Combined Neuromodulation and Yoga Intervention for Chronic Pain.

Abstract

Chronic pain is a multidimensional syndrome that frequently co-occurs with psychiatric disorders. Long-term management remains inadequate, and clinical guidelines increasingly recommend nonpharmacologic, multimodal approaches. This narrative review provides a rationale for combining intermittent theta burst stimulation (iTBS) with yoga to offer a synergistic treatment strategy for chronic pain. Literature was identified through targeted PubMed searches supplemented by manual review of reference lists. iTBS is a time-efficient transcranial magnetic stimulation protocol that increases cortical excitability in the primary motor cortex and engages descending pain-inhibitory pathways while inducing a transient window of heightened neuroplasticity. Yoga engages complementary bottom-up mechanisms-autonomic regulation, sensorimotor integration, interoceptive awareness, and cognitive-affective reframing-through postures, breath regulation, and meditation. The authors review chronic pain as a multifactorial construct, synthesize evidence for each treatment modality, and present the rationale for delivering yoga within the post-iTBS plasticity window to prime pain-relevant circuits. They then highlight the first pilot trial of this combined treatment among veterans with co-occurring mild traumatic brain injury and chronic musculoskeletal pain, in which six weekly sessions of iTBS followed by manualized group yoga were feasible, safe, and associated with significant pain improvement. The authors also shed light on limitations of the pilot and future directions for this work.