disability

Yogic life style course

Subjective pain scores

decreased

Table 4. Yoga intervention for neck pain.

Study ref

Type of study

Crow et al. (2015)

Systematic review

No of participants

Type of yoga

Findings

570

Iyengar yoga

Iyengar yoga is an effective means for both

back and neck pain in comparison to control
groups
Yoga interventions with appropriate modifications and supervision were safe and effective
for decreasing disability and pain
A 9-week yoga intervention improved pain and
neck-related disability for at least 12 months
after completion
Yoga was more effective in relieving chronic
non-specific neck pain than a home-based
exercise programme
Yoga led to superior pain relief and functional
improvements and might be a useful treatment option for chronic neck pain

Dunleavy et al. (2015)

Quasi-randomized parallel
controlled study

56

Yogic postures

Cramer, Lauche, Hohmann,

L
udtke, et al. (2013)

Follow-up

51

Iyengar yoga

Cramer, Lauche, Hohmann,

Langhorst, et al. (2013)

RCT

51

Iyengar yoga

Michalsen et al. (2009)

Pilot RCT

77

Iyengar yoga

consisting of 35 subjects with Irritable bowel syndrome

underwent Iyengar yoga and was reported to be beneficial for IBS patients (Shahabi et al., 2015).

Conclusions
The number of well-designed studies assessing effectiveness of yoga-based interventions in functional pain
disorders was limited. The efficacy has always been
qualitatively verified, but quantitative efficacy is difficult to study. Some studies include certain chronic
organic conditions like migraine, arthritis, etc., which
have been excluded from the current review, as we
defined the functional pain syndrome as Chronic
relapsing remitting pain conditions, the origin of
which is difficult to trace with no definite physical
pathology on clinical suspicion or available laboratory
measures and are valid based on subjective pain
reporting, associated distress and socio-occupational
dysfunction. Hence, most of the organic conditions
whose pathophysiology has been well studied to date
have become exclusion for our study. The purpose of
doing this segregation is
(1) To cover a broad range of disorders under
umbrella whose presentation is similar.
(2) To identify yoga-based interventions in these
disorders.

(3) To challenge the diagnostic nosology if certain

kind of interventions works for all disorders.
(4) To identify effect sizes of these studies.
The available search results point towards undoubtedly an important role of yoga-based interventions in
these disorders. However, better designed studies with
long-term follow-up would be useful in establishing
yoga-based intervention as a treatment modality in
functional pain disorders. The studies have also used
different methods of yoga intervention and there are
no studies which have compared different methods of
yoga interventions.

Disclosure statement
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of the
paper.

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