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In a perfect body, pain occurs only when needed, and turns off when the initial stimulus is withdrawn and the tissue has healed.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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Healthy and Unhealthy Stretching Sensations

by Nina

Flames by Melina Meza

Ever hear someone else groaning in a yoga class? Or maybe that you? Yes, when you are stretching a tight area of your body, you can experience quite a bit of sensation. And while healthy stretches can provoke an intense feeling, it’s a good idea to pay attention to the type of sensation you’re experiencing because this may indicate you should back off the stretch.

As we discussed in previous posts (see What is Flexibility, Anyway?), stretching a muscle or muscle group and fascia is healthy and beneficial, but stretching a tendon or ligament can cause an injury, such as a tear, inflammation, tendonitis, or tendonosis. In addition, compressing a joint when you are stretching can pinch the tissues caught between the bones closing in toward each other, which cause pain and lead to inflammation. So it’s important to learn to tell the difference between the sensations of healthy stretch of a tight muscle versus the pain, pinching, or “smashed together” feelings that are warnings of potential injury. 

Healthy Sensations. You will feel generally feel healthy stretch of a muscle in the mid-portion of a muscle, farther away from the tendons and ligaments are located close to joints. A good place to become familiar with this type of sensation is the hamstring muscle at the backs of your thighs, which you stretch in Standing Forward Bend (Uttanasana) and Reclined Leg Stretch (Supta Padangusthasana). As most of you know, the intensity of the stretch sensation there can be quite strong, and yet it generally doesn’t mean you are injuring yourself. So when you experience this type of sensation, as long as the stretch is a moderate one, take a deep breath and try to relax into the stretch. 

Unhealthy Sensations. You will generally feel an unhealthy stretch of muscle, tendon, or ligaments closer to a joint, such as your hip, knee, shoulder or elbow joint. And the quality of feeling will be different than a healthy stretch, maybe burning, sharp, stabbing, throbbing, or tearing in quality. For example, with the hamstring muscles, if you feel a tender burning sensation up toward your buttocks, this could be an indication you are overstretching the attachments. In all cases, when you experience these types of sensations, you should immediately back off the stretch if possible to see if that helps. If not, come out of the pose entirely.

It is possible to feel this burning, sharp, stabbing, throbbing, or tearing sensation in the muscle body as a result of a sudden, intense, quick stretch, so that is why we always recommend moving slowly and with in control into your stretches. 

Joint Compression. Sometimes when you are stretching a muscle, the joint that is bending can become compressed. For example, when you deeply bend your knee joints, as in Child’s pose (Balasana), the tissues at the back of the knee joint can become pinched together. This is potentially dangerous because the compression could produce tissue damage and inflammation, or even could injure nerves or blood vessels, leading to acute or chronic pain and dysfunction.

In general what you’ll feel when a joint is compressed is either a sensation of muscles, skins, tendons, fascia, and/or bones being “smashed together” or a pinching sensation. For example, some of less flexible folks feel smashed together or pinching sensations in our front hip when doing Extended Side Angle pose (Utthita Parsvakonasana) with our hand on the floor. Both of these sensations indicate that you are overdoing it, and you should back off the stretch, possibly by adding a prop. If you can’t eliminate the joint compression, come out of the pose. 

Compression can also put pressure on blood vessels and nerves, so if you have an unusual pressure sensation in the joint or feel numbness and tingling downstream from the compressed area, that is an indication that you are overdoing it and should back off the stretch or come out of the pose.

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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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Practicing with Pain

by Nina

Needle and Ice by Melina Meza

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

—Bhagavad Gita, trans. by Stephen Mitchell

We get many comments on our blog, but every once in a while there is one that makes me feel sad, like this one, which one of our readers left on a post about menopause:

This will certainly be relevant for me (65). Besides ongoing extreme irritability, yoga is not the joy it has always been for me because of joint stiffness and pain. What little stability I felt in life came from yoga, and feel that slipping away when I need it most.

My first reaction to this was to write to Shari and suggest that she write about menopause and joint pain because I knew that she, too, was currently suffering from joint problems (see Yoga for Menopause: Joint Problems). But even after ensuring that this topic was going to be addressed, I was concerned about the underlying issue:

yoga is not the joy it has always been 

what stability in life that came from yoga is slipping away

The thing is, I don't believe that physical pain means that yoga practice needs to be less joyful, or that the stability that practice brings will slip away if your asanas hurt more than they used to. And I speak from experience. Now that I'm over two bouts of frozen shoulder (which, trust me, were very painful), I'm still living with an arthritic hip that's not going to go away. So for many years, I've experienced pain when I practice asana at home or during a class. And, of course, I definitely cannot practice many of the poses I used to do on a regular basis. However, practicing yoga is still a positive, life-affirming experience for me, and as joyful as it ever was.

Because, after all, what is yoga? Definitions of yoga in the scriptures vary from "yoga is equanimity" to "yoga is cessation of the fluctuations of the mind" but nowhere is there anything about practicing pain-free asana. Indeed, as the quote at the beginning of the post tells us, being a yogi means being equally at ease in pain as in pleasure.

Both Ram and I have written about cultivating santosha as an important part of yoga practice (see Santosha: Happiness and Longevity  and Yoga and the Pursuit of Happiness ). Santosha means "contentment" and TKV Desikachar defines contentment as "the ability to be comfortable with what we have and what we do not have." And I believe that being comfortable with what we have and what we do not have must include practicing asana while in physical pain and being comfortable with that. And as for the joy, the Yoga Sutras tells us in sutra 2.42 "Perfect happiness is attained through contentment."

So the path back to joy is not through the elimination of pain, but rather through cultivating contentment. In his post Achieving Stillness in Turbulent Situations Ram told us how his grandfather taught him to meditate in a train station in India because achieving stillness in a noisy, chaotic environment was what the practice of meditation was all about. Likewise, I feel that learning how to find contentment in our asana practice, even while in physical pain, is also the essence of yoga. (Of course, you should continue to use pain as a guide to practicing safely as Shari describes in her post Yoga for Menopause: Joint Problems.)

So dear commenter and all our other readers, while I hope you may find some helpful hints on this blog that will help reduce your physical pain, we cannot remove all pain from your life  But we can offer you something more valuable. For practicing yoga by cultivating santosha inside and outside the yoga room will help see you through life's challenges in whatever form they take. As I wrote in my post Yoga and the Pursuit of Happiness, the Yoga Sutras make it clear which steps to take on that journey:

1.12 Practice and detachment are the means to still the movements of consciousness.

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.

1.34 Or, by maintaining the pensive state felt at the time of soft and steady exhalation and during passive retention after exhalation.

1.35 Or, by contemplating an object that helps to maintain steadiness of mind and consciousness.

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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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When to Stop Practicing Yoga

by Shari

Swan at Rest by Brad Gibson

Sometimes we do things that we think are healthy or beneficial for us, but which are actually not. Even practice of yoga, whether at home or in a class, can occasionally be problematic. Have you ever gone to a class feeling a “bit off” and then walked away from the class feeling drained or in actual pain? Or, have you ever gone to a class feeling a “bit creaky” but hope that the “kinks” will work themselves out, but instead of feeling in less pain, you are in more pain after class? I don’t think this is a situation that only I have experienced in my over 30 years of practice! And I have begun to think of this topic as a means of exploring self-empowerment and non-judgment.

So, why do we continue to participate when we know we should stop? All of my fellow bloggers have addressed this issue in slightly different ways, whether it is in our approach to eating, sleeping, or basic life stressors.

I think we can explore this idea on a psychological /emotional level or on a gross physical level. I will start this discussion with the gross physical level of the body. First off, the practice of asana is not just a physical body moving through space following the commands of our central nervous system. Each time we move into a yoga pose there can be a flurry of self-judgments and criticisms—”Oh no, not this pose again, I can’t ever do this, I hate this…”—the internal psychological dialogue can be unending. It takes a lot of mental discipline to quiet the mind to be fully in the asana. But then the actual physical body can start its own chorus of complaints—“This is making my knee hurt, or my back or my shoulder.” The mind can and does ignore a lot of this noise, “strong arming” the body into submission. But that cranky joint knows when to strike back and it often does. So, when should we listen to the body over the noise of the mind?

I often tell my students that it is extremely important to understand our own physical as well as mental limitations and to respect them. Pushing beyond one’s actual abilities does lead to injuries (see Baxter's post Getting Clearer on Yoga and Risk of Injury). So when and how do we improve our abilities without causing injury or damage? We have to know when to stop!

With that in mind, here is a list of physical warning signs that would be important to acknowledge:

1. Pain progression in both intensity and location. A back pain that is located centrally in your spine that starts to spread outward or downward is a warning sign to stop that activity. Another warning sign is when the area of pain totally changes location from back (spine) to arm or leg.
2. Pain intensity. Pain is usually quantified on a 0-10 point scale where 0= no pain and 10 is excruciating intense pain. Any pain that moves from negligible, like a 3, to a 6-7, is not something you want to encourage. 
3. Loss of sensation in a limb, an increase of numbness, a tingling, or burning that doesn’t stop once the position is changed.
4. Increase in a sense of “unease.” You don’t know why this activity is making your nervous, unsettled or agitated, but it would be wise to stop the activity and ask your teacher afterwards.
5. Any sensation of dizziness, nausea, double vision. These are not symptoms that are a healthy benefit from asana.
6. Any signs or symptoms of heart racing or feeling that your heart beat feels irregular.
7. Physical exhaustion. Instead of feeling better as the class progresses, you start to feel more and more exhausted.
8. Mental exhaustion.

If any of these events occur during a class it would be wise to stop and sit leaning against a wall. Sometimes closing your eyes or going to get a drink of water will be helpful. Other times just stopping and lying down in Savasana will work. Finally, there may be times actually leaving the class is necessary. If this occurs, quietly get up and leave the room. Your teacher may or may not come to talk with you. If he or she does approach you, briefly let the teacher know what is going on with you. If you are concerned about discussing medical issues in front of the class, only discuss what you feel comfortable with. Then, especially if this is a regular class that you attend, consider contacting the teacher afterward to give him or her the complete information. Having complete information about your condition will help your teacher do a better job of making your next experience in class a good one.

For information about what you might want to tell your teacher before a class, see What Your Yoga Teacher Really Wants to Know.

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Friday Q&A: Can Yoga Really Help Me?

Fallen Tree by Brad Gibson

Q: I have been getting the emails for some time and find them very interesting but have a question that has been nagging me for some time. I have been practicing yoga for years and have been teaching yoga for 10 years. I am now 63 and in the last 3 yrs despite my daily practice and veggie diet feel that my body has been deteriorating, i.e., increased aches and pains, worse in the morning, increased loss in vitality and recurring viruses, etc. I know I am getting old but I have always had faith in my yoga until the last year or so. Do you think yoga can really help with these problems in the way it claims to once we get older?

A: This question is what prompted Baxter to write his post What to Expect from Your Yoga Practice on Tuesday. But I thought it worth posting the original question for two reasons. The first reason is that this is not the first time we’ve received a question from someone who is having serious problems but whose description of their situation is too vague for us to provide a specific helpful answer. What we typically do in these cases is to suggest that the person be examined by a medical doctor to get a specific diagnoses. Only when there is a specific diagnosis is it possible for us to recommend specific yoga remedies. That's something for you all to keep in mind if you are having unexplained aches and pains, loss in vitality, recurring viruses, or any other troubling symptoms.

The second reason is that it may be be that you, as was the case with the person who asked the above question, have indeed been examined and nothing specific has been found wrong with you. In this case, it seems to me (and Shari and Baxter agree with me on this) that if someone has been medically checked out and they are perfectly healthy, but their yoga practice is be causing them to be tired and/or in pain all the time, it is probably a good idea for them to change their practice. While most folks out there don't exercise enough, there definitely are a few who overdo yoga! So it might be time to do different types of poses and/or sequences, at least for a while. This might mean a gentler practice, a practice from a yoga tradition different than the one you usually study, a break from standing poses or the poses that are painful for you, or studying with a new teacher. Or it might be good to take time off from active asana, focusing for a time on restoratives and relaxation until your body recovers. Sometimes a temporary break from yoga asana is even necessary (I've been there myself). I strongly recommend a private consultation with a teacher you respect—even if you are a teacher yourself—who can look at you with fresh eyes and make some recommendations for changing your practice. You'll probably have to experiment for a while to find out what's best for you, but I've personally found that a period of experimentation can be very fruitful for deepening your understanding of yoga.

And what about the answer to the specific question: Do you think yoga can really help with these problems in the way it claims to once we get older? I can say with complete confidence that all four of here at Yoga for Healthy Aging (and that includes, besides me, a medical doctor, a medical researcher, and a physical therapist) all do believe that yoga can help with these problems. That’s why we started this blog!

—Nina

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