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Does Yoga Help Patients With Irritable Bowel Syndrome?
EDITORIAL Does Yoga Help Patients With Irritable Bowel Syndrome? rritable bowel syndrome (IBS) is a highly prevalent functional bowel disorder found worldwide. It remains a topical and important disorder for all health care providers to fully understand because it is one of the most common reasons to seek out medical consultation, significantly reduces patients’ quality of life, and has a tremendous negative economic impact on the health care system.1 By using the Rome IV criteria, the diagnosis of IBS should be considered in any patient with chronic (6 mo) symptoms of abdominal pain and disordered bowel habits of either constipation or diarrhea (or both2). For many health care providers the treatment of IBS is more problematic than the diagnosis. The first step is to determine the severity of the patient’s symptoms. Mild symptoms are occasional in nature without any interference in daily activities. Moderate symptoms occur more frequently and have some impact on daily activities (eg, home life, social activities, or professional life). Severe symptoms are present daily, have a significant impact on daily activities, and generally are associated with some degree of psychological distress.3 Over the past decade several new medical treatment options have emerged, either for the treatment of IBS with constipation predominance (ie, lubiprostone, linaclotide) or the treatment of IBS with diarrhea predominance (ie, rifaximin, eluxadoline).2 National guidelines are available to help guide the treatment strategy, although no validated treatment algorithm exists, which can be frustrating to the busy clinician looking for a quick answer.4 Furthermore, many patients fail to respond adequately to medical therapy, or prefer alternative therapies, the latter owing to ease of access, perceived safety, perceived benefits, cost, and/or ability to purchase without seeing a health care provider.2 In fact, it is estimated that at least 40% of health care patients use some form of alternative therapy; this number is thought to be even higher in patients with functional gastrointestinal disorders.5 When one considers nonpharmacologic therapy for the treatment of IBS, a variety of treatments are used by patients, and recommended by health care providers, although data supporting their use are limited.4 Many patients first use dietary modification and a number of diets have been studied with mixed success.6 The 2 most widely used diets are those low in fermentable foods (ie, a low FODMAP diet) and one without gluten (gluten-free diet). These diets have improved symptoms in some IBS patients, although they can be difficult to institute, often are expensive, and long-term adherence can be problematic.7,8 Some patients find that lifestyle changes such as following a routine, working on better sleep habits, and/or reducing stress improves IBS symptoms,
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although large prospective studies with carefully predefined end points are lacking. Some health care providers recommend exercise to improve IBS symptoms and 1 small randomized control trial showed that increased physical activity can improve IBS symptoms.9 There is also evidence showing that various forms of psychotherapy are as effective as antidepressant medications, and gastrointestinal symptoms remain improved after psychotherapy at both short- (1–6 mo) and longterm (6–12 mo) follow-up evaluation.10 The effect of stress on the development and expression of IBS symptoms provides investigators with ample opportunity to study methods of stress reduction. Many patients worldwide attempt to reduce stress and improve overall health by performing yoga. The discipline of yoga, which has its origins in the ancient Hindu scriptures or Vedas, traditionally is practiced as a means to attain unity with the mind, body, and spirituality. It has been practiced for thousands of years and is an integral part of Ayurvedic or traditional Indian medicine. The modern practice of yoga, especially within Western cultures, has evolved and is associated primarily with a variety of poses involving stretching and breathing exercises, often performed in combination with meditation. The most common techniques focus on body posture (Asanas), breathing (Pranayama), or meditation (Dyana), and many different styles exist (ie, Astanga, Bikram, Hatha, Iyengar, Kripalu, Sivananda, and Vinyasa, among others), with some practitioners of yoga combining several methods. How yoga might improve IBS symptoms is not known, although current hypotheses include a reduction in stress and alteration of the brain–gut interaction, improved sleep, improved quality of life, changes in autonomic system function, and possibly changes in the gut microbiome, for those who also perform concurrent dietary interventions. In the current study, Schumann et al11 performed a systematic review of the literature using standard PRISMA guidelines. Studies were eligible for inclusion if they met the following criteria: randomized controlled trial or randomized cross-over trial; full article (no abstracts); adolescents or adults; diagnosis of IBS based on the Rome criteria or provider assessment; a comparison with pharmacologic interventions, exercise, or usual care; and predefined primary outcomes measures that could include IBS symptom severity using a validated scoring system, abdominal pain, or improvement in quality of life. Adverse events were categorized. Data extraction was performed by 2 of the authors using a standard form and the risk of bias was noted for each study. The authors identified a total of 94 articles, although only 6 articles were included in this analysis after 63 duplicate articles were removed and 57 articles were excluded for failing to meet study criteria. Not Clinical Gastroenterology and Hepatology 2016;-:-–-
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Patel and Lacy
surprisingly, these studies all were quite different in content, which is why a systematic review was performed, and not a meta-analysis. As an example, 3 of the studies used Rome III criteria to define IBS, 1 study used Rome I, 1 study used Rome II, and 1 study used a diagnosis of recurrent abdominal pain (which would not meet strict criteria for either Rome III criteria or the newly released Rome IV, and thus should have been excluded). Similar to many IBS studies, the patients included in this systematic analysis (n ¼ 273) generally were younger (median age, 32.5 y; range, 14.2–44.1 y) and predominantly were women (71.4%). Two studies used Iyengar yoga, whereas Vivekananda and Hatha were used in 1 study each, and a combination of Hatha and Iyengar was used in another study. One study used a combination of yoga exercises. Four studies used a certified yoga instructor to teach the participants, and 2 studies did not provide any information about the instructor. Although all studies provided instruction on yoga postures, breath control also was taught in 3 of the 6 studies, and meditation was taught in 1 study. Other notable differences between the studies included the intensity of the yoga program, length of the yoga program, and comparators, which included loperamide, psyllium, propantheline, diazepam, or exercise (walking). Given these critically important differences in study design, no common theme could be identified. The study by Kavuri et al,12 who used Hatha yoga, found an improvement in IBS symptom severity compared with patients placed on a wait-list, although this was not surprising given that nearly all IBS trials involving comparison with a wait-list control showed some benefit. Evans et al,13 using Iyengar yoga, found that young adults had some improvement in IBS symptoms, although abdominal pain, the keystone of IBS symptoms, was not improved. Kuttner et al14 found fewer gastrointestinal symptoms and lower anxiety levels in adolescents when compared with the control group, but this was noted only after the control group participated in the yoga intervention and the data were combined. Two separate studies failed to find any differences in outcomes for patients treated with yoga compared with patients treated with medication (loperamide, psyllium, propantheline, or diazepam).15,16 Interestingly, a walking program was as effective initially as yoga, although the group assigned to the walking program was better than the yoga group at 6 months after the end of the treatment.17 As a health care provider, how does this study help you treat your IBS patients? First, it tells us that Iyengar yoga, when practiced twice weekly for 60 minutes per session, may be as effective for young women as a walking program at improving IBS symptoms.17 The emphasis on precisely aligned postures as in Iyengar yoga and the physical intensity of practicing yoga for 60 minutes a few times a week likely plays a role in modulating stress and affecting the brain–gut axis. Second, yoga appears to be generally safe. Third, any intervention, such as yoga (or walking or meditation), which provides some respite from a busy
Clinical Gastroenterology and Hepatology Vol.
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No.
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work schedule or home life, may transiently improve IBS symptoms. Beyond that, however, because of the significant limitations in study design and the dramatic differences in study intervention, it is impossible to make any firm recommendations about the use of yoga for the treatment of IBS. Challenges exist in performing yoga research; it is impractical to have a sham group and there are various yoga styles each with different perceived benefits, but moving forward, this study should stimulate other researchers to perform well-designed and properly controlled studies to determine the efficacy and safety of yoga in IBS patients. Many IBS patients would prefer to use nonpharmacologic therapy to improve their symptoms. However, these interventions need to be evaluated using large prospective studies with careful study design to control for bias. Future research studies in this area all should use Rome IV criteria, identify clinically meaningful end points a priori, and the type of yoga used should have some clearly defined intervention with biologic plausibility for improving IBS symptoms. Furthermore, studies should include a comparator group and should be performed for a minimum of 12 weeks, with an additional 12-week follow-up period at least, but ideally incorporating a longer-term follow-up evaluation at 6 months and 12 months. When performed carefully, these studies then would have the potential to truly guide patient therapy. NIHAL PATEL, MD BRIAN LACY, MD, PhD Gastroenterology and Hepatology Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire
References 1. Longstreth GF, Wilson A, Knight K, et al. Irritable bowel syndrome, health care use, and costs: a US managed care perspective. Am J Gastroenterol 2003;98:600–607. 2. Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology 2016;150:1393–1407. 3. Drossman DA, Chang L, Bellamy N, et al. Severity in irritable bowel syndrome: a Rome Foundation Working Team report. Am J Gastroenterol 2011;106:1749–1759. 4. Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109:S2–S26. 5. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;1–23. 6. Lacy BE. The science, evidence, and practice of dietary interventions in irritable bowel syndrome. Clin Gastroenterol Hepatol 2015;13:1899–1906. 7. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 2014;146:67–75. 8. Vazquez-Roque MI, Camilleri M, Smyrk T, et al. A controlled trial of gluten-free diet in patients with irritable bowel
-
2016 syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterology 2013;144:903–911.
9. Johannesson E, Simren M, Strid H, et al. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol 2011;106:915–922. 10. Laird KT, Tanner-Smith EE, Russell AC, et al. Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clin Gastroenterol Hepatol 2016;14:937–947. 11. Schumann D, Anheyer D, Lauche R, et al. Effect of yoga in the therapy of irritable bowel syndrome: A systematic review. Clin Gastroenterol Hepatol 2016. 12. Kavuri V, Selvan P, Malamud A, et al. Remedial yoga module remarkably improves symptoms in irritable bowel syndrome patients: A 12-week randomized controlled trial. European Journal of Integrative Medicine 2015;7:595–608. 13. Evans S, Lung KC, Seidman LC, et al. Iyengar yoga for adolescents and young adults with irritable bowel syndrome. J Pediatr Gastroenterol Nutr 2014;59:244–253.
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14. Kuttner L, Chambers CT, Hardial J, et al. A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain Res Manag 2006;11:217–223. 15. Madhu SV, Vij JC, Bhatnagar OP, et al. Colonic myoelectrical activity in irritable bowel syndrome before and after treatment. Indian J Gastroenterol 1988;7:31–33. 16. Taneja I, Deepak KK, Poojary G, et al. Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback 2004;29:19–33. 17. Shahabi L, Naliboff BD, Shapiro D. Self-regulation evaluation of therapeutic yoga and walking for patients with irritable bowel syndrome: a pilot study. Psychol Health Med 2016; 21:176–188.
Conflicts of interest The authors disclose no conflicts. http://dx.doi.org/10.1016/j.cgh.2016.08.014
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although large prospective studies with carefully predefined end points are lacking. Some health care providers recommend exercise to improve IBS symptoms and 1 small randomized control trial showed that increased physical activity can improve IBS symptoms.9 There is also evidence showing that various forms of psychotherapy are as effective as antidepressant medications, and gastrointestinal symptoms remain improved after psychotherapy at both short- (1–6 mo) and longterm (6–12 mo) follow-up evaluation.10 The effect of stress on the development and expression of IBS symptoms provides investigators with ample opportunity to study methods of stress reduction. Many patients worldwide attempt to reduce stress and improve overall health by performing yoga. The discipline of yoga, which has its origins in the ancient Hindu scriptures or Vedas, traditionally is practiced as a means to attain unity with the mind, body, and spirituality. It has been practiced for thousands of years and is an integral part of Ayurvedic or traditional Indian medicine. The modern practice of yoga, especially within Western cultures, has evolved and is associated primarily with a variety of poses involving stretching and breathing exercises, often performed in combination with meditation. The most common techniques focus on body posture (Asanas), breathing (Pranayama), or meditation (Dyana), and many different styles exist (ie, Astanga, Bikram, Hatha, Iyengar, Kripalu, Sivananda, and Vinyasa, among others), with some practitioners of yoga combining several methods. How yoga might improve IBS symptoms is not known, although current hypotheses include a reduction in stress and alteration of the brain–gut interaction, improved sleep, improved quality of life, changes in autonomic system function, and possibly changes in the gut microbiome, for those who also perform concurrent dietary interventions. In the current study, Schumann et al11 performed a systematic review of the literature using standard PRISMA guidelines. Studies were eligible for inclusion if they met the following criteria: randomized controlled trial or randomized cross-over trial; full article (no abstracts); adolescents or adults; diagnosis of IBS based on the Rome criteria or provider assessment; a comparison with pharmacologic interventions, exercise, or usual care; and predefined primary outcomes measures that could include IBS symptom severity using a validated scoring system, abdominal pain, or improvement in quality of life. Adverse events were categorized. Data extraction was performed by 2 of the authors using a standard form and the risk of bias was noted for each study. The authors identified a total of 94 articles, although only 6 articles were included in this analysis after 63 duplicate articles were removed and 57 articles were excluded for failing to meet study criteria. Not Clinical Gastroenterology and Hepatology 2016;-:-–-
2
Patel and Lacy
surprisingly, these studies all were quite different in content, which is why a systematic review was performed, and not a meta-analysis. As an example, 3 of the studies used Rome III criteria to define IBS, 1 study used Rome I, 1 study used Rome II, and 1 study used a diagnosis of recurrent abdominal pain (which would not meet strict criteria for either Rome III criteria or the newly released Rome IV, and thus should have been excluded). Similar to many IBS studies, the patients included in this systematic analysis (n ¼ 273) generally were younger (median age, 32.5 y; range, 14.2–44.1 y) and predominantly were women (71.4%). Two studies used Iyengar yoga, whereas Vivekananda and Hatha were used in 1 study each, and a combination of Hatha and Iyengar was used in another study. One study used a combination of yoga exercises. Four studies used a certified yoga instructor to teach the participants, and 2 studies did not provide any information about the instructor. Although all studies provided instruction on yoga postures, breath control also was taught in 3 of the 6 studies, and meditation was taught in 1 study. Other notable differences between the studies included the intensity of the yoga program, length of the yoga program, and comparators, which included loperamide, psyllium, propantheline, diazepam, or exercise (walking). Given these critically important differences in study design, no common theme could be identified. The study by Kavuri et al,12 who used Hatha yoga, found an improvement in IBS symptom severity compared with patients placed on a wait-list, although this was not surprising given that nearly all IBS trials involving comparison with a wait-list control showed some benefit. Evans et al,13 using Iyengar yoga, found that young adults had some improvement in IBS symptoms, although abdominal pain, the keystone of IBS symptoms, was not improved. Kuttner et al14 found fewer gastrointestinal symptoms and lower anxiety levels in adolescents when compared with the control group, but this was noted only after the control group participated in the yoga intervention and the data were combined. Two separate studies failed to find any differences in outcomes for patients treated with yoga compared with patients treated with medication (loperamide, psyllium, propantheline, or diazepam).15,16 Interestingly, a walking program was as effective initially as yoga, although the group assigned to the walking program was better than the yoga group at 6 months after the end of the treatment.17 As a health care provider, how does this study help you treat your IBS patients? First, it tells us that Iyengar yoga, when practiced twice weekly for 60 minutes per session, may be as effective for young women as a walking program at improving IBS symptoms.17 The emphasis on precisely aligned postures as in Iyengar yoga and the physical intensity of practicing yoga for 60 minutes a few times a week likely plays a role in modulating stress and affecting the brain–gut axis. Second, yoga appears to be generally safe. Third, any intervention, such as yoga (or walking or meditation), which provides some respite from a busy
Clinical Gastroenterology and Hepatology Vol.
-,
No.
-
work schedule or home life, may transiently improve IBS symptoms. Beyond that, however, because of the significant limitations in study design and the dramatic differences in study intervention, it is impossible to make any firm recommendations about the use of yoga for the treatment of IBS. Challenges exist in performing yoga research; it is impractical to have a sham group and there are various yoga styles each with different perceived benefits, but moving forward, this study should stimulate other researchers to perform well-designed and properly controlled studies to determine the efficacy and safety of yoga in IBS patients. Many IBS patients would prefer to use nonpharmacologic therapy to improve their symptoms. However, these interventions need to be evaluated using large prospective studies with careful study design to control for bias. Future research studies in this area all should use Rome IV criteria, identify clinically meaningful end points a priori, and the type of yoga used should have some clearly defined intervention with biologic plausibility for improving IBS symptoms. Furthermore, studies should include a comparator group and should be performed for a minimum of 12 weeks, with an additional 12-week follow-up period at least, but ideally incorporating a longer-term follow-up evaluation at 6 months and 12 months. When performed carefully, these studies then would have the potential to truly guide patient therapy. NIHAL PATEL, MD BRIAN LACY, MD, PhD Gastroenterology and Hepatology Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire
References 1. Longstreth GF, Wilson A, Knight K, et al. Irritable bowel syndrome, health care use, and costs: a US managed care perspective. Am J Gastroenterol 2003;98:600–607. 2. Mearin F, Lacy BE, Chang L, et al. Bowel disorders. Gastroenterology 2016;150:1393–1407. 3. Drossman DA, Chang L, Bellamy N, et al. Severity in irritable bowel syndrome: a Rome Foundation Working Team report. Am J Gastroenterol 2011;106:1749–1759. 4. Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109:S2–S26. 5. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report 2008;1–23. 6. Lacy BE. The science, evidence, and practice of dietary interventions in irritable bowel syndrome. Clin Gastroenterol Hepatol 2015;13:1899–1906. 7. Halmos EP, Power VA, Shepherd SJ, et al. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology 2014;146:67–75. 8. Vazquez-Roque MI, Camilleri M, Smyrk T, et al. A controlled trial of gluten-free diet in patients with irritable bowel
-
2016 syndrome-diarrhea: effects on bowel frequency and intestinal function. Gastroenterology 2013;144:903–911.
9. Johannesson E, Simren M, Strid H, et al. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol 2011;106:915–922. 10. Laird KT, Tanner-Smith EE, Russell AC, et al. Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clin Gastroenterol Hepatol 2016;14:937–947. 11. Schumann D, Anheyer D, Lauche R, et al. Effect of yoga in the therapy of irritable bowel syndrome: A systematic review. Clin Gastroenterol Hepatol 2016. 12. Kavuri V, Selvan P, Malamud A, et al. Remedial yoga module remarkably improves symptoms in irritable bowel syndrome patients: A 12-week randomized controlled trial. European Journal of Integrative Medicine 2015;7:595–608. 13. Evans S, Lung KC, Seidman LC, et al. Iyengar yoga for adolescents and young adults with irritable bowel syndrome. J Pediatr Gastroenterol Nutr 2014;59:244–253.
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14. Kuttner L, Chambers CT, Hardial J, et al. A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain Res Manag 2006;11:217–223. 15. Madhu SV, Vij JC, Bhatnagar OP, et al. Colonic myoelectrical activity in irritable bowel syndrome before and after treatment. Indian J Gastroenterol 1988;7:31–33. 16. Taneja I, Deepak KK, Poojary G, et al. Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: a randomized control study. Appl Psychophysiol Biofeedback 2004;29:19–33. 17. Shahabi L, Naliboff BD, Shapiro D. Self-regulation evaluation of therapeutic yoga and walking for patients with irritable bowel syndrome: a pilot study. Psychol Health Med 2016; 21:176–188.
Conflicts of interest The authors disclose no conflicts. http://dx.doi.org/10.1016/j.cgh.2016.08.014