THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 20, Number 4, 2014, pp. 322–326 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2013.0340
Case Study
Iyengar Yoga Therapy as an Intervention for Cramp Management in Individuals with Amyotrophic Lateral Sclerosis: Three Case Reports Subbappa Ribeiro
Abstract
Objectives: Patients with amyotrophic lateral sclerosis (ALS), a neurodegenerative disease of motor neurons, experience cramps at all stages of the illness. There is, at present, no effective medication to control the cramps and no agreement on how to treat the symptom in ALS patients. Subjects: Three individuals who were diagnosed with ALS and reported suffering cramps in various parts of the body, which limited their activities or affected their sleep were invited to try Iyengar yoga. Intervention and outcome: Yoga therapy, composed of stretching, breathing, and relaxation exercises, was prescribed for each case, based on the subject’s physical disability and the presence of other symptoms. Although two subjects experienced cramps during the first therapy session, all three subjects reported the complete cessation of cramping within 3 weeks to 8 weeks of therapy. One of the subjects developed cramps in the hand after discontinuing yoga therapy for 7 months. However, the symptom stopped within 2 weeks of resuming yoga therapy. Conclusion: The alleviation of cramps in these three subjects indicates the possibility of yogic intervention for the management of cramps in individuals with ALS, but further research is necessary to understand the effectiveness of yoga therapy and to determine the exercises that are more prone to lead to cramping in some ALS individuals.
Introduction
P
atients with amyotrophic lateral sclerosis (ALS), which is a degenerative motor neuron disease, experience a variety of symptoms as a result, either directly or indirectly, of the disease. These symptoms, as noted by Borasio and Voltz1 as well as Mitsumoto (p. 28),2 include muscle cramping, an abrupt, spontaneous, and prolonged muscle contraction causing pain severe enough to interrupt activity or sleep. Although studies by Tartaglia et al.,3 Nalini et al.,4 and Mitsumoto (p. 21),2 report cramps as a presenting symptom in only 7%–12% of ALS patients, over 80%–90% of patients experience the symptom during the early stages of their illness. During the advanced stage of the illness, 59% of patients suffer from painful cramping.5 Although many ALS experts have speculated on the cause of the cramps, there is no definitive answer at this time. According to Gelinas, cramps in ALS patients are caused by a brief contraction of a weakened muscle due to overactivity of the motor nerves (p. 51).6 Bello-Haas and Montes suggest that the cramps are caused by muscle fatigue or lack of
flexibility (p.102).7 Still other experts have speculated that cramping results from an increase of persistent sodium currents in the affected lower motor nerve cells.8 In the Cochrane Reviews, Weber and Feinberg highlighted a study by Obi et al., in which the authors hypothesized that an important mechanism in cramping is the impairment of gammaaminobutyric acid (GABA) interneuron functioning.9,10 It has also been reported that certain types of exercise easily evoke cramps in the upper arms, abdomen, thighs, calf, and shoulders in a few ALS cases.11–13 However, the authors of these case reports did not identify the type of exercises that caused cramping. Management of cramps Evidence-based practice guidelines for the management of ALS symptoms, which include cramping, have been published and updated by the American Academy of Neurology (AAN) and by the Europen Federation of Neurolgical Societies (EFNS).14,15 In its guidelines for the care of ALS patients, AAN did not recommend any specific intervention for
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IYENGAR YOGA THERAPY AS AN INTERVENTION FOR CRAMP MANAGEMENT the treatment of cramps, because the academy’s review did not find sufficient data to support or refute any intervention. The AAN guidelines also highlighted the Food and Drug Administration warning regarding the use of quinine for the treatment of cramps.14 In contrast, the EFNS task force, in its 2012 guidelines, recommended levetiracetam as a first line of treatment for the management of cramps, based on a pilot study conducted in the United States.15,16 That study found levetiracetam to be effective in reducing the severity and frequency of cramps in a variety of neuromuscular diseases, including ALS.16 Currently, ALS patients with severe cramps are being recruited at multiple sites in California to investigate the efficacy of mexiletine.8 According to the protocol for the clinical trial of mexiletine, there is, at present, no effective medication to control the cramps and no consensus on treatment.8 Role of exercise Stretching exercises, particularly for night cramps in the legs (e.g., calf and hamstring muscles), have been found to be effective in curing and/or reducing the frequency and severity of the symptom in some neuromuscular conditions.17,18 In ALS, however, the role of stretching exercises in the management of cramps is unclear. Furthermore, there are no guidelines in the literature on neuromuscular conditions that specify the particular types of stretching exercises that manage cramping, especially stretching exercises that manage cramping in specific areas of the body. Unlike cramps in calf muscles, which are common in healthy people, patients with ALS develop cramps in unusual locations, including, as Mitsumoto has noted, the thighs, arms, hands, abdomen, neck, jaw, and tongue (p. 28).2 The 2012 EFNS guidelines do not identify any controlled study on stretching exercises for the management of cramps in ALS,15 but ALS experts Miller,19 and Bello-Haas (p. 96), 20 noted some years earlier in books written for patients and families that stretching the muscles should alleviate or stop cramps. In the 2009 third edition of Amyotrophic Lateral Sclerosis: A Guide for Patients and Families, Bello-Haas and Montes stated that the occurrence of muscle cramps can be lessened, but not necessarily stopped, by maintaining flexibility, frequent stretching, and massage.7 The authors say that gentle massage and stretching can also help to relieve a cramp while it is occurring, but note that it is unclear if it is beneficial for all ALS patients, particularly those who have severe pain (p. 103).7 Thus, it is unclear if stretching exercises are an effective means of alleviating or decreasing cramping in patients with ALS. The role of yoga stretching There is, then, no evidence supporting the effectiveness of yoga stretching for the management of cramps, particularly for patients with ALS. However, there are two reports of ALS patients who attended yoga therapy. The first appeared in Yoga Therapy in Practice in 2008.21 The second, which concerned a patient who started attending yoga therapy under the guidance of a certified teacher of the Iyengar yoga system, was been presented on a Minnesota Public Radio (MPR) news broadcast.22 Iyengar yoga is a specialized type of yoga developed by Sri B.K.S. Iyengar, a renowned exponent of yoga teachings. He has published numerous books (Light on Yoga and Light on Pranayama and Yoga: The Path to Holistic Health),
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that describe the principals underlying his teachings, which include a therapeutic approach to treating ailments as well as the innovative use of yoga props (e.g., belts, blocks, bolsters, chairs). Unfortunately, the author/reporter for MPR news did not mention cramp management in the report. In the absence of a cure, the primary objective of therapy should be to maintain a quality of life for patients with ALS. Given this, yoga therapy may become an important intervention that alleviates some ALS symptoms and thereby enhances a patient’s quality of life.23 This article presents the result of yoga therapy used specifically on cramps in three ALS subjects. The therapy was composed of postures (stretching), breathing exercises, and relaxation. Case reports This study of yoga therapy was conducted between 2005 and 2010 and included three ALS subjects who, for the purposes of this article, will be called Avery, Betty, and Carl. Each subject’s diagnosis had been confirmed by neurologists either in ALS clinics or in medical research centers. The subjects ranged in age from 45 to 62. Two subjects (Avery and Carl) experienced their ALS onset symptom in one or both legs. Betty experienced the onset of ALS symptoms in her left hand. At the time yoga therapy was initiated, Avery and Carl had developed lower extremity weakness, muscle atrophy, bilateral foot drop, and used, respectively, canes or a walker. Betty experienced muscle weakness in the arms and mild atrophy in the hands but reported normal strength in her legs. She was able to walk without any support. History of cramps All three subjects reported cramping in various parts of the body prior to yoga therapy. Avery, subject 1, experienced cramps in her legs (calves, hamstrings, and quadriceps), even before her diagnosis in September 2005. She reported the pain was moderately intensive and affected her mobility. Betty, subject 2, also started developing cramps in her legs a year before her diagnosis in May 2007 and noted the spread of the symptom to other parts of her body. By the time her diagnosis was confirmed and she started yoga therapy, which occurred in the same month as the confirmation of diagnosis, she was experiencing cramping in many areas of her body, including her upper and lower extremities, abdomen, and back. She reported that cramping occurred even with minor movement. The cramps caused severe pain and affected activities of daily living, including mobility. Carl, subject 3, whose diagnosis was confirmed in 2008, experienced cramps in both legs (calf, hamstrings, and quadriceps) and buttocks twice every night which affected his sleep. He also reported sometimes experiencing cramps during movement lasting more than 30 seconds. These cramps caused moderate pain. He reported that he attempted stretching exercises to relieve the cramps whenever they occurred but said that stretching was ineffective. Intervention An Iyengar yoga therapy program, composed of postures, breathing exercises, and relaxation, was implemented for each subject, based on the subject’s physical disability and other symptoms (see Table 1). Home practice also differed
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RIBEIRO Table 1. Iyengar Yoga Protocol for Cramp Management
Yoga therapy intervention
Frequency/duration and use of props
Home practice
Relaxation (Avery, Betty, and Carl)
Beginning: 5–10 min Between postures, if required: < 1 min End of therapy session: 5–10 min
Standing postures (Avery and Betty) 1. Tree pose 2. Raised Hand/s in Tree Pose 3. Upward Bound Fingers in Tree Pose 4. Triangle Pose 5. Extended Side Angle Pose 6. Warrior Pose I 7. Downward Dog Pose 8. Standing Forward Bending Pose
4–5 postures were prescribed for each session. Each posture was to be performed once. Hold time for a pose was set for < 2 min. Various props, including chair, wall, and ropes, fixed to wall/edge of the bed were used for balance and to prevent falls. Therapist assistance (e.g., holding the lifted arm and/or support by holding the hip), was provided for weak muscles.
Sitting postures (Avery, Betty, and Carl) 1. Staff Pose 2. Staff Pose with Raised Arms 3. Simple Crossed Legs Pose 4. Simple Crossed Legs with Raised Arm/s 5. Forward Bending in Simple Crossed Legs 6. Bound Angle Pose 7. Head to Knee Pose 8. Seated Forward Bending Pose (both legs straight) 9. Seated Wide Leg Pose Supine postures (Avery, Betty, and Carl) 1. Crossed Legged Supine Pose 2. Bound Legged Supine Pose 3. Bridge Pose 4. Reclined Back Big Toe Holding Pose I (bended or straight knees) 5. Reclined Back Big Toe Holding Pose II (Variation: leg extension side way)
6–7 postures were performed 1–2 times in each session. Hold time was set for 2–3 min for all postures, except for 2 and 4, due to weakness in the subjects’ arms. Assistance (e.g., holding weak arms when raised above the head/sideway), was provided. Various props, including chair, straps, bolster, and blankets, were used.
Practice during the day, prior to bedtime, and intermittently during self-practice. Specified amount of time to practice was not set. Each session posture was to be performed once. Hold time was not set. Subjects were advised to perform according to personal comfort. Subjects used various supports, including edge of the bed, wall support, walker, and yoga props, such as chair, bricks and ropes. Avery performed all except 7, which was too difficult due to weakness in her legs. Betty performed all postures. Each session posture was to be performed 1–2 times. Hold time was not set. Avery and Betty practiced either on the floor or on the bed. Carl practiced all postures except for 6 and 9 on a chair.
Inversions/variations (Avery and Betty) 1. Supported Shoulder Stand 2. Single Leg, Shoulder Stand 3. Half Plough Pose
Twisting postures, sitting/supine (Avery, Betty, and Carl) 1. Bharadvajas Spinal Twist 2. Marichyas’ Spinal Twist 3. Simple Crossed Legs Spinal Twist 4. Supine Belly Twisting Pose (bended or straight knees)
Each posture was performed once for < 3 min. Assistance (e.g., holding the legs when elevated), was provided. Various props, such as bolsters or blankets were used under the back and head. Postures were performed either on the floor (supine), or in an elevated position (on a blanket or in a wheelchair).
Each posture was performed once for < 3 min. Both subjects performed with the support of the wall, with knees bent and feet on the wall. Assistance was provided by holding the lifted trunk. Intermittent relaxation was given between each posture. Various props including bolsters and blankets were used to support the shoulder, neck, and lower back. A chair was provided to perform the Half Plough Pose. Each posture was performed twice for 2–3 min. Avery and Betty performed on a chair or on the floor. Carl performed only in a chair/ wheelchair due to the inability to get down and up from the floor.
For Avery and Betty, various postures were recommended according to their physical ability. Each was performed 1–2 times. Hold time was not set. Due to weakness and an inability to raise her legs, Avery practiced either on the floor or on the bed for postures 1, 2, and 3. Due to normal strength in her legs, Betty performed all postures independently. Although Carl was able to perform many postures on the bed, he did not wish to use the bed or could not get down or up from the floor. A length of time for practice was not set. For Betty, postures 1 and 2 were recommended and were performed with the support of the wall, bolsters, and blankets to support the shoulder and neck. No hold time was assigned. Avery was not assigned these postures because she was unable to lift her legs in supine position.
A length of time for practice was not set. Postures were to be performed 2– 3 times. Avery and Betty performed either on a chair/bed or the floor. Carl performed only on the chair for postures 1, 2, and 3. (continued)
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Table 1. (Continued) Yoga therapy intervention Breathing exercises (Avery, Betty, and Carl) 1. Ujjayi Breathing (victorious) 2. Right Nostril Breathing 3. Left Nostril Breathing 4. Both Nostrils Breathing
Frequency/duration and use of props
Home practice
2–3 techniques were practiced in each therapy session for 10–15 min, either on the floor or on a chair. Each exercise concluded with relaxation techniques. Various props, including bolsters, blankets, and eye masks to cover the eyes, were used when breathing exercises were taught in the supine position.
For Avery and Betty, the length of practice time was not set. 2–3 techniques were recommended for 10–15 min of daily practice. Both practiced in early morning, before going to bed, and during the day when time permitted. Carl wished to continue the breathing exercises that he had practiced for many years.
for each subject, as some of the postures taught during therapeutic intervention could not be performed by the subjects without assistance. Subject 1, Avery, started yoga at her home and attended a 1-hour session twice a week. The other subjects, Betty and Carl, came to the studio. Betty came to the studio for a 1-hour session twice a week, and Carl came for a 1-hour session once a week. Avery continued therapy for 32 months and then halted it for 7 months. After 7 months, she asked to have the therapy reinstituted, which was done. After 6 months, however, it was discontinued by the therapist who traveled to India for professional development. Upon the therapist’s return, Avery did not show an interest in continuing therapy. Betty, subject 2, attended therapy for 3 years, until 3 days prior to her death in May 2010. Carl, attended therapy for 1 year (2009–2010) and then stopped. He was asked to continue his yoga therapy at home as his illness did not show any further progression during the continuity of yoga therapy. He is still alive. Results During the first therapy session, Avery and Betty experienced exaggerated cramping in various parts of the body while performing certain sitting (head-to-knee), standing (Warrior I and Downward Dog), and supine (reclined back, big toe holding) postures (see Table I). This cramping led to some distress and even panic. Avery and Betty did not want to move their affected parts until the symptoms relieved spontaneously. To prevent distress, postures in which cramping was exaggerated, were halted and noncramping postures were selected. As Avery and Betty continued with this modified therapy, they reported the cessation of cramping. They were then asked to perform the same postures that had initially induced cramping. None of these postures caused cramping, and they were then successfully added to Avery’s and Betty’s regular practice (Table 1). At the start of therapy, Carl reported that the stretching exercises he performed to relieve cramping in his legs were ineffective. However, 1 month after starting yoga therapy, he reported that his cramping was alleviated. All three subjects reported the cessation of cramps within 3 weeks to 8 weeks of the start of yoga therapy, and they remained symptom free for the duration of therapy. When she first halted therapy, Avery reported the return of cramps in her hand. Within 2 weeks of resuming Iyengar yoga therapy, however, she reported the alleviation of the
symptom and remained symptom free for as long as she continued yoga therapy. Discussion Recently updated guidelines by the EFNS task force recommend levetiracetam as the first choice of medication for the management of cramps in patients with ALS.15 If ALS patients experience side effects due to this drug, the guidelines recommend quinine sulphate as a second choice of treatment.15 However, levetiracetam does not completely alleviate cramps in ALS patients,16 and AAN practice parameters for the care of ALS patients highlight the FDA warning about the use of quinine.14 Thus, the options for the management of cramps in patients with ALS are limited. In this study, cramping, which was prevalent in various parts of the body in three subjects, was alleviated soon after the institution of Iyengar therapy. In addition, when Avery, subject 1, developed cramping in a new area of her body during the absence of yoga therapy, the symptom was alleviated within 2 weeks of resuming therapy. No matter what mechanism causes cramping in ALS patients and no matter what medications are beneficial for the management of cramps, the evidence of cramp remission in these cases demonstrates a high possibility for cramp management through Iyengar Yoga therapy. Currently there is no other evidence to support either yoga therapy or stretching exercises for the alleviation cramps in ALS patients. Because ENFS guidelines recommend physical exercise and AAN recommends future research on the impact of therapeutic exercises for cramp management, these case studies act as a start in assessing the effectiveness of yoga stretches on subjects with ALS.14,15 Conclusion At present there is no effective medication to control the cramping that occurs in ALS patients, and no agreement on how to treat this symptom. Although stretching exercises are frequently recommended, their effectiveness is unclear and there are no guidelines for the specific types of stretching exercises that can be used with ALS patients who complain of cramping. Furthermore, some forms of exercise evoke cramps, which may distress and/or discourage patients from participating in an exercise program. Although Iyengar yoga therapy interventions appear to be an option for cramp management in ALS patients, further studies of various types of exercise, including yoga, are
326 necessary. Future studies could assist in identifying the types of exercises that evoke cramps and the types of exercises (particularly stretching exercises), that are effective in stopping or decreasing and/or relieving cramps. The outcomes of such studies could then inform the development of guidelines for clinicians and the available options in cramp management for ALS patients. Acknowledgments The author gratefully acknowledges Avery, Betty, and Carl and their families and other caretakers who were very supportive of the yoga therapy. The author wishes to thank Dr. Michele D. Ribeiro and Erik Ackerson for their assistance in editing and working with the author to complete this article. The author would also like to acknowledge the encouragement provided by B.K.S. Iyengar to write about the yoga interventions being practiced with patients affected with ALS. Author Disclosure Statement No competing financial interests exist. References 1. Borasio GD, Voltz R. Palliative care in amyotrophic lateral sclerosis. J Neurol 1997;244(Suppl 4):S11–S17. 2. Mitsumoto H. The clinical features and prognosis of ALS. In: Mitsumoto H, Munsat TL, eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:17–36. 3. Tartaglia MC, Rowe A, Findlater K, et al. Differentiation between primary lateral sclerosis and amyotrophic lateral sclerosis: Examination of symptoms and signs at disease onset and during follow-up. Arch Neurol 2007;64:232–236. 4. Nalini A, Thennarasu K, Gowrie-Devi M, et al. Clinical characteristics and survival pattern of 1,153 patients with amyotrophic lateral sclerosis: Experience over 30 years from India. J Neurol Sci 2008;272:60–70. 5. Hicks F, Corcoran G. Should hospices offer respite admissions to patient with motor neuron disease? Palliat Med 1993;7:145–150. 6. Gelinas D. Treating the symptoms of ALS. In: Mitsumoto H, Munsat TL, eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:47–62. 7. Bello-Haas VD, Montes J. Physical therapy. In: Minsumoto H, ed. Amyotrophic lateral sclerosis: A guide for patients and families. 3rd ed. New York: Demos Medical Publishing, 2009:99–114. 8. Mexiletine for the treatment of muscle cramps in ALS. http://clinicaltrials.gov/ct2/show/NCT01811355. Accessed August 21, 2013. 9. Weber M, Feinberg D. Treatment for cramps in amyotrophic lateral sclerosis/motor neuron disease (protocol). Cochrane Database of Systematic Reviews 2003. DOI: 10.1002/ 141651858.CD004157.
RIBEIRO 10. Obi T, Mizoguchi K, Matsuoka H, et al. Muscle cramp as the result of impaired GABA function—an electrophysiological and pharmacological observation. Muscle Nerve 1993;16: 1228–1231. 11. Okuda B, Kodama N, Tachibana H, Sugita M. Motor neuron disease following generalized fasciculations and cramps. J Neurol Sci 1997;150:129–131. 12. de Carvalho M, Swash M. Cramps, muscle pain, and fasciculations: Not always benign? Neurology 2004;63:721–723. 13. Swash M, Ingram D. Preclinical and subclinical events in motor neuron disease. J Neurol, Neurosurg Psychiatry 1988; 51:165–168. 14. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009;73: 1227–1233. 15. Andersen PM, Abrahams S, Borasio GD, et al. EFNS guidelines on the clinical management of Amyotrophic Lateral Sclerosis (MALS)—revised report of EFNS task force. Eur J Neurol 2012;19:360–375. 16. Bedlack RS, Pastula DM, Hawes J, Heydt D. Open-label pilot trial of levetiracetam for cramps and spasticity in patients with motor neuron disease. Amyotroph Lateral Scler 2009; 10:210–215. 17. Daniel DW. Simple cure for nocturnal cramps. N Engl J Med 1979;301:216. 18. Hallegraeff JM, van der Schans CP, de Ruiter R, de Greef MH. Stretching before sleep reduces the frequency and severity of nocturnal cramps in older adults: A randomized trial. J Physiother 2012;58:17–22. 19. Miller RG, Gelinas D. O’Conor P. Amyotrophic lateral sclerosis: treating the symptoms of ALS. New York: Demos Medical Publishing, 2005:91–102. 20. Bello-Haas VD. Physical therapy. In: Mitsumoto H, Munsat TL eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:93–102. 21. Stevens J. Teaching reflection: Yoga therapy for ALS. International Association of Yoga Therapists 2008;20–23. 22. Wurzer C. Yoga helps reconnect a patient’s disconnected body. MPR news 2013 Apr 24. http://minnesota.publicradio .org/display/web/2013/04/23/health/living-with-als-yogareconnects-disconnected-body. Accessed August 8, 2013. 23. Drory VE, Goltsman E, Reznik JG, et al. The value of muscle exercise in patients with amyotrophic lateral sclerosis. J Neurol Sci 2001;191:133–137.
Address correspondence to: Subbappa Ribeiro Certified Iyengar Yoga Teacher BKS Iyengar Yoga Center of the Willamette Valley 511 NW 11th Street Corvallis, OR 97330 E-mail: [email protected]
Case Study
Iyengar Yoga Therapy as an Intervention for Cramp Management in Individuals with Amyotrophic Lateral Sclerosis: Three Case Reports Subbappa Ribeiro
Abstract
Objectives: Patients with amyotrophic lateral sclerosis (ALS), a neurodegenerative disease of motor neurons, experience cramps at all stages of the illness. There is, at present, no effective medication to control the cramps and no agreement on how to treat the symptom in ALS patients. Subjects: Three individuals who were diagnosed with ALS and reported suffering cramps in various parts of the body, which limited their activities or affected their sleep were invited to try Iyengar yoga. Intervention and outcome: Yoga therapy, composed of stretching, breathing, and relaxation exercises, was prescribed for each case, based on the subject’s physical disability and the presence of other symptoms. Although two subjects experienced cramps during the first therapy session, all three subjects reported the complete cessation of cramping within 3 weeks to 8 weeks of therapy. One of the subjects developed cramps in the hand after discontinuing yoga therapy for 7 months. However, the symptom stopped within 2 weeks of resuming yoga therapy. Conclusion: The alleviation of cramps in these three subjects indicates the possibility of yogic intervention for the management of cramps in individuals with ALS, but further research is necessary to understand the effectiveness of yoga therapy and to determine the exercises that are more prone to lead to cramping in some ALS individuals.
Introduction
P
atients with amyotrophic lateral sclerosis (ALS), which is a degenerative motor neuron disease, experience a variety of symptoms as a result, either directly or indirectly, of the disease. These symptoms, as noted by Borasio and Voltz1 as well as Mitsumoto (p. 28),2 include muscle cramping, an abrupt, spontaneous, and prolonged muscle contraction causing pain severe enough to interrupt activity or sleep. Although studies by Tartaglia et al.,3 Nalini et al.,4 and Mitsumoto (p. 21),2 report cramps as a presenting symptom in only 7%–12% of ALS patients, over 80%–90% of patients experience the symptom during the early stages of their illness. During the advanced stage of the illness, 59% of patients suffer from painful cramping.5 Although many ALS experts have speculated on the cause of the cramps, there is no definitive answer at this time. According to Gelinas, cramps in ALS patients are caused by a brief contraction of a weakened muscle due to overactivity of the motor nerves (p. 51).6 Bello-Haas and Montes suggest that the cramps are caused by muscle fatigue or lack of
flexibility (p.102).7 Still other experts have speculated that cramping results from an increase of persistent sodium currents in the affected lower motor nerve cells.8 In the Cochrane Reviews, Weber and Feinberg highlighted a study by Obi et al., in which the authors hypothesized that an important mechanism in cramping is the impairment of gammaaminobutyric acid (GABA) interneuron functioning.9,10 It has also been reported that certain types of exercise easily evoke cramps in the upper arms, abdomen, thighs, calf, and shoulders in a few ALS cases.11–13 However, the authors of these case reports did not identify the type of exercises that caused cramping. Management of cramps Evidence-based practice guidelines for the management of ALS symptoms, which include cramping, have been published and updated by the American Academy of Neurology (AAN) and by the Europen Federation of Neurolgical Societies (EFNS).14,15 In its guidelines for the care of ALS patients, AAN did not recommend any specific intervention for
BKS Iyengar Yoga Center of the Willamette Valley, Corvallis, OR.
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IYENGAR YOGA THERAPY AS AN INTERVENTION FOR CRAMP MANAGEMENT the treatment of cramps, because the academy’s review did not find sufficient data to support or refute any intervention. The AAN guidelines also highlighted the Food and Drug Administration warning regarding the use of quinine for the treatment of cramps.14 In contrast, the EFNS task force, in its 2012 guidelines, recommended levetiracetam as a first line of treatment for the management of cramps, based on a pilot study conducted in the United States.15,16 That study found levetiracetam to be effective in reducing the severity and frequency of cramps in a variety of neuromuscular diseases, including ALS.16 Currently, ALS patients with severe cramps are being recruited at multiple sites in California to investigate the efficacy of mexiletine.8 According to the protocol for the clinical trial of mexiletine, there is, at present, no effective medication to control the cramps and no consensus on treatment.8 Role of exercise Stretching exercises, particularly for night cramps in the legs (e.g., calf and hamstring muscles), have been found to be effective in curing and/or reducing the frequency and severity of the symptom in some neuromuscular conditions.17,18 In ALS, however, the role of stretching exercises in the management of cramps is unclear. Furthermore, there are no guidelines in the literature on neuromuscular conditions that specify the particular types of stretching exercises that manage cramping, especially stretching exercises that manage cramping in specific areas of the body. Unlike cramps in calf muscles, which are common in healthy people, patients with ALS develop cramps in unusual locations, including, as Mitsumoto has noted, the thighs, arms, hands, abdomen, neck, jaw, and tongue (p. 28).2 The 2012 EFNS guidelines do not identify any controlled study on stretching exercises for the management of cramps in ALS,15 but ALS experts Miller,19 and Bello-Haas (p. 96), 20 noted some years earlier in books written for patients and families that stretching the muscles should alleviate or stop cramps. In the 2009 third edition of Amyotrophic Lateral Sclerosis: A Guide for Patients and Families, Bello-Haas and Montes stated that the occurrence of muscle cramps can be lessened, but not necessarily stopped, by maintaining flexibility, frequent stretching, and massage.7 The authors say that gentle massage and stretching can also help to relieve a cramp while it is occurring, but note that it is unclear if it is beneficial for all ALS patients, particularly those who have severe pain (p. 103).7 Thus, it is unclear if stretching exercises are an effective means of alleviating or decreasing cramping in patients with ALS. The role of yoga stretching There is, then, no evidence supporting the effectiveness of yoga stretching for the management of cramps, particularly for patients with ALS. However, there are two reports of ALS patients who attended yoga therapy. The first appeared in Yoga Therapy in Practice in 2008.21 The second, which concerned a patient who started attending yoga therapy under the guidance of a certified teacher of the Iyengar yoga system, was been presented on a Minnesota Public Radio (MPR) news broadcast.22 Iyengar yoga is a specialized type of yoga developed by Sri B.K.S. Iyengar, a renowned exponent of yoga teachings. He has published numerous books (Light on Yoga and Light on Pranayama and Yoga: The Path to Holistic Health),
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that describe the principals underlying his teachings, which include a therapeutic approach to treating ailments as well as the innovative use of yoga props (e.g., belts, blocks, bolsters, chairs). Unfortunately, the author/reporter for MPR news did not mention cramp management in the report. In the absence of a cure, the primary objective of therapy should be to maintain a quality of life for patients with ALS. Given this, yoga therapy may become an important intervention that alleviates some ALS symptoms and thereby enhances a patient’s quality of life.23 This article presents the result of yoga therapy used specifically on cramps in three ALS subjects. The therapy was composed of postures (stretching), breathing exercises, and relaxation. Case reports This study of yoga therapy was conducted between 2005 and 2010 and included three ALS subjects who, for the purposes of this article, will be called Avery, Betty, and Carl. Each subject’s diagnosis had been confirmed by neurologists either in ALS clinics or in medical research centers. The subjects ranged in age from 45 to 62. Two subjects (Avery and Carl) experienced their ALS onset symptom in one or both legs. Betty experienced the onset of ALS symptoms in her left hand. At the time yoga therapy was initiated, Avery and Carl had developed lower extremity weakness, muscle atrophy, bilateral foot drop, and used, respectively, canes or a walker. Betty experienced muscle weakness in the arms and mild atrophy in the hands but reported normal strength in her legs. She was able to walk without any support. History of cramps All three subjects reported cramping in various parts of the body prior to yoga therapy. Avery, subject 1, experienced cramps in her legs (calves, hamstrings, and quadriceps), even before her diagnosis in September 2005. She reported the pain was moderately intensive and affected her mobility. Betty, subject 2, also started developing cramps in her legs a year before her diagnosis in May 2007 and noted the spread of the symptom to other parts of her body. By the time her diagnosis was confirmed and she started yoga therapy, which occurred in the same month as the confirmation of diagnosis, she was experiencing cramping in many areas of her body, including her upper and lower extremities, abdomen, and back. She reported that cramping occurred even with minor movement. The cramps caused severe pain and affected activities of daily living, including mobility. Carl, subject 3, whose diagnosis was confirmed in 2008, experienced cramps in both legs (calf, hamstrings, and quadriceps) and buttocks twice every night which affected his sleep. He also reported sometimes experiencing cramps during movement lasting more than 30 seconds. These cramps caused moderate pain. He reported that he attempted stretching exercises to relieve the cramps whenever they occurred but said that stretching was ineffective. Intervention An Iyengar yoga therapy program, composed of postures, breathing exercises, and relaxation, was implemented for each subject, based on the subject’s physical disability and other symptoms (see Table 1). Home practice also differed
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RIBEIRO Table 1. Iyengar Yoga Protocol for Cramp Management
Yoga therapy intervention
Frequency/duration and use of props
Home practice
Relaxation (Avery, Betty, and Carl)
Beginning: 5–10 min Between postures, if required: < 1 min End of therapy session: 5–10 min
Standing postures (Avery and Betty) 1. Tree pose 2. Raised Hand/s in Tree Pose 3. Upward Bound Fingers in Tree Pose 4. Triangle Pose 5. Extended Side Angle Pose 6. Warrior Pose I 7. Downward Dog Pose 8. Standing Forward Bending Pose
4–5 postures were prescribed for each session. Each posture was to be performed once. Hold time for a pose was set for < 2 min. Various props, including chair, wall, and ropes, fixed to wall/edge of the bed were used for balance and to prevent falls. Therapist assistance (e.g., holding the lifted arm and/or support by holding the hip), was provided for weak muscles.
Sitting postures (Avery, Betty, and Carl) 1. Staff Pose 2. Staff Pose with Raised Arms 3. Simple Crossed Legs Pose 4. Simple Crossed Legs with Raised Arm/s 5. Forward Bending in Simple Crossed Legs 6. Bound Angle Pose 7. Head to Knee Pose 8. Seated Forward Bending Pose (both legs straight) 9. Seated Wide Leg Pose Supine postures (Avery, Betty, and Carl) 1. Crossed Legged Supine Pose 2. Bound Legged Supine Pose 3. Bridge Pose 4. Reclined Back Big Toe Holding Pose I (bended or straight knees) 5. Reclined Back Big Toe Holding Pose II (Variation: leg extension side way)
6–7 postures were performed 1–2 times in each session. Hold time was set for 2–3 min for all postures, except for 2 and 4, due to weakness in the subjects’ arms. Assistance (e.g., holding weak arms when raised above the head/sideway), was provided. Various props, including chair, straps, bolster, and blankets, were used.
Practice during the day, prior to bedtime, and intermittently during self-practice. Specified amount of time to practice was not set. Each session posture was to be performed once. Hold time was not set. Subjects were advised to perform according to personal comfort. Subjects used various supports, including edge of the bed, wall support, walker, and yoga props, such as chair, bricks and ropes. Avery performed all except 7, which was too difficult due to weakness in her legs. Betty performed all postures. Each session posture was to be performed 1–2 times. Hold time was not set. Avery and Betty practiced either on the floor or on the bed. Carl practiced all postures except for 6 and 9 on a chair.
Inversions/variations (Avery and Betty) 1. Supported Shoulder Stand 2. Single Leg, Shoulder Stand 3. Half Plough Pose
Twisting postures, sitting/supine (Avery, Betty, and Carl) 1. Bharadvajas Spinal Twist 2. Marichyas’ Spinal Twist 3. Simple Crossed Legs Spinal Twist 4. Supine Belly Twisting Pose (bended or straight knees)
Each posture was performed once for < 3 min. Assistance (e.g., holding the legs when elevated), was provided. Various props, such as bolsters or blankets were used under the back and head. Postures were performed either on the floor (supine), or in an elevated position (on a blanket or in a wheelchair).
Each posture was performed once for < 3 min. Both subjects performed with the support of the wall, with knees bent and feet on the wall. Assistance was provided by holding the lifted trunk. Intermittent relaxation was given between each posture. Various props including bolsters and blankets were used to support the shoulder, neck, and lower back. A chair was provided to perform the Half Plough Pose. Each posture was performed twice for 2–3 min. Avery and Betty performed on a chair or on the floor. Carl performed only in a chair/ wheelchair due to the inability to get down and up from the floor.
For Avery and Betty, various postures were recommended according to their physical ability. Each was performed 1–2 times. Hold time was not set. Due to weakness and an inability to raise her legs, Avery practiced either on the floor or on the bed for postures 1, 2, and 3. Due to normal strength in her legs, Betty performed all postures independently. Although Carl was able to perform many postures on the bed, he did not wish to use the bed or could not get down or up from the floor. A length of time for practice was not set. For Betty, postures 1 and 2 were recommended and were performed with the support of the wall, bolsters, and blankets to support the shoulder and neck. No hold time was assigned. Avery was not assigned these postures because she was unable to lift her legs in supine position.
A length of time for practice was not set. Postures were to be performed 2– 3 times. Avery and Betty performed either on a chair/bed or the floor. Carl performed only on the chair for postures 1, 2, and 3. (continued)
IYENGAR YOGA THERAPY AS AN INTERVENTION FOR CRAMP MANAGEMENT
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Table 1. (Continued) Yoga therapy intervention Breathing exercises (Avery, Betty, and Carl) 1. Ujjayi Breathing (victorious) 2. Right Nostril Breathing 3. Left Nostril Breathing 4. Both Nostrils Breathing
Frequency/duration and use of props
Home practice
2–3 techniques were practiced in each therapy session for 10–15 min, either on the floor or on a chair. Each exercise concluded with relaxation techniques. Various props, including bolsters, blankets, and eye masks to cover the eyes, were used when breathing exercises were taught in the supine position.
For Avery and Betty, the length of practice time was not set. 2–3 techniques were recommended for 10–15 min of daily practice. Both practiced in early morning, before going to bed, and during the day when time permitted. Carl wished to continue the breathing exercises that he had practiced for many years.
for each subject, as some of the postures taught during therapeutic intervention could not be performed by the subjects without assistance. Subject 1, Avery, started yoga at her home and attended a 1-hour session twice a week. The other subjects, Betty and Carl, came to the studio. Betty came to the studio for a 1-hour session twice a week, and Carl came for a 1-hour session once a week. Avery continued therapy for 32 months and then halted it for 7 months. After 7 months, she asked to have the therapy reinstituted, which was done. After 6 months, however, it was discontinued by the therapist who traveled to India for professional development. Upon the therapist’s return, Avery did not show an interest in continuing therapy. Betty, subject 2, attended therapy for 3 years, until 3 days prior to her death in May 2010. Carl, attended therapy for 1 year (2009–2010) and then stopped. He was asked to continue his yoga therapy at home as his illness did not show any further progression during the continuity of yoga therapy. He is still alive. Results During the first therapy session, Avery and Betty experienced exaggerated cramping in various parts of the body while performing certain sitting (head-to-knee), standing (Warrior I and Downward Dog), and supine (reclined back, big toe holding) postures (see Table I). This cramping led to some distress and even panic. Avery and Betty did not want to move their affected parts until the symptoms relieved spontaneously. To prevent distress, postures in which cramping was exaggerated, were halted and noncramping postures were selected. As Avery and Betty continued with this modified therapy, they reported the cessation of cramping. They were then asked to perform the same postures that had initially induced cramping. None of these postures caused cramping, and they were then successfully added to Avery’s and Betty’s regular practice (Table 1). At the start of therapy, Carl reported that the stretching exercises he performed to relieve cramping in his legs were ineffective. However, 1 month after starting yoga therapy, he reported that his cramping was alleviated. All three subjects reported the cessation of cramps within 3 weeks to 8 weeks of the start of yoga therapy, and they remained symptom free for the duration of therapy. When she first halted therapy, Avery reported the return of cramps in her hand. Within 2 weeks of resuming Iyengar yoga therapy, however, she reported the alleviation of the
symptom and remained symptom free for as long as she continued yoga therapy. Discussion Recently updated guidelines by the EFNS task force recommend levetiracetam as the first choice of medication for the management of cramps in patients with ALS.15 If ALS patients experience side effects due to this drug, the guidelines recommend quinine sulphate as a second choice of treatment.15 However, levetiracetam does not completely alleviate cramps in ALS patients,16 and AAN practice parameters for the care of ALS patients highlight the FDA warning about the use of quinine.14 Thus, the options for the management of cramps in patients with ALS are limited. In this study, cramping, which was prevalent in various parts of the body in three subjects, was alleviated soon after the institution of Iyengar therapy. In addition, when Avery, subject 1, developed cramping in a new area of her body during the absence of yoga therapy, the symptom was alleviated within 2 weeks of resuming therapy. No matter what mechanism causes cramping in ALS patients and no matter what medications are beneficial for the management of cramps, the evidence of cramp remission in these cases demonstrates a high possibility for cramp management through Iyengar Yoga therapy. Currently there is no other evidence to support either yoga therapy or stretching exercises for the alleviation cramps in ALS patients. Because ENFS guidelines recommend physical exercise and AAN recommends future research on the impact of therapeutic exercises for cramp management, these case studies act as a start in assessing the effectiveness of yoga stretches on subjects with ALS.14,15 Conclusion At present there is no effective medication to control the cramping that occurs in ALS patients, and no agreement on how to treat this symptom. Although stretching exercises are frequently recommended, their effectiveness is unclear and there are no guidelines for the specific types of stretching exercises that can be used with ALS patients who complain of cramping. Furthermore, some forms of exercise evoke cramps, which may distress and/or discourage patients from participating in an exercise program. Although Iyengar yoga therapy interventions appear to be an option for cramp management in ALS patients, further studies of various types of exercise, including yoga, are
326 necessary. Future studies could assist in identifying the types of exercises that evoke cramps and the types of exercises (particularly stretching exercises), that are effective in stopping or decreasing and/or relieving cramps. The outcomes of such studies could then inform the development of guidelines for clinicians and the available options in cramp management for ALS patients. Acknowledgments The author gratefully acknowledges Avery, Betty, and Carl and their families and other caretakers who were very supportive of the yoga therapy. The author wishes to thank Dr. Michele D. Ribeiro and Erik Ackerson for their assistance in editing and working with the author to complete this article. The author would also like to acknowledge the encouragement provided by B.K.S. Iyengar to write about the yoga interventions being practiced with patients affected with ALS. Author Disclosure Statement No competing financial interests exist. References 1. Borasio GD, Voltz R. Palliative care in amyotrophic lateral sclerosis. J Neurol 1997;244(Suppl 4):S11–S17. 2. Mitsumoto H. The clinical features and prognosis of ALS. In: Mitsumoto H, Munsat TL, eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:17–36. 3. Tartaglia MC, Rowe A, Findlater K, et al. Differentiation between primary lateral sclerosis and amyotrophic lateral sclerosis: Examination of symptoms and signs at disease onset and during follow-up. Arch Neurol 2007;64:232–236. 4. Nalini A, Thennarasu K, Gowrie-Devi M, et al. Clinical characteristics and survival pattern of 1,153 patients with amyotrophic lateral sclerosis: Experience over 30 years from India. J Neurol Sci 2008;272:60–70. 5. Hicks F, Corcoran G. Should hospices offer respite admissions to patient with motor neuron disease? Palliat Med 1993;7:145–150. 6. Gelinas D. Treating the symptoms of ALS. In: Mitsumoto H, Munsat TL, eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:47–62. 7. Bello-Haas VD, Montes J. Physical therapy. In: Minsumoto H, ed. Amyotrophic lateral sclerosis: A guide for patients and families. 3rd ed. New York: Demos Medical Publishing, 2009:99–114. 8. Mexiletine for the treatment of muscle cramps in ALS. http://clinicaltrials.gov/ct2/show/NCT01811355. Accessed August 21, 2013. 9. Weber M, Feinberg D. Treatment for cramps in amyotrophic lateral sclerosis/motor neuron disease (protocol). Cochrane Database of Systematic Reviews 2003. DOI: 10.1002/ 141651858.CD004157.
RIBEIRO 10. Obi T, Mizoguchi K, Matsuoka H, et al. Muscle cramp as the result of impaired GABA function—an electrophysiological and pharmacological observation. Muscle Nerve 1993;16: 1228–1231. 11. Okuda B, Kodama N, Tachibana H, Sugita M. Motor neuron disease following generalized fasciculations and cramps. J Neurol Sci 1997;150:129–131. 12. de Carvalho M, Swash M. Cramps, muscle pain, and fasciculations: Not always benign? Neurology 2004;63:721–723. 13. Swash M, Ingram D. Preclinical and subclinical events in motor neuron disease. J Neurol, Neurosurg Psychiatry 1988; 51:165–168. 14. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009;73: 1227–1233. 15. Andersen PM, Abrahams S, Borasio GD, et al. EFNS guidelines on the clinical management of Amyotrophic Lateral Sclerosis (MALS)—revised report of EFNS task force. Eur J Neurol 2012;19:360–375. 16. Bedlack RS, Pastula DM, Hawes J, Heydt D. Open-label pilot trial of levetiracetam for cramps and spasticity in patients with motor neuron disease. Amyotroph Lateral Scler 2009; 10:210–215. 17. Daniel DW. Simple cure for nocturnal cramps. N Engl J Med 1979;301:216. 18. Hallegraeff JM, van der Schans CP, de Ruiter R, de Greef MH. Stretching before sleep reduces the frequency and severity of nocturnal cramps in older adults: A randomized trial. J Physiother 2012;58:17–22. 19. Miller RG, Gelinas D. O’Conor P. Amyotrophic lateral sclerosis: treating the symptoms of ALS. New York: Demos Medical Publishing, 2005:91–102. 20. Bello-Haas VD. Physical therapy. In: Mitsumoto H, Munsat TL eds. Amyotrophic lateral sclerosis: A guide for patients and families. 2nd ed. New York: Demos Medical Publishing, 2001:93–102. 21. Stevens J. Teaching reflection: Yoga therapy for ALS. International Association of Yoga Therapists 2008;20–23. 22. Wurzer C. Yoga helps reconnect a patient’s disconnected body. MPR news 2013 Apr 24. http://minnesota.publicradio .org/display/web/2013/04/23/health/living-with-als-yogareconnects-disconnected-body. Accessed August 8, 2013. 23. Drory VE, Goltsman E, Reznik JG, et al. The value of muscle exercise in patients with amyotrophic lateral sclerosis. J Neurol Sci 2001;191:133–137.
Address correspondence to: Subbappa Ribeiro Certified Iyengar Yoga Teacher BKS Iyengar Yoga Center of the Willamette Valley 511 NW 11th Street Corvallis, OR 97330 E-mail: [email protected]
