Multiple Sclerosis (MS) is an autoimmune, demyelinating chronic disease in the central nervous system (CNS) [1]. MS entails perivenular inflammatory lesions, leading to demyelinating plaque. MS symptomatology results from a combination of location and size of lesions, and MS is characterized by progressive neurodegeneration which over time often leads to an increasing symptom burden [1]. People with MS (PwMS) experience a wide range of symptoms with varying severity [2]. Hence, many PwMS receive treatments and engage in activities to maintain functions and alleviate symptoms such as fatigue, poor sleep quality, walking disabilities, spasticity, and cognitive challenges [2].

Although different disease-modifying treatment options exist, they do not control the neurodegenerative processes and do not cure the disease [3] while often also resulting in adverse events [4]. Physical activity is increasingly recommended to PwMS as it is a beneficial rehabilitating approach addressing the multifaceted aspects of the disease [3]. Many PwMS also turn to complementary or integrative health (CIH) practices to supplement conventional treatment and rehabilitation, not least in the hope that such therapies can strengthen the body’s ability to cope with MS [5]. Yoga is one of the more popular CIH practices among PwMS [6].

Yoga is an ancient Indian mind-body approach, and consists of eight principles including specific postures, breathing technics and meditation with the aim of improving the individual’s health and wellbeing. In the western world, the postures and breathing practices of Hatha yoga and meditation are most common [7]. Yoga seems to be a safe activity combining flexibility, strength, endurance mobility and balance and has been investigated as a compliment method to routine practice in many chronic diseases [8]. Several reviews and meta-analyses have suggested that yoga may have a positive impact on PwMS [6], [9], [10], [11]. Positive effects from yoga include, but are not limited to, improvement in fatigue, mental status, muscle strength and function, sensory disturbances, balance, gait, bladder dysfunction, self-efficacy and quality of life (QoL) [6], [8], [9], [10], [11], [12].

Yoga has become increasingly popular in Western countries and is practiced for, among other reasons, its promotion of the mind-body connection [14]. Studies on the effects of yoga suggest that yoga may affect the brain, brain networks and the nervous system in such ways that yoga can improve sensory awareness and interoceptive awareness [14]. Interoceptive awareness may be defined as the information that arises within the body involving emotions, conscious awareness and behavior [15].

The connection between yoga and body awareness has been investigated in a number of studies. A narrative review, focusing primarily on studies comparing trained meditators to healthy matched non-meditators, concludes that yoga seems to increase sensory awareness and interoception [14]. Among primary care patients with low back pain Mehling et al. found a positive association between yoga and body awareness [15], [16]. Patients having experience with meditation and yoga scored significantly higher on a body awareness scale, compared to mind-body inexperienced patients [16]. Cramer et al. found similar associations in a study among women with abdominal obesity [17] and significant improvements in interoceptive bodily awareness were detected among veterans with PTSD performing yoga [18]. Crystal et al. suggest increase of interoceptive awareness to be one of the main aspects explaining the effect of yoga as stress-reducing [19]. Among healthcare providers a meditation program, grounded in the system of yoga, significantly improved the interoceptive awareness [20].

Qualitative studies indicate that yoga may assist in enhancing body awareness – e.g. among patients with paroxysmal atrial fibrillation [21], systemic lupus erythematosus [22], obstructive pulmonary diseases [23], PTSD [24], cancer [25], [26], [27], Chronic neck pain [28] and back pain [29].

Within the MS field, the connection between yoga and body awareness has only been investigated by Franklin in a small qualitative study (n=2), where they found that PwMS who practice yoga experienced an ongoing development of body awareness [30].

The concept of interoception in relation to MS has been described in several publications; alterations in the sensing of bodily signals is prevalent among PwMS, indicating distinctively impaired interoceptive processes within this patient group [31], [32], [33], [34]. Alterations related to sensing of bodily signals also characterizes related disorders such as Parkinsons disease [35], [36], [37], [38], [39], Tourette Syndrom [40] and Alzheimers [41].

As the sensing of bodily signals is important as a tool to continuously assess possible effects and adverse effects of treatments, impaired interoceptive processes may constitute a barrier to finding optimal treatment strategies – in dialogue with HCPs as well as self-initiated in daily life - among PwMS. Interventions that may strengthen the interoceptive processes may therefore be highly relevant for PwMS. Within the field of Parkinson’s Disease, Nicholas et al. [39] underline the relevance of further research regarding the efficacy of mind-body techniques, specifically yoga, to improve body awareness.

Limited qualitative data points to a possible association between yoga and improved body awareness. However, possible benefits from yoga regarding body awareness among PwMS has not been sufficiently investigated and not using a validated instrument for assessing the interoceptive awareness. Thus, this pilot study aims to investigate if a 12-week yoga course can improve interoceptive awareness in PwMS as measured with the Multidimensional Assessment of Interoceptive Awareness (MAIA), a validated self-report instrument.