Chairperson

Dr. Netravathi M

Additional Professor

Department of Neurology

NIMHANS

Presenter

Dr.Usha Rani M.R

Research Officer

CCRYN-NIMHANS

Collaborative Center1

Outline

Introduction to MS

Challenges in MS

How is it addressed throughYoga

Studies conducted so far

Projects that have been ongoing at IMD

How does the combination ofYoga and Ayurveda help in addressing MS?

Future directions in Research

Considerations

2

Multiple Sclerosis

Multiple sclerosis (MS) is chronic auto immune

disorder - of the central nervous system – incurable.

The brain, spinal cord and optic nerves can be affected.

The cause of MS is not known, although genetic and

environmental factors are involved.

Leading cause for neuro-debility among young adults

worldwide.

Hawkes CH, Macgregor AJ Mult Scler. 2009 Jun; 15(6):661-73

Prevalence

GBD 2016 Multiple Sclerosis Collaborators;, Prevalence and patterns of demyelinating central nervous system disorders in urban Mangalore, South India. Pandit L, Kundapur

R Mult Scler. 2014 Oct; 20(12):1651-3. Multiple sclerosis is prevalent in the Zoroastrians (Parsis) of India.WadiaNH, Bhatia K Ann Neurol. 1990 Aug; 28(2):177-9.

2.1 million people world wide

Canada has highest number of

MS patients in the world

USA and UK, the frequency is

about 90 to 150/100,000

Prevalence in India 8/100,000

Parsi populace 21/100,000

Mangalore 8/100,000

4

Causes and Risk factors

20-40 yrs

5

Multiple Sclerosis

6

Protection, support, speed

of conduction of nerve impulse

Loss of myelin, Neuronal loss, impaired

conduction of nerve impulse

Clinical Manifestations

Sleep deprivation

Uhthoff ’s sign

Increase in temperature

eg.Visual blurring after exercise

L’Hermitte’s sign

Electrical sensations run down

the legs when the patient

bends her head forward

‘MS Hug’ - tightening around

the chest

https://www.mstrust.org.uk/a-z/ms-hug#; https://www.ncbi.nlm.nih.gov/pmc/articles/7

Patterns of MS

8

Clearly defined attacks + periods of partial or

complete recovery

Steadily worsening

neurologic function from

the beginning with

occasional relapses

Worsening from the onset of symptoms, without early relapses or

remissions

RRMS - progressive worsening of

disability over time w/o attacks

Treatment for MS

Pharmacological treatment – Disease modifying drugs for RRMS

Steroids –

Glatiramer acetate

Interferon β

Natalizumab

Fingolimod

Dimethyl fumarate

Teriflunomide

Non-pharmacological treatment

Physiotherapy

Ergotherapy

Cognitive behaviour therapy

Sociotherapy

Psychotherapy etc.

(Eleonora Tavazzi,2014)

Maintenance – prevention

of frequency of relapse

Acute conditions (relapse)

9

Role of Yoga in MS

10

57.1% - one CAM;

70.2% - three or more CAM therapies

Sherria AO,2019

Probable mechanism of Yoga in MS

Immune System

Alteration in Cytokines

• Yoga - partial role of reducing

proinflammatory cytokines such as IL-6, interleukin-2, C-reactive

protein

Nervous System

Alteration in Neurotransmitters

Endocrine system Alteration in hormones

•Yoga - lowers cortisol –

decrease - perceived stress,

anxiety, improves pain and

increase the feeling of well-

being,

11

Balance in Neurotransmitters -

cognitive and physiological

functionalities – through Yoga and

Meditation

(Catherine Woodyard,2011; Divya Krishnakumar et.al., 2015;Sanjay Uddhav Shete et.al.,2017 )

RELAPSE

Studies so far.........

12

Year Author Design and Sample

size

N Duration Conclusion

2012 Shahla Najafi

Doulatabad

RCT - Pain managing Yoga

method vs control

60

*women

90 minutes X 8

sessions/month

Yoga techniques can alleviate physical pain

and improve the quality of life

2014 Ali

Hassanpour-

Dehkordi

Quasi-experimental study

Yoga vs aerobic exercises vs

control

90 3 sessions/week

for 12 weeks

Yoga and aerobic exercises - improved quality

of life in patients with MS.

2014 Bryan

Coleman

Salgado

Pre-post 24 5 days intensive

training - 4

months F/U

(home practice)

Functional strength and balance improved

2015 Ali

Hasanpour

Dehkordi

RCT – 3 arms – Yoga vs

aerobics exercise vs control

60 3 sessions/week

for 12 weeks.

Yoga and aerobics exercise could decrease some

of the MS symptoms, therapeutic costs,

hospital stay, and days lost from work as

well as increasing the patients' efficiency.

2015 Senem

Guner

Short term yoga therapy 8 2 sessions/week –

12 weeks

Yoga therapy - improved fatigue, balance and

spatiotemporal gait parameters

2016 Gerson de

Oliveira

RCT – 2 groups

Yoga vs control

12 1 hour – 6 months Yoga improved postural balance and

decreased the influence of postural balance

impairment on activities of daily living.

2019 Hui-Ju Young RCT – 3 arms - exercise

movement-to-music (M2M)

vs adapted yoga (AY) vs

Education programme on MS

81 3 sessions/week –

12 weeks

M2M - enjoyable exercise form - improved

mobility and walking endurance compared

to control. N/S in AY compared to controls.

13

Year Author Design and Sample

size

N Duration Conclusion

2013 Azra Ahmadi RCT – 3 arms - Treadmill

training vs yoga vsr control

groups

31

*women

Weekly 3 days for

8 weeks

Treadmill training and yoga practice improved

ambulatory function, fatigue and mood status

in patients with mild to moderate MS.

2016 Ipek Ensari RCT – 2 arms

Yoga vs control

24 20 minutes Walking and yoga improved acute mood

symptoms while single bout of walking improved

feelings of vigor.

2016 Nazanin

Razazian

RCT – 3 arms – yoga vs

aquatic exercise vs non-

exercise control.

54

*women

8 weeks Yoga and exercise reduced fatigue – improved

depression and paresthesia.

2017 Turhan

Kahraman

27 persons with MS and 17

healthy family members

44 1 session/week

(atleast 1h) for 6

months.

Yoga improved health-related quality of life,

walking speed, fatigue, and depression.

2017 Evan T

Cohen

Integrated yoga program -

feasibility study

14 8 weeks and F/U

after 8 weeks

(home practice)

Physical performance, mental function, and QOL

improved

2016 Ali

Hasanpour-

Dehkordi

RCT – 2 arms

Yoga vs control

60 3 sessions/week

for 12 weeks

Yoga increased self-efficacy of MS patients

through enhancing physical activity, strength of

lower limbs and balance. Decreased fatigue and

pain, reduced stress and anxiety, promoted social

functioning.

2014Shahla

Najafidoulata

bad

RCT – 2 arms – Yoga vs

control group

60

*women

1-1.5 hrs – 8

sessions/month.

F/U – 3 months. Yoga techniques may improve physical activities

and sexual satisfaction function.

2016 Shivaji

Chobe,

Pilot study - Integrated Yoga

and Physical therapy (IYP)

11 1 hour/day – 5

days/week - 21

Improvement in visual reaction time; anxiety

and depression decreased after 3 weeks

Year Author Design and Sample

size

N Duration Conclusion

2012 N J Patil

(Case series)

Pre-post 11 2 hours/day for

21 days

Integrated Yoga – safe and effective for

Neurogenic bladder dysfunction.

2010 OrjanaVelikonja RCT - sports climbing (SC)

vs yoga

20 1 session/wk for

10 weeks

Increase in selective attention performance after

yoga but not executive function. SC reduced

fatigue but not yoga.

2016 Prerana Bhargav 2 groups – immediate effect

of relaxation

18 30 min of Cyclic

meditation and

supine rest

CM was better than SR in improving processing

speed, short term memory and verbal working

memory.

2017 B.S. Oken RCT – yoga vs aerobic

exercise vs control

69 6 months Yoga or exercise improvement in fatigue

compared to wait-list control group. No relative

improvement of cognitive function

2011 Jinny Tavee Pilot study – sitting/moving

and focused walking

meditation

22 1/week – 2

months

Meditation - reducing pain and improving

quality of life in patients with MS . No

improvement in clinical course

2010 Grossman RCT - Mindfulness-based

stress reduction vs usual

care

150 1 session/wk X

8 wks

6 months F/U

Mindfulness training improved depression fatigue

, anxiety and QOL.

2016 Somayeh Nejati MBSR + conscious yoga

program and control

24 2 hour X 8

sessions

Reduction of fatigue severity and improved

QOL.

2017 Rachel M

Gilbertson

Mindfulness in Motion

(gentle stretching, chair

yoga relaxation, mindfulness

meditation, and relaxing

piano music)

22 1 hr/week X 8

weeks –

feasibility study

Physical health (fatigue) + Mental health

(anxiety, depression, mood) - improved QOL

– feasible in a short duration.

2018 Cristiano

Crescentini

Mindfulness Meditation

and control

33 2 hrs/week X 8

weeks

Promoted adaptive and mature personality profiles

– promote intrapersonal and

interpersonal relationship.15

Assessment tools Fatigue - Severity Scale (FSI) or the Modified Fatigue Impact Scale (MFIS) .

Disability Status - Expanded Disability Status Scale (EDSS), Multiple Sclerosis Functional

Composite (MSFC).

Balance - Berg Balance Scale (BBS), self-reported postural balance.

Mobility/muscle function - Timed Up and Go (TUG, s) test, 6-minute walk test (6MWT, m),

and 5 times sit-to-stand test (FTSST, s), Multidirectional Reach Test (MDRT).

Neurogenic bladder - Incontinence impact questionnaire-7 (IIQ-7), Urogenital distress

inventory-6 (UDI-6)

Paresthesia - Visual analogue scale Pain - Likert scale- 1 to 6

Mood - Depression (Beck Depression Inventory – BDI), Epidemiologic Studies Depression

Scale (CES-D) Cognitive function - Neuropsychological tests.

Quality of Life - SF-36, Multiple Sclerosis Quality of Life Inventory (MSQoL)

16

Ayurveda for MS

Reduced Fatigue,

inflammation,

cognitive performance.

Prevented neuronal loss

during optic neuritis

Improved patients' mobility,

spasticity, quality of sleep

Improved QOL

Zingiber

officinale

Panax

ginseng

Vitis

vinifera

Boswellia

papyrifera

Ginkgo

biloba

Cannabis sativa

Curcuma

longa

17 Sina Mojaverrostami,2018

Studies proposed at IMDDisability

Structural and

functional changes in

the MRI

Autonomic Dysfunction

in MS

Serum Inflammatory

biomarkers

Verbal new learning, memory,

mood, QOL

Ayurveda (Sadyovirechana – Rasayana Therapy)

+ Yoga Intervention (180 days)

Treatment as usual group - 40; Ayurveda and Yoga group - 40

Development and feasibility of Integrated Yoga Module for

patients suffering from Multiple sclerosis

10 days of intervention

CAM research in MS – exploratory – possible

mechanism and therapeutic effect

Well-described, reproducible yoga models - Type

of yoga and instructors - Contraindications with

justification/Adverse events - not reported

Studies

@

IMD

18 Azra Ahmadi,2013

AMK

PMK

Samsodhan (cleansing through Panchakarma

therapy)

Samshamana (palliative care through

researched internal medicines)

Kaya kalpa (rejuvenation)

Yogic counseling

Pranayama – Nadishuddhi, Ujjayi, Bhramari,

cooling pranayama

Relaxation techniques – Cyclic meditation

Asanas - Sukshma vyayama, Tadasana, Garudasana,

Trikonasana, Poorna Titali A ̄sana (full butterfly),

Skandha Chakra (shoulder socket rotation), Greeva ̄

Sanchalana (neck movements), Tadasana (palm tree

pose), Tiryaka Tadasana (swaying palm tree pose),

Kati Chakrasana (waist rotating pose),

Simhagarjanasana (roaring lion pose), Sarvangasana

(shoulder stand pose), Matsyasana (fish pose) and

Eka Pada Pranamasana (one-legged prayer pose).

Ayurveda and Yoga – Holistic science

19

Future direction

Reasons for individual differences in response to therapies.

Programs tailored to the needs of people with MS that are scalable to

accommodate different levels and types of disability.

Studies with individualized yoga programme (IYP) in future.

Understand the unique and changing needs of patients - which components

of the program is effective - explored.

Collaborative research - CAM practitioners - academic researchers –

NEED OF THE HOUR

Andrew F. Long,2018; Evan T. Cohen,201620

Considerations

The site must be accessible - parking close by - student should not get

fatigued.

The bathroom must be readily accessible.

The site should have air conditioning/adequately cooling ventilation.

Heat can be debilitating for many with MS – approximate temperature to

be maintained 23 - 26 °C.

21 Azra Ahmadi,2013

22

Yoga session with props

Shirley Kishiyama,200223

24