Understanding Pain

by Nina

The Black Finger Bandage by Berthe Morisot

If you stub your toe, cut your finger while chopping vegetables, burn your hand while taking something out of the oven, or twist your ankle while walking down the street, you experience a physically and emotionally unpleasant sensation. That’s because when something harmful or irritating occurs, your body reacts by creating an urge for you to stop it. And that urge is what we call pain. 

So as uncomfortable as it is, pain is actually beneficial. As part if your body’s protective mechanisms, its function is to: 

1. Motivate you to pull out from a damaging situation and prevent further damage to the tissue.
2. Allow the damaged tissue to rest and begin the healing process.
3. Avoid similar encounters.

But while pain is generally a good thing—people who suffer from congenital insensitivity to the pain response are easily injured and most die at an early age—pain is also a major symptom in several medical conditions and can interfere with your quality of life and general functioning. 

Besides being influenced by the type and intensity of the stimulus that causes your pain, the level of pain you feel is also influenced by how your brain perceives the experience. Several factors can influence your pain perception, including: 

Age. As brain areas degenerate with age so does brain circuitry, so older people have lower pain tolerance and sometimes face problems dealing with pain.

Memory. Our past experience dealing with pain can influence our neural responses to it, causing us to be more sensitive to pain.

This is exactly why yoga pain management techniques can be so effective. Using yoga, you can change your relationship to pain, influencing your pain perception, improving pain tolerance, and changing habitual ways of reacting to pain. 

Acute vs. Chronic Pain

Pain that is the result of injury, surgery, or illness and that lasts for short period of time is acute pain. Acute pain starts when there is a real threat to your body and leads to a reasonable protective response. It then recedes when the stimulus is removed or the damaged tissue has healed. Common examples of acute pain include sprained ankle, headache, paper cut, and stomach ache.

In a perfect body, pain occurs only when needed, and turns off when the initial stimulus is withdrawn and the tissue has healed. However, there are certain medical conditions, such as arthritis, chronic fatigue syndrome, and low back issues, in which pain is a constant feature and persists for at least three months. This is chronic pain. 

Typical causes of chronic pain include:

• Chronic neck and back conditions, such as a herniated disc or vertebra slippage. 
• Chronic conditions that have pain as a symptom, such as many forms of arthritis, chronic fatigue syndrome, fibromyalgia and related conditions, and Lyme’s disease.
• Cancer and/or post-cancer treatment pain from chemo and radiation therapy. 
• Terminal illnesses that cause immobility, such as severe emphysema, congestive heart failure, and Parkinson’s disease. 

In addition, there are chronic conditions that cause intermittent pain, such as migraine headaches, irritable bowel syndrome, and multiple sclerosis. Because this pain occurs regularly, it is essentially is a form of chronic pain and you can treat it as such. 

Chronic pain differs from acute pain in three ways: 

1. Your body can become more sensitive to the threat of possible pain symptoms leading to feelings of fear and anxiety.
2. Your brain can become more likely to interpret situations as threatening, and sensations as painful (eliciting a pain response).
3. With the experience of repeated reactions to pain, your ability to differentiate between the many aspects of the pain response (sensations, suffering, and stress) maybe become blurred.

So chronic pain is challenging because it goes beyond the physical presence of pain, and affects your mind-body connection. And the ongoing presence of chronic pain can affect your daily functioning due to changes in: 

• Breathing. Your breath can become more shallow and shaky, making exercise and even normal physical activities more challenging. 
• Muscle Tension. Because your body is in a constant state of “alert,” muscle tension can increase. This will limit your range of motion, which in turn will can worsen stiffness. 
• Movement Patterns. As you try to protect the area of pain, your movement patterns can change dramatically. Some people stop all inessential movement, obviously limiting what they can do in the short term and causing both stiffness and weakness in the long term. Other people grit and bear the pain, only stopping when the pain is so intense that they can’t continue, but they may be creating unhealthy movement patterns that result in uneven physical wear and tear. 
• Body Image. How you view yourself can change from physically capable to weak and incapable, which makes you less willing to take on physical challenges or even to keep yourself exercising regularly. 
• Thought Patterns. Chronic pain can cause you to become less optimistic about your pain and your life in general.
• Emotions. Your emotions may become generally more volatile, leading you to become angry, frustrated, tearful, and/or overwhelmed. 

Although chronic pain can cause all these serious issues, they are all problems that you can address with yoga. And as you consciously address your chronic pain, you can reverse the physical, mental, and emotional damage that it has caused. 

Whew! Now that you’ve learned about the difference between acute and chronic pain, and about the side effects caused by periods of chronic pain, you’ll be better able to use the tools we describe in our posts Techniques for Managing Pain with Yoga and Changing Your Relationship with Pain.

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Techniques for Managing Pain with Yoga

by Baxter and Nina

Beams of Light by Melina Meza

This post recommends techniques for helping you manage acute and/or chronic pain. Although the causes of acute and chronic pain differ, depending on your condition on a given day, you can use similar techniques to reduce your pain.

Start by considering your pain levels both today and, if you are suffering from chronic pain, over time. By reviewing your pain levels through the course of a day, week, or month, you will begin to see patterns. To do this, you might find it useful to assign a rating to your pain and keep a journal of pain levels that you can periodically review. To get a better picture of how pain is affecting your entire being, you could also note your stress levels and your predominate mood. You can then use all this information to guide you to practice differently on different days. 

For chronic pain, on high pain days, start or stay with gentle poses, relaxing breath practices, and meditation. If your pain is very severe, focus on relaxation and breath practices, and maybe imagine the poses. And on low pain days, try carefully increasing the intensity of your practice.

For acute pain, if your pain is tolerable, this is a good time to practice asanas, which will increase oxygen flow to brain and muscle tissues, and release held tension from the muscles. But if your pain is severe, you should focus solely on relaxation and breath practices. 

For everyone, practicing stress management on a regular basis is very beneficial, as reducing stress levels can lower pain levels. We will compare and contrast some of the techniques below. 

How Often to Practice. For chronic pain, it is important to have rest days, where you are practice only restorative or extremely gentle poses, or skip the asana portion of your practice entirely. So we recommend that you practice more actively 3 to 4 times a week, and at least do breath practices and meditation on your resting days, if possible. 

For acute pain, follow a similar schedule. Because acute pain will ideally resolve more quickly, as your pain subsides and your functioning returns to normal, you can gradually increase your practice days to 5-6 days a week. 

Balanced Practice. We recommend that your active practice be a well-rounded one, including yoga poses from all the basic groups (as long as they are appropriate for you unique pain situation), in both dynamic and static variations. In addition to your poses, try to include breath work, resting poses, and mediation. Because down-regulating your sympathetic nervous system is so beneficial for pain management, we recommend that at least 25 percent of your practice be devoted to breath work, restorative poses and/or meditation.

For both types of pain, always begin your asana practice with gentle poses. Start with simple movements that improve breathing, such as Cat-Cow pose, seated or standing side-bends, and arm range-of-motion actions. Then, if you are feeling up to it, add in more active asana, dynamic or static, such as Arms Overhead pose, Warrior 1 and 2 poses, Downward-Facing Dog pose, and Locust pose, and any other basic poses that work well for your particular condition. Finish up with one or more relaxing restorative poses, such as Easy Inverted pose, Legs Up the Wall pose, Supported Child’s pose, or Supported Relaxation pose. 

Dynamic Poses. Use dynamic poses either to create a balanced practice or to address a particular area where you have pain. When you first try a dynamic pose that may stimulate the area of your pain, move slowly and mindfully in and out of the pose. If this movement stimulates pain, modify it so you come up to the edge of pain without fully triggering your pain response. When you find a way to practice that feels safe, you can move at a pace that feels good to you, be it slower or slightly faster.

Static Poses. Use static poses to stretch areas that are stiff and tight, and, if you have chronic pain, that may have developed limited mobility as a result of pain. Focus on the particular flexibility poses that will gently stretch your tight areas. For example, if you have low back pain and are tight in the backs of your legs, Reclined Leg Stretch could be a good choice. 

Also use static poses to strengthen muscles that have been become weak due to lack of use. For example, chronic low back pain often results in weakness for the lower back muscles. Focus on strength building poses that will gradually build strength in your weak areas, For example, for weak lower back muscles, choose poses that builds back strength, such as Locust pose, to regain lost strength.

As you work with both flexibility and strength building, practice mindfully and note if these poses also begin to reduce pain levels. If they do reduce pain levels, continue practicing the poses and gradually add in other similar poses. However, if they don’t reduce your pain levels, try reducing the time in each pose or consult with an experienced teacher to help you re-organize your practice choices.

For acute pain with no history of chronic pain, practicing strengthening poses is less important, because it takes time for weakness to develop. However, if the acute pain becomes chronic, we recommend adding strengthening poses to your practice to help prevent weakness from developing.

Breath Practices. You can use any breath practice you find helpful. Generally, we recommend starting with calming breath practices, such as:

• gently lengthening both inhalation and exhalation
• 1:2 ratio breathing
• alternate nostril breath

When you reach a point where you are working on stress hardiness or active strength building practices, you could try adding in a few more stimulating practices, such as 2:1 ratio breathing or Kapala Bhati, as these practices can help energize your body and mind, contributing to your strength and endurance. 

Restorative Poses & Focused Relaxation. All forms of focused relaxation are helpful for reducing stress. However, if you are in acute or severe pain, you may find recorded guided versions are easier to focus on, as your mind will be more attentive to the recording than your own attempts at moving your focus away from pain. 

In general, start with a comfortable relaxation pose, from simple Savasana (Relaxation pose) to any form of supported Savasana, or any symmetrical restorative pose. Then practice any conscious relaxation technique that works for you, such as simple breath awareness, a body scan or guided imagery, or the rotation of consciousness portion of yoga nidra. 

Meditation. For both acute and chronic pain, you can practice any form of meditation, from simple breath awareness to more formal practices that cultivate feeling of kindness towards your self. We especially recommend meditating on an image in your mind that is calming and joyful or a color that is peaceful and pleasant, or using the formal Vipassana Metta meditation (Loving Kindness Meditation). To get a handle on how much of your mental energy is going to thinking about your pain versus other topics, you can try simply observing your thoughts. Experiment with these various different techniques to see what works best for you (see Yoga Meditation Techniques).

Imagining Asana. For those with chronic pain, on days when you don’t feel up to moving, imagining you are doing an asana actually prepares your body to move with greater ease and comfort when you are ready to move again. To prepare yourself to do this, you may want to rehearse this technique on a low pain day while you are actively practicing. For example, as you using whatever method you normally use to practice, whether using a sequence from a book, a video, or an audio recording, or creating your own sequence, after each pose, stop, close your eyes, and do the pose or mentally, as a way of memorizing it. Then, the next day, try out a short practice mentally. As you improve at this technique, you will be able to easily access the mental practice on the days you don’t feel up to moving.

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Friday Q&A: Techniques for Pain Management

Tulips Through a Screen by Melina Meza

Q: I loved your post this week Yoga for Pain Management. In that post, you recommended four different ways to use yoga to manage chronic pain. Are all these techniques the same? How do I decide which of these to use? 

A: In that post I recommended the following four yoga tools to use for pain management: breath work, yoga asana, focused relaxation, and meditation practices. Today, I will try to give some of the “whys” for each of these recommendations. Let’s jump right in! 

Breath Work: The way you are breathing is a good barometer of your pain and stress response. And it may be one of the easiest habits to change. Learning to slow down and deepen your breath, for example, can have immediate effects on how your body and mind operate, including lowering stress hormones and reducing sensitivity to pain. Even something as simple as paying attention to your breath and the sensations of breathing can interrupt pain and stress responses, so you can use this kind of practice for acute flares of pain as well as chronic, persistent pain. And using structured breath techniques, such as 1:2 ratio breath and alternate nostril breath, can help re-pattern breathing that is initially a legitimate response to acute pain, but may not serve you well with chronic pain. Research has also shown that alternate nostril breathing, for example, can reduce the effects of stress, lowering blood pressure as well as heart rate. 

Chronic pain is often associated with changes in emotional states as well, such as increases in anger, sadness, and fear. Research has shown that how you breathe can change the way you feel, so breath work can have this added benefit of altering emotions for those this additional challenge. 

Finally, adding in gentle movements aimed at releasing physical tension that could inhibit easy breathing can help improve overall breathing ability and add to greater ease when doing specific breath work. Gentle actions like Cat/Cow pose (LINK) and seated side bending are two examples of movements that could add to the overall effectiveness of your breath work. 

Asana: There are two different ways of working with the yoga poses: statically, where you hold the pose for a given amount of time, and dynamically, where you move into and out of pose with the your breath. As you can imagine, many people with chronic pain are fearful that any movement will worsen their pain. In contrast to this real concern, research has shown that movement using either static and dynamic yoga asana can reduce pain, improve function, and reduce pain medication usage for a range of conditions, including low back pain and arthritis, in people who are otherwise reluctant to move. With a gradual, gentle approach to your yoga poses, your movement practice may relax physical tension and lower stress, improve your mood, release endorphins (the body’s natural pain-relieving molecules), lead to improved strength and energy, and improve your self-listening skills and self-care responses. And even on days when you really don’t feel like moving, research has demonstrated that using your imagination, such as imagining you are doing an asana, actually prepares your body to move with greater ease and comfort for when you are ready to move again. 

Focused Relaxation: Many studies in the last 10 years alone have demonstrated that relaxation practices can reduce pain and improve the quality of life for many chronic pain conditions, such as migraine headaches, back pain, and fibromyalgia. Relaxation practices have immediate effects, turning off the stress response to pain and turning on immune, digestive and repair and growth functions instead, making it a great first line practice for acute flares of pain. These practices have long-term benefits as well, helping to train your mind to differentiate the sensations of physical pain from a true full emergency response. And focused relaxation can be practiced in a variety of restorative poses or with an audio guided relaxation, such as yoga nidra. 

Meditation: One of the ways meditation is helpful is by shifting your attention and interrupting your pain and stress responses. This is true, in some ways, with all the tools mentioned here. But research has shown specifically that several meditation techniques (breath awareness, mantra repetition, and visualization) can increase your tolerance for pain and quickly shift you from a state of stress to one of relaxation. In addition, meditation has the added benefit of producing positive states of mind. One study showed, for example, that meditating on joy activated the areas of the brain that produce positive emotions. In addition to immediate benefits, meditation also has the long-term benefits of assisting you in unearthing your personal habits of mind that can be contributing to pain and stress, and allowing you to consciously choose new, healthier ones. 

To learn more about all of these ways that your yoga tools are effective for chronic pain, consider reading Yoga for Pain Relief by Kelly McGonigal. 

—Baxter

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Yoga and Pain Management

by Shari

Since I have been on a “pain alert” myself for the past 10 days (a very cranky knee is having trouble settling down), I thought I would discuss the difference between acute and chronic pain, and how yoga may assist in pain management.

More than 115 million people nationwide (1 in 3 Americans) suffer from some type of long-term pain, according to the Institute of Medicine. People often try to alleviate pain with conventional therapies and medications. According to the CDC, narcotic pain medication addiction and overdosing accounted for over 16,651 deaths in 2010. When conventional treatment fails, people will often turn to complementary medicine techniques, and yoga is often tried to alleviate pain symptoms.

I thought I would first define the difference between acute and chronic pain. An acute injury will typically resolve within three months of the body’s normal healing process. Chronic or persistent pain is pain that lasts more than this time frame. Acute pain is associated with tissue damage. Pain (nerve) receptors are activated with an acute injury because the body is trying to protect the damaged area - this minimizes usage so normal healing can occur.

But with chronic pain, the brain’s perception of the cause of the pain changes. The inhibitory mechanisms of the central nervous system become faulty, and we may avoid physical activity because we have learned “If I do this, it will hurt.” We may be afraid that, because we are in pain, activity will further damage or injure the area. But generally the tissue damage is healed after three months, and avoidance of physical activity is therefore no longer beneficial in the healing process.

However, the brain may now remember stress and pain in an exaggerated way, as if it were in a continuous sympathetic feed back loop of fight or flight. So some of us can become hyper vigilant about everything that causes pain. But one of the beauties of yoga practice is how helpful it can be for people both in acute and chronic pain!

Physical asana has properties of both squeezing and soaking areas of the body. Compressive forces, with and without weight bearing, and long restorative poses move fluid, assisting the body to decrease edema in a joint after an acute injury. Decreasing the edema reduces the pressure on nerves and muscles, resulting in a reduction of pain symptoms. (However, it is key to understand how much can you can move your cranky joint and when you need to stop, so see When to Stop Practicing Yoga for information.) Along with the practice of physical asana, long relaxation poses and Savasana can help because of their restorative qualities and the way they quiet the sympathetic nervous system while stimulating the parasympathetic system (the relaxation response). And at this time, modifying the asanas that you regularly do is important. This way, you can still get the benefit of the asana with modifications, and then as the injury heals you can slowly bring the full asanas back into your regime.

For chronic pain the “prescription” is a bit different. Chronic pain is a global body phenomenon. When your body is in chronic pain you walk differently and you may even sit differently. Your attention is often directed to the painful region because keeping it still may make it worse and positional change needs to be frequent. The individual may be chronically exhausted because the ability to sleep well has been affected. There may be difficulty in completing tasks in a timely manner so things “start to slide” and don’t get done. Because energy is limited, the individual may rush through tasks to get things done and then be in more pain because they hurried. It is a terrible wheel to be on and difficult to get off onto solid ground!

In my own practice and teaching of yoga, I try to share with my students how yoga helps to focus the mind, quiet the breath and improve the mental focus. Yoga meets us where we are NOW. Yoga is nonjudgmental and everyone can do yoga. Yoga teaches us self-awareness. Yoga gives hope where there may be no hope.

Simple grounded breathing while you sit on a chair or lie in bed in your position of comfort is a great way to start. Set a timer and do simple breathing for three to five minutes. Notice how this may affect your mind and sense of self. Progressing to GENTLE range of motion of all body parts within your ability and not pushing yourself is beneficial. You can even do your range of motion activities in your position of comfort. Notice your pain levels (0-10) at start of practice and then again when you are done. If your pain levels stay the same, you are teaching your body NOT to be afraid of movement. Once your confidence has improved, then you might be ready to join a local class. Look for instructors who will be sympathetic to your pain but not overly solicitous. Make sure the teacher understands that you will stop when you need to, not necessarily when the teacher tells the class to release the position. Try to set aside five minutes a day to practice your own breathing awareness and your own Savasana. It becomes your sacred time to care for yourself.

Remember, the results may be slow in coming but persistence and gentleness are the keys to relieving and managing both acute and chronic pain.

Note: For my achy, swollen and hot knee, I am trying to work with my available range of motion, not moving too much into pain but inching into the pain and then backing up and repeating multiple times trying to make the available movement  smoother. Also, stretching related areas like my hip flexors, hamstring muscles, gastroc/soleus is really helpful for pain relief of my knee. In the standing poses, I’m working with gentle isometric contractions but not going into my full knee flexion (bending)—pumping a lot. I’m doing a lot of passive inversions like Viparita Karani (Legs Up the Wall pose) and Chair Shoulderstand, with pumping from my ankles. And, finally, modifying poses, for example, for Virasana (Hero pose), which I was previously able to do without any props, I now use two blocks stacked up high because I have just about 100 degrees of flexion (ability to bend the knee). And, lastly, cautious, aware walking. Patience is the crux though I am not a very patient individual.

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