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Review article

NEURO-PHYSIOLOGICAL CORRELATION BETWEEN YOGA, PAIN AND ENDORPHINS

Manjula Suri*, Rekha Sharma** & Namita Saini***

**Department of Physiology and Promotive Health, University of Delhi, Institute of

Home Economics, New Delhi, India. **Department of Physical Education, University of Delhi, Institute of Home Economics

New Delhi, India. Received 14th August 2017, Accepted 28th August 2017

Abstract

The objective of this review is to study the selected research papers regarding neuro- physiological correlation between yoga, pain and endorphin. Several observational and scientific studies suggest that yoga as a comprehensive exercise programme may modulate pain behaviours. Literature suggests that yoga protects against harmful consequences of stress which is closely linked to pain. Various researchers suggest that the neuro-physiological mechanism of exercise and yoga is multifactorial and involves endorphins in pain modulation. Endorphins exert their effect on pain modulation as a part of endogenous opioid system. Thus yoga is an emerging discipline of mind body medicine which has promotive, preventive as well as therapeutic potential for the chronic painful conditions as it modulates the endogenous opiod system through the release of endorphins. Keywords: Yoga, Pain, Endorphins, Endogenous Opioid

© Copy Right, IJAPEY, 2016. All Rights Reserved

Corresponding Author: Dr. Namita Saini e-mail: [email protected]

INTRODUCTION Pain is not exclusively a physical

condition but a complex syndrome including physical, physiological, psychological, and social processes. The widely accepted definition of pain was developed by a taxonomy task force of the International Association for the Study of Pain: “Pain is an unpleasant sensory and emotional experience that is

associated with actual or potential tissue damage or described in such terms” (Gebhart GF , 2000). With respect to the multifaceted causes, there is a need for interdisciplinary approach in the diagnosis and management of pain. Approximately 60 - 80% of world population experienced chronic back pain (LBP) within their lifetime which leads to functional disability and activity

Manjula Suri., Rekha Sharma., & Namita Saini. (2017). ISSN: 2455-8958

International Journal of Adapted Physical Education & Yoga, Vol. 2, No. 9 www.ijapey.info 19

limitations. (Manchikanti, 2000). Such chronic pain disorders are most commonly treated with potent drugs such as non-steroidal anti-inflammatory drugs, opioid analgesics, steroids, trycyclic antidepressants, and several others but with varied results. The Mayo Clinic has also studied, the chronic pain cycle and reported that ineffective treatment for pain can lead to a downward spiral of frustration, decreased functioning, insomnia, stress, isolation, and worsening pain (Mayo Clinic,2010) . However, more recent reports from Tibet (Hoy et al., 2003), Turkey (Cakmak et al., 2004; Gilgil et al., 2005), China (Barrero et al., 2006) and Africa (Louw et al., 2007) suggest that prevalence rates are not that dissimilar from Western countries with one year prevalence in adults in these studies between 36% and 64%. A significant population of India also suffers from chronic pain, and their QoL is affected leading to disability. Epidemiological study by Dureja et al. (2014) in India identified point prevalence of chronic pain and concluded that respondents with chronic moderate and chronic severe pain were 37% and 63%, respectively (Dureja et al, 2014).

Physical exercise and Yoga are an important component in the treatment and rehabilitation of many patients with chronic pain, as well as vital to the overall health and well-being of any individual. Recent studies have shown that multimodal exercise programs are effective at significantly reducing pain in osteoarthritis, fibromyalgia, CLBP and rheumatoid arthritis. (Hagen KB,2012; Stavropoulos-Kalinoglou

A,2013; Gonzalez GJ,2015). Yoga may also offer potential reductions in pain and disability caused by knee OA (Kolasinski SL, 2005). Exercise stimulates the release of endogenous opioid like endorphins (Harber VJ, 1984). Endorphins has been involved in the process of pain modulation and play a significant role in inhibiting pain perception (Stratton SA,1982).Therefore this review aims at describing neuro-physiological mechanism and its implications on correlation between Pain, Yoga and endorphins. Effect of yoga and exercise on pain

Acute exercise reduces the sensitivity to painful stimuli in healthy individuals, indicative of a hypoalgesic response. This phenomenon has been termed as exercise-induced analgesia or exercise-induced hypoalgesia (EIH) (Koltyn K.2000; 2002). Further comprehensive understanding is needed to exploit this analgesia/hypoalgesia in limiting or reversing pain conditions and to develop exercise and/or yoga module for pain management.

Despite the wide range of pharmacological and surgical treatment options currently available for patients with chronic low back pain, a substantial proportion of patients fail to achieve adequate pain relief and continue to experience significant pain, pain related distress and disability(Balague F,2012 Haldeman S,2008;). Indeed, approximately 40% of patients with chronic back pain report using complementary and alternative modalities such as massage, reflexology and acupuncture.( Foltz V, 2005 ) Yoga has



also generated a great deal of interest and attention among the general public and the scientific community as an alternative treatment for a variety of chronic health conditions, including chronic pain ( Holtzman, S,2013 ).

Yoga as an exercise modality has positive effects on physical aspect of pain. Yogic practitioner may achieve a union of the mind, body and spirit, which means yoga may have effect on mental health and psychological aspect of pain. This mind - body therapy involves physical postures, breathing exercises and meditation to improve overall well-being. Yoga is one of the strategies that can be used to meet the nationally established guidelines for muscle strengthening, flexibility, and balance activities in older adults which indirectly modulate pain perception. One of the most popular holistic approaches to health globally has been classified by the National Institutes of Health as a "form of Complementary and Alternative Medicine"(CAM) which includes Yoga (Williams, K., 2003). The choice of yoga, as a main form of therapy for individuals with chronic pain, is because of yoga's ability to minimize, heal and correct the physical mechanical causes of pain and functional disability (Williams, K., 2003). A growing body of research supports yoga’s effectiveness for reducing cLBP intensity and improving back-related function (Bussing A, 2011; Posadzki P, 2011; Cramer H,2013; Nambi GS, 2014 ). Yoga has also been shown to improve psychosocial outcomes, suggesting it may be particularly advantageous as a holistic treatment for complex pain conditions such as cLBP

(Bussing A2012). Other qualitative studies have evaluated yoga as a treatment for other forms of chronic pain. For example, Tul et al. interviewed chronic pain patients in Canada(Tul Y, 2010) and Cramer et al. analyzed participant interviews after a yoga program for chronic neck pain in Germany(Cramer H,2011). Both studies reported body awareness, pain acceptance, and increased control over health as major themes discussed by participants. Furthermore, participants with chronic neck pain perceived improved coping mechanisms and reflected on the social benefits of yoga (Cramer H, 2011).

Yoga has been used to alleviate musculoskeletal pain and has been associated with significant improvement in range of motion and function, decreased tenderness (Garfinkel MS et al ,1998; Sherman KJ et al,2005), lower levels of depressive symptoms [Krishnamurthy MN et al,2007) and decreased pain during activity in patients with musculoskeletal disorders (Garfinkel MS et al , Sherman KJ et al,2005).Now-a-days, a biopsychosocial approach is the gold standard for treating chronic pain (Gatchel RJ,2007). Researchers suggest that yoga can reduce pain catastrophizing, increase pain acceptance and improve overall emotional functioning among individuals with chronic pain (Carson JW, 2010; Curtis K ,2011; John PJ ,2007; Tilbrook HE,2011) To conclude randomized clinical trials suggests yoga has the potential for alleviating pain. Scientific community should be aware that yoga could be used as an alternative treatment for physiological, social, and psychological



aspects of chronic pain. Though, research in this area is in its early stages and further effort in this direction is the need of hour. Effect of yoga and exercise on psychological aspect of pain and stress

Stress itself is subjective, with different emotions contributing to its manifestations, often with conflicting effects on pain perception as evidenced by the analgesic and hyperalgesic responses. The stress system does not function alone; the genetic and psychological makeup of a person, experience and environmental factors all contribute to the response to pain (AhmadA.H, 2015) In preclinical studies, voluntary exercise alters the releases of corticotrophin-releasing factor (CRF) from the hypothalamus and ACTH from the anterior pituitary (Salmon, 2001; Droste et al., 2003). These findings suggest that exercise induced changes in the HPA axis modulates stress reactivity and anxiety in humans. Evidence is now emerging that changes in pain and stress may be mechanisms by which exercise improves subjective well-being (SWB) among people with spinal cord injury (SCI). (Ginis, K. A. M., 2003) . Nowadays Pain Management Programmes (PMPs)in cancer survivors consist of imparting information on the pain physiology, the psychological aspects of pain and exercise (Rev Pain. 2010) thereby emphasizing the effect of exercise on psychological aspect of pain and stress related to cancer.

In a study conducted by Petruzzello et al. (1991), the relationship between exercise and anxiety was extensively examined. The results substantiate the claim that exercise is

associated with reductions in anxiety, but only for aerobic forms of exercise. Exercise training programmes also need to exceed 10 weeks before significant changes in trait anxiety occur. For psycho-physiological correlates, cardiovascular measures of anxiety (e.g. blood pressure, heart rate) yielded significantly smaller effects than did other measures (e.g. EMG, EEG). Exercise of at least 21 minutes seems necessary to achieve reductions in state and trait anxiety, but there were variables confounding this relationship. Exercise is associated with reductions in anxiety and several mechanisms may be operating simultaneously (Petruzzello, S.J., Landers, D.M., Hatfield, B.D. et al. Sports Med (1991). Results of cross-sectional and longitudinal studies are more consistent in indicating that aerobic exercise training has antidepressant and anxiolytic effects and protects against harmful consequences of stress. Clinically, exercise training continues to offer clinical psychologists a vehicle for nonspecific therapeutic social and psychological processes which may be helpful in reducing stress. (Salmon P; 2001). Stress and pain are often closely linked. Each one can have an impact on the other, creating a vicious cycle that sets the stage for chronic pain and chronic stress. So, part of getting pain relief is learning how to better manage stress.

Yoga has components of exercise; flexibility; and wellness education, particularly with regard to coping skills. The women in a 8-week yoga training module showed clinically significant improvements in well-being, pain,



fatigue, sleep, tenderness, depression, memory, anxiety, and balance compared with controls. (Carson JW,2010).In addition, the yoga group reported greater use of adaptive coping strategies, such as relaxation, and decreased use of maladaptive coping strategies, such as pain catastrophizing, disengagement, and acceptance. Results from another study showed patients experienced significantly lower levels of pain and fatigue, and higher levels of invigoration, acceptance and relaxation following participation in a yoga intervention ( Carson JW,2007). Similarly Freitas -Swerts et al assessed the effect of a compensatory workplace exercise program on workers with the purpose of reducing work-related stress and musculoskeletal pain. Workplace Exercise promoted a significant pain reduction in the spine, but surprisingly did not result in a significant reduction in the levels of work-related stress. It was suggested that future studies should use an RCT design with a larger sample size, (Freitas -Swerts, 2014). Therefore future studies are needed to specifically explore role of exercise on psychological aspect of pain and stress. Effect of exercise on endorphins

Ossipov et al reported that brain imaging studies revealed a “pain matrix,” consisting of cortical and subcortical regions that respond to noxious inputs and can positively or negatively modulate pain through activation of descending pain modulatory systems.. (OssipovM.H, 2012). Endogenous opioid peptides have been involved in the process of pain modulation and to play a significant role

in inhibiting pain perception. This mechanism is thought to be influenced by supraspinal centers, especially the raphe magnus nucleus of the brainstem reticular formation.( Stratton SA.1982) Endorphins are endogenous opioids (neurotransmitters that produce cellular and behavioral effects similar to morphine)which regulate and essentially inhibit pain perception. These endorphins are neuro-modulators that act by modifying the way in which nerve cells respond to neuro-transmitters (Stoppler, M C, 2014).Endorphins also play a distinct role in emotional aspects of pain. By modulating level of arousal, endorphins allow organisms to adapt behavior in a given situation. Fear, stress, anxiety and even rage can also trigger this response. (https://www .macalester.edu/ academics/psychology /whathap/ ubnrp/ pain/regulatepain.htm)

Many studies have examined the relationship between exercise and endorphin release, studying the role of these peptides in exercise-induced euphoria as well as the reduction of pain (Farrell, 1985; Goldfarb et al., 1987; Goldfarb et al., 1998 Langenfeld et al., 1987, Pierce et al., 1993). Endorphins are often implicated in the euphoria known as “runner’s high,” the relaxed psychological state sometimes experienced during or after vigorous exercise such as running (Pierce et al., 1993). Inconsistent evidence for a significant rise in endorphin release, however, makes it very difficult to simply deduce that endorphins released due to exercise are the cause of euphoric feelings. In addition, Dishman (1985) maintains that the so-called “runner’s



high” has not been systematically nor thoroughly documented. Clinical research studies measuring endorphin levels before, during, and after exercise are conflicting: some show significant increases where as others do not.

Exercise stimulates the release of endorphins within approximately 30 minutes from the start of activity. These endorphins tend to minimize the discomfort of exercise and are even associated with a feeling of euphoria. There is some uncertainty around the cause of this euphoria since it's not clear if endorphins are directly responsible for it, or if they just block pain and allow the pleasure associated with neurotransmitters such as serotonin and dopamine to be more apparent. (Gheorghiu A.; 2010) If the latter is true, this would indicate a connection to BDNF via the serotonin-BDNF loop. In this case, BDNF is again the underlying chemical providing the benefits of exercise, and endorphins act in a supporting role by blocking pain and reducing the cost associated with acquiring the benefits of exercise. The release of endorphins has an addictive effect, and more exercise is needed to achieve the same level of euphoria over time. (Russo-Neustadt AA,2000) (http://sulcus.berkeley.edu/ mcb/ 165_001 /papers /manuscripts /_512.html)

Endorphins are endogenous opioids released from the pituitary gland that are believed to mediate analgesia, induce euphoria, and play a role in the reward system in the brain. It has been suggested that endorphins are responsible for creating the relaxed psychological state known as “runner’s high.” Studies

examining the relationship between vigorous exercise and blood plasma endorphin levels have produced conflicting results. Some indicate a significant increase of endorphins during or after exercise while others do not. Inconsistent methods and experimental techniques have made it difficult to determine a relationship between exercise and endorphin elevations.( Sharma A , 2014 ) Recent findings show that exercise also increases serum concentrations of endocannabinoids. Compared with the opioid analgesics, the analgesia produced by the endocannabinoid system is more consistent with exercise induced analgesia. Activation of the Endocannabinoids and endocannabinoid system also produces sedation, anxiolysis, a sense of wellbeing, reduced attentional capacity, impaired working memory ability, and difficulty in time estimation. This behavioural profile is similar to the psychological experiences reported by long distance runners.( Dietrich A,2004)

Various researchers suggest that neuromodulation of exercise is multi-factorial and involves endorphins, cortisol, endocannabinoids , brain-derived neurotrophic factor (BDNF), dopamine, and serotonin etc.( Heijnen S,2015; Farrell, 1985). Yadav et al reported that yoga-based lifestyle intervention reduced the markers of stress and inflammation (β-endorphins, cortisol , IL-6, TNF-α) as early as 10 days in patients with chronic diseases( Yadav RK,2012). To conclude, endorphins are often implicated in the neuro-modulation of exercise but are one of the many



modalities used by the pain matrix of the body. Effect of endorphin on physical aspects of pain

Endorphin causes modulation of pain pathways leading to hypoalgesia .Chronic pain involves peripheral and central sensitization, as well as the alteration of the pain modulator pathways. Imbalance between the descending facilitatory systems and the descending inhibitory systems is believed to be involved in chronic pain in pathological conditions. Therefore, a pharmacological treatment that could restore the balance between these two pathways by diminishing the descending facilitatory pain pathways and enhancing the descending inhibitory pain pathways would be a valuable therapeutic option for patients with chronic pain. (Kwon, M., Altin, M., Duenas, H. and Alev, L., 2014) Opioidergic pathways are involved in pain modulation. Opioids like beta-endorphins are proteins that are primarily synthesized by the pituitary gland in response to physiologic stressors such as pain. They function through various mechanisms in both the central and peripheral nervous system to relieve pain when bound to their mu-opioid receptors. (Sprouse-Blum et.al) The involvement of opioids specifically beta-endorphin has been reported in initial analgesia as it is attenuated by pre-naloxone treatment (Blass et al, 1987) while its deficiency has been hypothesized in the late hyperalgesia (Mukherjee et al, 2001). Endorphin exerts their analgesic effects by binding to and activating receptors that are part of an endogenous opioid system.

This system normally modulates sensory input caused by painful stimuli and its response is activated by endogenous peptide neurotransmitters. The endogenous opioid system includes opioid peptides that are ligands for numerous types of opioid receptors. Some of these naturally occurring opioids produce morphine like effects. There are three distinct families of endogenous opioid peptides: the endorphins, enkephalins, and dynorphins, In the CNS, there are 3 primary opioid receptor types that mediate analgesia and are designated as μ, κ, and δ. Preferentially, enkephalins interact with the δ receptor, dynorphins interact with the κ receptor, and endorphins bind to both μ and δ receptors with comparable affinity.( Koneru A,2009 ) These peptides have diverse physiological functions as neurotransmitters, neuro-modulators or neuro-hormones. High densities of opioid receptors are located in all areas of the CNS known to be involved in integrating information about pain—the brainstem, the medial thalamus, the spinal cord, the hypothalamus, and the limbic system. ( Koneru A,2009 ) Recent research provides evidence that opioids may also cause hyperalgesia (Richebe et al, 2009). Patients receiving opioid therapy for relieving pain, become paradoxically sensitive to pain. It has been shown that morphine administered acutely to rats evoked a consistent, biphasic, and dose-dependent response. Initial antinociceptive effects were followed by mechanical hyperalgesia. these hyperalgiesic effects may be related to opioids dose (Angst and Clark, 2006). Several possible mechanisms associated



with opioid-induced hyperalgesia have been proposed e.g. sensitization of peripheral nerve endings, enhanced descending facilitation of nociceptive signal transmission, enhanced production, release and decreased uptake of neurotransmitters and sensitization of second order neurons to nociceptive neurotransmitters (Angst and Clark, 2006). Opioids have been shown to potentiate the actions of glutamate at NMDA receptors by a PKC-dependent pathway, probably involving increased open probability, reduction of the Mg2+ block and recruitment of NMDA receptors to the membrane (Chen and Huang, 1991; Chen and Huang, 1992; Martin et al., 1997; Lan et al., 2001). This may occur at the level of the primary afferent terminal, leading to increased transmitter release (Ossipov et al., 2003). These and other excitatory neurotransmitters are believed to cause "central sensitization" that result in hypersensitivity of the spinal cord to nociceptive inputs from the periphery. Thus pain signals being transmitted into the spinal cord become amplified as a result of the action of these neurotransmitters.

To conclude endogenous opioid like endorphin has been involved in the process of pain modulation and play a significant role in inhibiting pain perception. This mechanism is thought to be modulated at supra-spinal and spinal level. Effect of endorphin on psychological aspects of pain

Several lines of evidence suggest that the endogenous opioid peptides

endorphins may play a role in the defensive response of the organism to stressful conditions like pain. ( Amir S, 1980 ) Scientific evidence suggests a link between endorphins and anterior pituitary polypeptide hormone adreno-corticotropin (ACTH). ( Amir S, 1980 ) Various researchers have shown that endorphins may function as tropic hormones in peripheral target organs such as the adrenal medulla and the pancreas. As such they may be part of the physiological mechanisms that mediate adrenaline and glucagon release in response to pain stimuli. Endorphins are also suggested to play a role in the control of the pituitary gland during stress. In such capacity they may act as hormone-releasing or inhibiting factors. Finally, endorphins appear to play a role in the behavioural concomitants of stress. ( Amir S, 1980 ) In such capacity endorphins are suggested to function as modulators of neural systems that mediate the elaboration and expression of the reactive/affective components of pain. There may be an interaction between endorphins and ACTH in the global response to stressful conditions like pain ( Amir S, 1980 ).

A role for β-endorphin (β-END) in the patho-physiology of major depressive disorder (MDD) is suggested by both animal research and studies examining clinical populations. The major etiological theories of depression include brain regions and neural systems that interact with opioid systems and β-END. (Hegadoren KM, 2009) Recent preclinical data have demonstrated multiple roles for β-END in the regulation of complex homeostatic and behavioral



processes that are affected during a depressive episode. Additionally, β-END inputs to regulatory pathways involving feeding behaviors, motivation, and specific types of motor activity have important implications in defining the biological foundations for specific depressive symptoms. Early research linking β-END to MDD did so in the context of the hypothalamic–pituitary–adrenal (HPA) axis activity, where it was suggested that HPA axis deregulation may account for depressive symptoms in some individuals. (Hegadoren KM,2009) .To conclude , endorphins interact with the opiate receptors in the brain to modulate psychological aspects of pain perception and act similarly to opioid drugs such as morphine and codeine.

To summarize, this review provides information regarding the effects of yoga and exercise as it has been studied in various populations concerning a multitude of different ailments and conditions to prevent, reduce or alleviate structural, physiological, emotional and spiritual pain. Exercise induced elevated serum beta-endorphin concentrations have been linked to several psychological and physiological changes including altered pain perception, exercise-induced euphoria', mood state changes and the stress responses of numerous hormones (ACTH, cortisol , catecholamines, and growth hormone). Therefore evidence suggests that a neuro-physiological correlation exists between yoga, pain and endorphins which compel researchers to further explore yoga and exercise as a tool in limiting or reversing pain.

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Site this article: Manjula Suri., Rekha Sharma., & Namita Saini. (2017). Neuro-Physiological Correlation between Yoga, Pain and Endorphins. International Journal of Adapted Physical Education & Yoga, Vol. 2, No. 9, pp. 18 to 32.

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