The Effect of Pranayama Breathıng Exercıses on Paın, Anxıety,aAnd Sleep Qualıty in Indıvıduals wıth Fıbromyalgıa

Fibromyalgia syndrome (FMS) is a rheumatological syndrome characterized by symptoms such as increased pain sensitivity, sleep disturbances, fatigue, musculoskeletal pain, stiffness, tenderness, cognitive dysfunction, and mood disorders due to dysregulation of neurophysiological functions (Singh \& Rao, 2023; Verma et al., 2020). The incidence of FMS in the general population is reported to be 2-8%, predominantly affecting women (between 61% and 90%), with a male/female ratio of 2.3 (Galvez-Sánchez et al., 2019; Jones et al., 2015; Schmidt-Wilcke \& Diers, 2017). Although there are insufficient prevalence studies in Turkey, a study conducted in the Trabzon region found the prevalence of FMS to be 3.6% in women aged 20-64 and 0.9% in women aged 20-29 (Topbas et al., 2005).

The American College of Rheumatology (ACR) first defined the FM Diagnostic Criteria in 1990, and these criteria were revised in 2010, 2011, and 2016 (Plesner \& Vaegter, 2018). While there is no definitive treatment method, pharmacological and non-pharmacological treatment methods are applied. Non-pharmacological treatments include acupuncture, biofeedback, capsaicin, chiropractic, cognitive behavioral therapy, exercise, hydrotherapy, spa therapy, massage, meditative movement (Qigong, yoga, and Tai Chi), mindfulness/mind-body therapy, multicomponent therapy, and S-adenyl methionine. In addition, methods such as physical therapy, stretching, strengthening, aerobic exercise, and endurance training are also used (Chitra et al., 2017; Prabhakar et al., 2019).

Fibromyalgia is a common disease associated with numerous comorbidities and is often difficult to diagnose, which can have a devastating impact on quality of life, impair patients' abilities, lead to social and psychological problems for patients, and create a significant socioeconomic burden on healthcare systems (Atahan et al., 2023; Kang et al., 2022).

Fibromyalgia presents with chronic pain without any apparent peripheral tissue damage. This pain results from threatening tissue damage that activates peripheral nociceptors without real or definitive evidence (Ruschak et al., 2023). The pain is characterized by morning stiffness and increasing intensity throughout the day, is anatomically widespread, and is accompanied by hyperexcitability with increased response of the central nervous system to various stimuli (pressure, temperature, light, and medication, etc.). It is characterized by hyperalgesia, allodynia, and features reflected in multiple spinal segments (Araya-Quintanilla et al., 2020).

Patients with FM syndrome may experience emotionally impactful situations in the form of high levels of stress, anger, and catastrophic scenario-based pain, and these situations can worsen existing symptoms (Galvez-Sánchez et al., 2019). Studies have reported that a significant proportion of FM patients experience depression, panic disorder, and anxiety disorder (Basar et al., 2023; Siracusa et al., 2021). It is thought that the cognitive and psychological processes experienced by patients are related to pain (Cetingok et al., 2022). One study reported that FS patients were more likely to experience depression (20%-80%) and anxiety (13%-63.8%) (Henao-Pérez et al., 2022). A meta-analysis study suggested that the lifetime prevalence of depression in fibromyalgia is approximately 65% (Galvez-Sánchez et al., 2020).

Sleep problems are one of the factors triggered by pain and impairing quality of life in individuals diagnosed with fibromyalgia (FS) (Choy, 2015; Keskindag \& Karaaziz, 2017). One study reported that poor sleep quality was perceived as a serious symptom in patients diagnosed with FS, negatively impacting multiple health-related symptoms such as pain, fatigue, cognitive complaints, poor functionality, and low work performance (Climent-Sanz et al., 2020). Another study found that compared to healthy individuals, individuals diagnosed with FS had significantly higher numbers of awakenings, awakening index, and sleep apnea syndrome, and poor sleep quality (Çetin et al., 2020). Pranayama involves the control of breath, a dynamic bridge between body and mind. In Sanskrit, "Pranayama" is a combination of the words "Prana" and "ayama." Prana means breath, vitality, life, and energy, while ayama means restriction, control, or regulation. Pranayama can be described as 'the science of breath, breath control, willful breathing' (İlter \& Ovayolu, 2021). The breathing cycle in pranayama consists of three stages: Puraka (inspiration), Rechaka (expiration), and Kumbhaka (inhalation and holding the breath after inhalation) (İyengar, 2022).

Recent studies have shown that pranayama, by providing body and mind control, contributes to the improvement of many symptoms of fibromyalgia (Singh \& Rao, 2023). Pranayama has been reported to significantly improve the management of many symptoms of fibromyalgia, including pain intensity, stiffness, anxiety, stress, low muscle strength, fatigue, sleep problems, as well as flexibility and cognition, and to improve quality of life (Chitra et al., 2017; Firestone et al., 2014; Hennard, 2011; Lazaridou et al., 2019; Verma et al., 2020). This research was designed as a pre-test-post-test, randomized controlled, experimental study to determine the effects of pranayama breathing exercises on pain, anxiety, sleep quality, and overall health status in individuals with fibromyalgia.

Research Objectives and Hypotheses This research was planned to determine the effects of pranayama breathing exercises applied to individuals with fibromyalgia on pain, anxiety, sleep quality, and health status.

H1: Pranayama breathing exercises applied to individuals with fibromyalgia have an effect on pain. H2: Pranayama breathing exercises applied to individuals with fibromyalgia have an effect on anxiety.