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In a perfect body, pain occurs only when needed, and turns off when the initial stimulus is withdrawn and the tissue has healed.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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Friday Practical Pointers: Changing Your Relationship with Pain

by Baxter and Nina

Jim Coughlin, Age 60

Those of you with health conditions or injuries that have resulted in ongoing, chronic pain or intermittent pain, (think low back injuries, fibromyalgia, and chronic migraine headaches, to name just a few) may have developed a certain adverse relationship with pain over time in the form of feelings of anger, fear, worry, anxiety, despair, sadness, or loss. Unfortunately these responses to pain will often trigger your stress response, which typically increases your pain. And brooding about the pain in general can increase your perception of your pain levels, something we call “the pain on top of the pain.” 

In addition to allowing you to actually reduce your pain levels (as your pain reduces, your attitudes and feelings toward it may also shift), yoga enables you to actively change your adverse relationship to pain in the following ways: 

1. Because brooding or thinking excessively about your pain can distort your accurate perception of your true pain levels, using yoga stress management techniques to quiet your mind allows you to short-circuit your mind’s tendency to focus on pain. In your new, clear state of observation, you may discover that your true pain levels are lower, sometimes significantly, than the pain you experience while focusing on it. 
2. You can improve your pain tolerance by listening to your body and improving your overall self care. You can also improve pain tolerance by cultivating mental and emotional equanimity, which enables you to be more content with what you have and what you don’t have. 

The following sections provide details about how to use this techniques.

How to Quiet Your Mind While in Pain 

To short-circuit your tendency to brood about pain, use any stress management techniques that work for you. We particularly recommend:

• Breath Awareness. Repeatedly coming back to your sensations of breathing interrupts your thoughts about pain 
• Structured Breath Practices. Simple breath practices that require concentration, such as timed 1:1 or 1:2 inhale/exhale patterns and alternate nostril breathing, keep your mind focused on your breathing. 
• Guided Relaxation. Recorded or self-guided relaxation practices keep your mind engaged on physical relaxation or positive imagery. 

As you practice these techniques, your pain levels may decrease, your tolerance for pain may improve, and your typical mental-emotional responses to your pain may become less intense or may even dissipate. 

In addition to quieting your mind, meditating on positive emotions, such as gratitude or joy, or on positive images, enables you to transform feelings of sadness, frustration, fear and anger into more positive states of mind. One study showed that meditating on joy literally activated the areas of the brain that produce positive emotions. This surge of positive emotions may reduce your pain levels, while also improving your pain tolerance and your attitude about the pain.

Meditation also has the long-term benefit of teaching you about mental habits that might be contributing to your pain, allowing you to consciously choose new, healthier ones. For example, your chronic pain may have triggered stress eating, which led weight gain that is worsening your pain (which can happen, for example, with knee arthritis). By observing your thoughts during a meditation practice, you may become aware of the chain of events that leads to your stress eating and then choose a healthier response to the pain, such as taking a short movement break that actually lowers your pain, rather than turning to food. 

How to Improve Your Pain Tolerance 

Mindfulness practices where you focus on your physical sensations other than pain, such as meditation, breath awareness, and mindful practice of asanas, allow you to tune into your body and recognize its needs. These practices teach you to differentiate between chronic, low- level pain and acute surge in pain, which will allow you to have a better sense of when to exercise and when to rest, of how far you can safely move in various yoga poses, and of which practices actually help your pain. (Of course, If your pain becomes severely acute and disabling, it would be wise to get to your doctor urgently.) 

Tuning into your physical sensations will also allow you to improve your self-care in general, as you, for example, realize you need more sleep or to schedule a health care treatment. Becoming an active participant in your self care can give you a sense of control, which can help you move past your adverse relationship towards chronic pain And improving self-care may even allow you to start participating more in the activities that matter to you, improving your overall quality of life.

Another way to improve your pain tolerance is to cultivate equanimity, the original aim of yoga:

When a man has mastered himself,
he is perfectly at ease in cold,
in heat, in pleasure or pain,
in honor or in disgrace. —Bhagavad Gita 

Studying yoga philosophy provides you with an alternative way of thinking about your life, enabling you to be more content with what you have and what you don’t have. And that includes accepting chronic pain as part of your life, which allows you to tolerate the pain more easily. In general, cultivating contentment as described in sutra 1.33 Patanjali’s Yoga Sutras, can be very helpful. 

1.33 Through cultivation of friendliness, compassion, joy, and indifference to pleasure and pain, virtue and vice respectively, the consciousness becomes favorably disposed, serene and benevolent.

Another particularly helpful technique for countering the negative reactions of your mind is pratipaksha bhavana, which means “cultivating the opposite.” 

3.3 When disturbed by negative thoughts, opposite [positive] ones should be thought of. —Swami Satchidananda 

Here’s an example of how to apply pratipaksha bhavana: If you had an increase in pain, your first thought might be, “I won’t be able to go to work today with this level of pain.” But practicing pratipaksha bhavana could allow you to reframe this thought to, “I will be able to work today, despite this pain level” or “Let’s see if I can work today, despite this pain level.” See Cultivating the Opposite for more information on pratipaksha bhavana.

But any yoga philosophy that speaks to you and helps you cultivate balance and equanimity in your mental and emotional life is going to help you increase your pain tolerance and improve the quality of your life.

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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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How and Why Yoga Helps with Pain

by Ram

Self Portrait with Bandaged Ear by Vincent van Gogh

Say, a heavy object fell on your big toe, or you cut your finger while peeling vegetables, or you applied alcohol over a bruise, or while walking down the street you twisted your ankle and immediately let out a shout—in all these situations, you have experienced an unpleasant feeling due to a tissue damage. When something harmful or irritating affects a part of our body, there is a biological response to try to remove it. This response takes the form of the unpleasant feeling/sensation called pain (see Yoga for Pain Management). 

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” You may ask why should anyone experience pain? Well, pain is part of the body’s inherent protective mechanism to:

• motivate you to pull out from a damaging situation and prevent further damage to the tissue
• allow the damaged tissue to rest and begin the healing process
• avoid similar encounters

Thus, you may appreciate the fact that pain is beneficial in a true sense when, for example, your back sustains a blow and the injured tissues need care and protection. Individuals who suffer from congenital insensitivity to the pain response are easily injured and most of them die at an early age. On the flip side, pain is a major symptom in several medical conditions that can interfere with a person's quality of life and general functioning as well see Interview with Shari and Bonnie on Pain Management). In these cases, pain turns out to be the most common reason for individuals to visit their physician.

Several classes of pain exist based on the initial stimulus and the site of damage:

1. Nociceptive pain (pain due to excess heat or cold; pain due to mechanical damage as in crushing, tearing; pain due to chemicals: pepper powder in the eyes; alcohol on bruises), 
2. Inflammatory pain (pain associated with acute or chronic inflammation—see Chronic Inflammation and Yoga)
3. Neuropathic pain (pain due to damage to nerves as in burning, tingling, stabbing, pins and needles, etc.)
4. Pathological pain (pain due to abnormal function such as arthritic pain, fibromyalgia, headaches, etc.)
5. Cancer pain (Cancer pain is complex as it constitutes a varied combination of pain types)

Just like inflammation, the phenomenon of pain is generally transient, and recedes when the stimulus is removed or the damaged tissue has healed. In a perfect setting or perfect body, pain occurs just as it should when needed, and turns off when the stimulus is withdrawn and the tissue has healed. However, there are certain abnormal pathological conditions where pain is a constant feature and persists for a long time. This is chronic pain that lasts beyond the expected period of healing. Unfortunately, chronic pain brings with it other health issues including constant fear, worry, anxiety, depression, and memory deficits. It is unclear if chronic pain triggers these co-morbidities or vice versa.

The entire process, starting from the initial stimulus to the actual pain response and the waning of the pain, involves several specialized receptors, neurochemicals, and transmission of the pain information through specialized channels. For example, if you cut your finger while chopping vegetables, this response triggers numerous events: a) mechanical stimulation from the sharp object, b) injury to the tissue, c) release of certain chemicals at the site of damage, d) signals from damaged tissue and the chemicals stimulate nerve endings found in the skin, muscle, joints, bone and viscera, e) information travels from the nerve endings to the spinal cord, for suitable action to be generated. The end result is the damaged area gets flooded by various inflammatory molecules and chemicals, including Histamine, Arachidonic acid, and Substance P, all of which trigger the pain response. Furthermore, when these pain signals traverse through certain areas of the brain, they stimulate a set of autonomic responses resulting in increased heart rate and blood pressure, rapid breathing and sweating.

Several factors can influence the pain perception including:

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

Gender. In general, women have lower pain threshold and a higher sensitivity to pain. This could be due to hormonal changes that may be modifying the pain perception system.

Memory. Our past experience dealing with pain can influence neural responses to the incoming pain stimulus. 

Whether for acute or chronic pain, interventions include pain relievers/killers, including over-the-counter medicines like acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs-Advil, Motrin), or prescription painkillers that are opium-like powerful drugs. Is there an alternate way to overcome pain, especially chronic pain? There are several studies that report the benefits of yoga in curbing pain. Yoga helps in the following ways: 

1. Yoga asanas trigger increased flow of oxygen to the brain and muscle tissues that improves energy levels and sense of wellbeing.
2. Yoga asanas help to release muscle tension and stretch the muscles thereby reducing the intensity of the pain
3. Yoga asanas can create more mental clarity thereby decreasing the level of perceived suffering
4. Yoga stress management practices, including meditation, focused relaxation, and relaxing asanas, help you cope with stress that can have a feedback effect on improving pain.

Furthermore, in animal models, research studies show that physical activity and a socially enriched environment reduce pain behavior. Similarly, studies in humans reveal that the practice of meditation and/or yoga reduces pain perception. Patients with chronic pain have accelerated, age-associated gray matter loss and decreased insular connectivity. The gray matter together with the associated insular areas plays important roles in emotion, perception, motor control, and self-awareness. It is not clear if pain triggers the gray matter loss and insular connectivity or vice versa.

In a recent study Insular Cortex Mediates Increased Pain Tolerance in Yoga Practitioners, a group of researchers concluded that yoga may prevent age-related gray matter loss and also increase intra-insular connectivity, thereby increasing the pain tolerance. The research study involved 14 experienced yoga practitioners and 14 individuals who did not have any practice of mind-body techniques (individuals were matched for gender, age, body mass index, left/right handedness, education, and exercise level other than yoga). The cold pain tolerance test involved immersing the hand in cold water until they could no longer tolerate the cold pain. The researchers conducted brain-imaging scans to examine the structural and functional differences in gray matter and white matter between the two groups. They also noted the strategies adopted by the individuals to tolerate the pain. The results were not very surprising: 

1. Yoga practitioners tolerated cold pain more than twice as long as the non-yoga individuals.
2. Researchers found a significant difference in gray matter volume in brain areas associated with pain processing, pain regulation, and attention.The increase in gray matter volume was associated with increases in the insular connectivity that correlated with the higher pain tolerance
3. Yoga practitioners had increased white matter (this would indicate extension of nerve fibers and improved nerve signaling). 
4. Yoga practitioners used various cognitive strategies to withstand the pain (such as observing the pain sensation but not reacting and using breath-relaxation techniques to accept the sensation) while most non yoga individuals were unable to think of such strategies. 

While definitive causal conclusions cannot be made, it is worthwhile to note that regular, long-term yoga practice seems to help individuals to deal with unpleasant sensory and emotional experience associated with pain. Take home message: Yoga In, Pain Out!

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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 for Pain Management

by Baxter

Just today, I met with one of my students for a private yoga session to address her continued experience of chronic pain. For this student, a combination of age-related changes to her spine and musculoskeletal system, as well as ongoing side effects from past chemotherapy, have conspired to result in chronic low back, hip, and leg pain. Her experience of chronic pain is complex and fluctuating, and for the past few weeks has been worse than normal. Fortunately for her, she has already established a combination of practices (some of which are listed later) that have served her well in the recent past and, with some appropriate modifications and additions, will likely help her with this and future periods of fluctuating pain.

We have written a bit about using yoga to address chronic pain in the past, so I will share some of the relevant info we have already covered as well as some new additional information to consider today. In our post Interview with Shari and Bonnie on Yoga for Chronic Pain, some essential ideas about chronic pain were clearly presented. Bonnie said:

“Pain itself is defined as an unpleasant sensory and emotional experience. It is also the way the brain interprets this information that contributes to the experience as well. Acute pain is of short duration as a result of injury, surgery, or illness. Chronic pain is an ongoing condition persisting longer than six months. Kelly McGonigal, Ph.D., author of Yoga for Pain Relief, defines acute pain as a response to some kind of injury or illness. It begins with a real threat to the body and leads to a reasonable protective response. Chronic pain differs in three ways: 1) The body can become more sensitive to the threat of possible pain symptoms leading to feelings of fear and anxiety, 2) The brain can become more likely to interpret situations as threatening, and sensations as painful (eliciting a pain response), and 3) In chronic pain with the experience of repeated reactions to pain, the ability to differentiate the many aspects of the pain response (sensations, suffering, and stress) get blurred.”

Here at YFHA, we have addressed many conditions that can result in the development of chronic pain, such as arthritis, migraine headaches, chronic fatigue syndrome, low back issues, and others. And of course, we have shared practices that can lead to a decrease in overall pain and improvement in function.

One of the reasons chronic pain is so challenging is that it goes beyond just a physiological presence of pain, and begins to affect the mind-body connection, often resulting in new issues to contend with, such as the fear of worsening or triggering pain, and the anxiety around the persistence or re-emergence of pain. And the presence of chronic pain starts to affect other parts of our daily function, too, as Sheri Ser, our in-house physical therapist pointed out that some of the physiological changes that pain causes include:

• Breathing changes (the breath is more shallow and shaky) 
• Muscle tension changes because the body is in a constant state of “alert” 
• How we move changes dramatically as we try to protect the area of pain—sometimes people will stop all movement that they deem extraneous while others will grit and bear it only stopping when the pain is so intense that they can’t continue. 
• Body image (how we view ourselves) changes 
• Thinking patterns change: we are less optimistic and our emotions may be more changeable 

Despite the seemingly unchanging nature of chronic pain for those who suffer with it, yoga is actually quite beneficial in both decreasing the pain and in changing our relationship and response to pain. Yoga helps in the following ways:

1. Mild to moderate exercise actually decreases physical pain. Yoga qualifies!
2. The increased flow of oxygen to the brain and muscle tissues in yoga improves your energy levels and sense of wellbeing. 
3. Combining breath awareness with the physical movements of a yoga practice helps release muscle tension held in your body. 
4. For people with certain conditions, such as arthritis, moving your joints through their range of motion and stretching your muscles can decrease the intensity of your pain or relieve your pain completely. 
5. Practicing yoga on a regular basis may affect your response to pain, decreasing your level of perceived suffering.
6. Although chronic pain can worsen our ability to handle other stresses in our lives, regular yoga practice can improve stress management and can have a feedback effect on improving chronic pain. 

Additionally, in her book Yoga for Pain Relief, Kelly McGonigal points out to chronic pain sufferers that, “Yoga can teach you how to focus your mind to change your experience of physical pain. It can teach you how to transform feelings of sadness, frustration, fear and anger. It can teach you how to listen to your body and take care of your needs so that you can participate in the activities that matter to you. It can give you back the sense of safety, control, and courage that you need to move past your experience of chronic pain.”

The yoga tools that lead to these profound changes are those we discussed in many past posts, including breath work, asana, conscious relaxation, and meditation. Here are the main tools I recommend:

Breath Work: You can practice any breath practice you find helpful, from simple breath awareness, to more complex pranayama, such as, alternate nostril breathing.

Yoga Asana: When using asana, always start out with a gentle practice. Start with simple movements to improve breathing, such as Cat-Cow pose , seated or standing side-bends, and arm range-of-motion actions (see Standing Shoulder Stretches). Then, add in more active asana, such as Mountain pose (Tadasana) to Arms Overhead pose (Urdva Hastasana), either dynamic or static, Warrior 1 and 2 poses (Virabradrasana 1 and 2) done similarly, Locust pose (Salabasana), Downward-Facing Dog pose (Adho Mukha Svanasana) and many more. You can also practice restorative postures (see Restorative Yoga: An Introduction), such as Easy Inverted pose, Legs up the Wall pose (Viparita Karani), and Supported Childs pose (Balasana), to name just a few.

Focused Relaxation: Many forms of focused relaxed are helpful, from simple Savasana (Relaxation pose) to restorative poses and supported Savasana (see Savasana Variations). Conscious relaxation techniques include simple breath awareness, body scans and many other forms of guided relaxation, including the rotation of consciousness portion of Yoga Nidra. 

Meditation Practices: You can practice any form of meditation, from simple breath awareness techniques to practices that cultivate feeling of kindness towards your self. Kelly McGonigal has a nice section on this in her book, for those that want more types of meditation to practice.

I also recommend the following two resources: 

Recovery Yoga by Sam Dworkis
Yoga for Pain Relief by Kelly McGonigal, Ph.D. 

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Interview with Shari and Bonnie on Yoga for Chronic Pain

by Nina, Shari, and Bonnie

Grasses and Reflections by Brad Gibson

Shari Ser and her teaching partner, Bonnie Maeda, who is a registered nurse and a yoga teacher, will be teaching a special workshop on yoga for chronic pain this coming weekend, on Saturday, September 21 (see Brentwood Yoga Center). So I thought that it would be a good time to interview the two of them about this important topic. —Nina

NINA: Why did you two decide to teach workshops on yoga for chronic pain?

BONNIE: As I began teaching yoga with a therapeutic approach, it was evident that discomfort and pain were often a component for the student living with a chronic illness or injury. With the philosophy of teaching yoga to the whole person in a holistic way, I felt that there needed to be an awareness in the practice of the individual's experience of pain. As a teacher, I was also aware of another component for these students: the fear of pain (or of increasing their pain) was present as they practiced yoga.

The development of the workshop came after much thought and research on pain management. Iyengar yoga, with its focus on alignment, use of props, and teaching to the individual's abilities, is a wonderful healing modality for this student population. A workshop is a great way for a student to be introduced to a gentle yoga practice, as well as begin to know how to listen to the messages of the body, which will protect them from injury and pain while practicing a yoga sequence. For a yoga teacher attending this type of workshop, it will provide information about the physiology of pain, and how to support and maintain the safety of a student in a yoga class.

SHARI: People often come to yoga because they are in chronic pain and nothing they have tried in the past has alleviated this pain. Pain is very difficult to quantify and objectify, and our language to describe pain is often unsuccessful. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” In his article in Yoga Therapy Today “Know Pain? A Brief Guide to Understanding Pain for Yoga Therapists,” Neil Pearson quotes Australian Physical Therapist, Lorimer Moseley, Ph.D.:

"Pain is a multisystem output that motivates and assists the individual to get out of a situation that the brain concludes is dangerous."

The key point is that pain is real, whether or not a diagnosis confirms it, and pain will be responded to by the whole person, including body, mind and spirit. This is where the application and practice of yoga can be so important because we meet the student where they are and practice with them. We don't do yoga "to” them!

NINA: What is chronic pain and what are some typical conditions that cause chronic pain?

BONNIE: Pain itself is defined as an unpleasant sensory and emotional experience. It is also the way the brain interprets this information that contributes to the experience as well. Acute pain is of short duration as a result of injury, surgery, or illness. Chronic pain is an ongoing condition persisting longer than six months. Kelly McGonigal, Ph.D., author of Yoga for Pain Relief, defines acute pain as a response to some kind of injury or illness. It begins with a real threat to the body and leads to a reasonable protective response. Chronic pain differs in three ways: 1) The body can become more sensitive to the threat of possible pain symptoms leading to feelings of fear and anxiety, 2) The brain can become more likely to interpret situations as threatening, and sensations as painful (eliciting a pain response), and 3) In chronic pain with the experience of repeated reactions to pain, the ability to differentiate the many aspects of the pain response (sensations, suffering, and stress )get blurred.

Some conditions associated with chronic pain are back pain, headaches, arthritis, fibromyalgia, and pain related to a specific illness.

SHARI: We can understand chronic pain if we put it into a mind-body-spirit experience. Pain changes everything that we do. It changes how we breath, how we move, and what we will or will not do. The anxiety that “if I do this will I suffer more later” is always present. Often there isn’t a direct correlation between activity and pain exacerbation so sometimes knowing what is possible isn’t an option because it changes. What doesn’t change is our anxiety and fear. Some of the physiological changes that pain causes include: 

• Breathing changes (the breath is more shallow and shaky) 
• Muscle tension changes because the body is in a constant state of “alert” 
• How we move changes dramatically as we try to protect the area of pain—sometimes people will stop all movement that they deem extraneous while others will grit and bear it only stopping when the pain is so intense that they can’t continue. 
• Body image (how we view ourselves) changes 
• Thinking patterns change: we are less optimistic and our emotions may be more changeable 

NINA: Why is yoga particularly helpful for chronic pain?

BONNIE: Yoga is beneficial for someone coping with chronic pain for many reasons. Studies have shown that mild to moderate exercise actually decreases physical pain! The increased flow of oxygen to the brain and muscle tissues improves your energy levels and sense of wellbeing. And combining breath awareness with the physical movements of a yoga practice helps release muscle tension held in your body. In addition, for people with certain conditions, such as arthritis, moving your joints through their range of motion and stretching your muscles can decrease the intensity of your pain or relieve your pain completely. Finally, practicing yoga on a regular basis may affect the response to pain, decreasing the level of perceived suffering.

SHARI: Yoga provides a system for the individual to re-learn how to inhabit their bodies. It assists the brain in learning to re-categorize noxious stimuli versus safe stimuli. The brain and body are on overdrive when you are experiencing pain for long periods of time. According to Neal Pearson, “yoga provides a path toward calming the body- mind- spirit…. And through yoga we can create positive neuroplastic change, leading to less pain, better movement and improved quality of life in the face of chronic pain.”

When we are doing an asana or preparation for an asana, it is through the gentle self exploration of learning how to move with the breath that we begin to approach pain with respect and humility. Learning how much movement is available and learning to respect those limitations is a way to improve function and movement over time. There can never be a time frame on how long it will take to get better!

NINA: Which are a few of your favorite practices for addressing chronic pain?

BONNIE: Setting the tone for a gentle yoga practice within a safe environment is primary when you teach individuals with chronic pain or when you start to practice on your own. So begin a sequence in a chair or on the floor, which helps reassure the practitioner that he or she can can practice at his or her own level of ability and comfort. Breathing and body awareness are a beneficial way to begin the practice, as it gives you time to feel comfortable, and to start to build confidence in yourself and the choices you make as you move through the practice.

Continuing with range of motion/stretching of the major joint structures offering modifications as needed. Standing poses are often fatiguing for people with chronic pain, although important to offer. To build strength and stamina over time, be sure to incorporate restful poses with attention to the breath between the standing poses.

Always end the practice with a restorative pose followed by Savasana to elicit the relaxation response. This reduces stress held in the body and creates a renewed sense of vitality.

SHARI: In general, I would say that you encourage the joint surfaces to move to their capacity without increasing pain responses. Utilizing props encourages the student to maintain the position for longer periods of time than they might actively be able to hold a pose. The longer a muscle is held in a gentle stretched position, the longer the muscle memory will last. Also, if pleasure is learned to be associated with movement, then the individual/body will crave that movement because of the pleasure association.

Doing standing poses builds strength and it is important to be both strong and flexible. Individuals who have restricted their movement for long periods of time will need to build strength slowly. Alternating between sitting and standing allows the student to begin to build strength within a safe context.

My favorite pose for addressing chronic pain is positioning your body in a supine pose with props (various versions of Supported Savasana). Ginger Garner, MPT (Professional Yoga Therapy) presents a wonderful three-tiered blanket set up for deep breathing. The blankets are set up so the lumbar spine is supported, the thoraco-lumbar junction is supported and the head is supported. I like to put a bolster under the knees and pad the heels, and support under the arms if necessary. I love this pose because it allows me to open my chest and to feel the rhythm of my breath. It allows me to focus my attention on my inhale and exhale, giving my mind something to focus on while supporting my physical structure. The more I breath, the better I feel!

If this position doesn’t work then try any restorative position that comforts and supports the body in as many places as possible. I like to think of the support as taking up “the gaps” so the whole body can touch the supporting surface.” If there are no gaps, then the muscles can be encouraged to release. By concentrating on the breath and, if possible, lengthening the exhalation, you can gently stimulate the Relaxation Response (the parasympathetic system).

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