Mindfulness Meditation and Pain Management: Recent Findings!

by Ram

Branches by Melina Meza

This is part one of two articles that focus on some of the latest findings on meditation and its an amazing variety of neurological benefits. Dhyana or meditation is a state of being where the mind stops wandering, is calmer, and maintains a period of stillness. In this state of mind, an individual no longer possess bodily awareness, the sense organs are not distracted, and the stillness produces few or no thoughts at all (see Yoga Meditation Techniques). One of the original goals of meditation was to quiet the mind. Because our minds are typically busy with thoughts and emotions—many of which disturb our equanimity—quieting the mind and letting go of these daily dramas of life allows us to experience feelings of peace and contentment. Meditation also fosters feelings of compassion, which improve relationships with others. And you can also use meditation to cultivate feelings of gratitude that in turn fosters contentment (Honesty and Contentment in the Yoga Room). There are many different kinds of meditation. Some are designed to help us relax; others are meant to produce altered states of consciousness. 

Mindfulness meditation is one of the techniques where your mind is not only fully aware of the stillness but also keeps observing when your attention starts to wander from the object of the meditation (in most cases the object of meditation is the repetitious breath, flow of thoughts, emotions or feelings). And as you observe these objects with a sense of detachment, you will notice familiar patterns that may seem irrelevant to harbor and you may want to let go these patterns. Detachment or letting go of these patterns helps in cultivating equanimity in your daily life (Meditation and Equanimity). Thus, mindfulness meditation allows you to observe your habitual thought patterns and emotional responses and provides the opportunity to change them to more positive ones. Mindfulness meditation helps us become aware of what is already true at every moment, providing us with an opportunity to become more present with ourselves just as we are. This, in turn, helps us to overcome the unnecessary suffering that results from trying to escape the discomfort and pain that we experience in our daily lives.

Today’s discussion is about mindfulness meditation and its role in alleviating the acute pain response. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and is part of the body’s inherent protective mechanism to motivate the individual to pull out from a damaging situation and prevent further damage to the tissue, allow the damaged tissue to rest and heal, and avoid similar encounters. Thus, the phenomenon of pain is beneficial in a true sense when, for example, your back sustains a blow and the injured tissues need care and protection (Understanding Pain). 

Just like inflammation, the phenomenon of pain is generally transient, and recedes when the stimulus is removed or the damaged tissue has healed (How and Why Yoga Helps with Pain). When your body encounters an acute pain stimulus, your brain releases a large number of pain reducing chemicals called opioids. Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord, gastrointestinal tract, and other organs in the body. The binding of the endogenous opioids to their specific receptors results in reduction of the perception of pain. However, there are certain abnormal pathological conditions where pain is a constant feature and persists for a long time (chronic pain). While in some chronic cases the levels of the endogenous opioids are not sufficient to alleviate the pain response, in most cases the body becomes insensitive to the body’s levels of opioids. Chronic pain that lasts beyond the expected period of healing can interfere with a person's quality of life and general functioning. Unfortunately, chronic pain brings with it other health issues including constant fear, worry, anxiety, depression, and memory deficits and turns out to be the most common reason for individuals to visit their physician (Techniques for Managing Pain with Yoga). 

One of the methods of pain management is the external administration of opioids like vicodin, morphine, codeine, or oxycontin. These external opioids not only blunt the pain response, they also produce a euphoric response since they also affect the brain regions involved in reward. Regular or long-term use or abuse of opioids can lead to physical dependence and, in most cases, addiction. Naloxone is a drug that works as an antidote to the opioids and is mainly used to reverse an opioid overdose. Naloxone works by blocking the analgesic (anti-pain) and the euphoric response of the opioids in the system. Naloxone only works if a person has opioids in their system; the medication doesn't work on other drugs. 

Now what does all this have to do with mindfulness meditation? Well, we know that meditation produces relaxation and the lovely blissful feelings that result from release of tension. The question is: does meditation trigger the release of endogenous opioids which in turn produces the pain relief and the pleasant effects thereafter? This was the premise of a new study Mindfulness-Meditation-Based Pain Relief Is Not Mediated by Endogenous Opioids in which the researchers set out to ask a simple question, “does mindfulness meditation (MM) produce pain relief and if yes, then does it do so through the release of endogenous opioids”? 

The double blind randomized study involved 78 healthy, pain-free people who were randomly assigned to receive different interventions. The first group was trained in mindfulness meditation for 20 minutes a day for four days. And the second group, which served as a control group, spent the same amount of time listening to a book read aloud. The scientists then exposed all the participants to a pain stimulus by placing a hot probe on the back of their legs. The group that practiced mindfulness meditation experienced significantly reduced pain intensity and pain unpleasantness than the control group. 

The next thing to determine was if the pain reduction in the mindfulness meditation group was due to release of endogenous opioids. One way to test this was to block the release of endogenous opioids (if any) by administering the drug Naloxone, which would then reverse the beneficial analgesic effects of mindfulness meditation. (A control group was given simple saline as a placebo.) To the surprise of the researchers, the meditators who received the drug Naloxone before being subjected to the hot probe continued to experience significantly reduced pain intensity and pain unpleasantness than the control group, suggesting that Naloxone administration failed to reverse the meditation-induced pain relief. There were also no significant differences in pain intensity or pain unpleasantness reductions between the meditation + naloxone and the meditation + saline groups.

The findings clearly demonstrate that mindfulness meditation eases pain through some distinct pathways that are independent of the endogenous opioid mechanisms, suggesting that meditation-based pain relief does not require the role of endogenous opioids. The researchers do not have a clear explanation of the effect of mindfulness meditation on the brain that results in the pain relief. But based on their past results, they believe that meditation activates several regions of the brain that are associated with emotion regulation, focus, and cognitive control. At the same time, meditation also down-regulates the thalamic activity that transmits painful information from and to the body. Thus, the global effect of mindfulness meditation helps to prevent pain and painful information from spreading throughout the brain and body. 

It remains to be determined whether mindfulness meditation would be helpful in the treatment of chronic pain and also be effective in overcoming opiate drug abuse. For now though, mindfulness meditation seems to be a very attractive technique for acute pain relief and for those seeking a non-opiate pain therapy. And, if this is the case, getting hooked on meditation would also be a perfect panacea for pain and other pathological systems some of which we described earlier (Meditation: Effects on Gene Expression). 

This reminds me of an anecdotal report of a senior monk who underwent a complicated surgery without the use of any anesthetics. His years of meditation practice helped him to tide over the pain during and after the surgery. But based on the above-mentioned scientific study, it is also clear that you don’t need to be a monk to reap the benefits of mindfulness meditation. 

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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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Yoga, Pain Management, and Sound Therapy

by Ram

Ann Dyer, Yoga Teacher and Musician, by Melina Meza

Yoga stress management practices, including meditation, focused relaxation, and relaxing asanas, help manage stress, which can have a feedback effect on improving pain. In my post How and Why Yoga Helps with Pain, I highlighted the benefits of yoga in curbing pain. Yoga (asanas, meditation, and pranayama) helps in the following ways: 

• Triggers increased flow of oxygen to the brain and muscle tissues that improves energy levels and sense of wellbeing.
• Helps to release muscle tension and stretch the muscles thereby reducing the intensity of the pain
• Creates more mental clarity thereby decreasing the level of perceived suffering
• Helps manage stress that can have a feedback effect on improving pain.
• In animal models and in humans, studies show that the practice of yoga reduces pain perception. 

In today’s article, I present yet another evidence-based study that describes the benefit of another Yoga relaxation technique, the effect of sound therapy in reducing the pain response. In several yoga studios, the practice of asans is accompanied by soft sounds of music. The sounds could be from an audio setting or it could be a live music. Several Bay Area yoga studios also feature soft music/kirtans/mantra recordings/or live chanting while the asana class is in progress. In some cases, teachers start and end their practice with the chanting of Aum, an invocation to Patanjali or Ganesh, a Peace (shanti) mantra, etc. For a moment, keep aside your religious affiliation and recall just what those sounds did to your body, mind, and intellect. If you are unable to recall, the next time you are in a class where the asana practice is accompanied by some sound, be more attentive and notice what it does to you before and after the class. 

In my own home practice, I always like to play some soft music as I go through my Yoga routine. When I hear the mantras or sounds of Aum or some musical sounds of nature, a sense of calmness prevails, the chattering in my mind stops, and I feel more attentive and motivated. This state of the body and mind helps as I go through my asana practice. Did you know that since time immemorial, sound was used as a healing tool in almost all of the spiritual traditions? Be it the soft temple bells, chants of Aum, notes from various musical instruments, resonance from the tuning forks, crystal bowls, or Tibetan bowls, among others, sounds have been an integral part of the healing power of not just Hindu or shamanic culture but other traditions as well. My grandfather and his colleagues practiced Sandhya-vandhana (salutations at dawn and dusk that included asanas, mudras, meditation, and pranayama), either at the temple courtyard, in the farm, or by the riverside so they could tune in to the gentle sounds. 

The basic principle of sound/music therapy is that the tune, articulation, pitch, and the arrangement of the musical notes have a major impact on a person’s body, mind, and intellect. Pleasant and relaxing sounds shift the predominant beta brain waves (which keeps us aroused, alert, but also stressed) to alpha waves that puts the individual in the state of “Zone/Flow,” characterized by a state of improved focus, concentration and performance (see Positive Psychology vs. Yoga Philosophy). This is also the state characterized by the release of feel-good brain chemicals, such as endorphins, noradrenaline, and dopamine. Sounds alter the energy patterns in the body and mind, facilitate the connection between mind-body-intellect, and transform the individual into a high state of consciousness. This is why sound therapy is highly recommended for panic attacks and anxiety. Sound therapy serves as a tonic to the brain and is used frequently in the treatment of depression and pain as well.

In a recent study entitled “Complimentary effect of yogic sound resonance relaxation technique in patients with common neck pain," a group of scientists decided to investigate the role of a yogic relaxation technique called mind sound resonance technique (MSRT) as a form of non-surgical management for chronic neck pain. MSRT involves paying attention to the vibrations and resonance from chanting the syllables A, U, M, (Aum/Om) and the Mahamrityunjaya mantra sounds, with the eyes closed. It can be practiced in a supine or sitting posture. The chants are an alternate combination of loud chants and mental sounds repeated three times.

The sample size consisted of 60 literate patients in the age group of 20–70 years with no previous exposure to yoga. All of them suffered from chronic neck pain due to spasm (myalgia), strain of the neck muscles, ligament strain, or cervical spondylosis. Patients were randomized into two groups of 30 each using a computer-generated algorithm. The group included 28 females and 32 males. Both groups received conventional physiotherapy for 10 minutes and ultrasound massage for 10 minutes. Following these procedures, the control group had a non-guided supine rest for 20 minutes. The Yoga group received the mind sound resonance technique (MSRT) through a prerecorded audio tape played with head phones for a period of 20 minutes. The chants alternated from loud notes (Ahata) to unheard sounds (Anahata-mental notes). Instructions were provided to relax, focus, and concentrate on the sounds. The sessions lasted for 10 days. 

Data was collected before the onset of the study and on the final day. Several parameters for pain were measured. Improvements in neck muscle tenderness, neck disability, and movements of the neck were observed in both groups. The MSRT-yoga group showed significant reduction in pain (by 95.5%), tenderness (by 92.82%), and neck disability (91.32%). The cervical spinal flexibility, movements of the neck, (flexion, extension, lateral flexion—to right and left—and lateral rotation—right and left) all improved significantly in the MSRT group compared to the control group. 

This study reminded me of Jon Kabat-Zinn’s impressive articles on mindfulness and pain management all of which point out to the fact that mindfulness strategies including but not limited to relaxing and meditative sounds serve as an appropriate adjunctive treatment for chronic pain by lowering stress, reducing pain response, improving mental emotions, and physical flexibility. So if you wish to see health benefits from your yoga practice, you could complement your practice by  listening to or chanting  soothing/relaxing sounds.

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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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Friday Q&A: Neck Pain and Fear

Q: I read of yoga for back pain, but little about neck pain. I've been in PT for months, with good ideas about posture/extension/alignment, etc. And now I'm in a series of skillful massage targeted to the neck muscles...but such stiffness in spite of it all! Did yoga for years, but not lately (still active!) I'm wary of yoga that my pain might be exacerbated. I'm 52. My work is varied, with some hours at a desk but broken up with people interaction. Thanks for your counsel!

 A: I understand why you might be afraid of doing yoga again but I want to reassure you that starting to practice again will be beneficial for you in so many ways. I currently have a student with a lot of physical challenges and chronic pain from prior surgeries. She has told me so many times that even though her body may not be able to move the way she wants it to, when she wants it to do something, she finds that “yoga is good for my mind. It makes me tune in and just listen to myself.” This individual needs a lot of modifications when she practices, but because she trusts both me and my co-teacher Bonnie, she is willing to try new things, "even when they are scary,” specifically because she knows she can stop WHENEVER she needs or wants to and we respect her decisions. We have a “circle of trust” in our class that is very valuable to both the teachers, the students and our assistants.

The great thing about yoga in my mind is the ability to stop whenever necessary. The practice is an internal dialogue not an external show. Sometimes we need to be reassured we can still do an activity but are afraid because it might hurt. Well, if something or an activity causes an increase in pain, then we have the ability to stop the action. Sometimes although our minds fear something when there really isn't a physical correlation between the fear and the action, we have to teach our mind not to fear the action. It is kind of like relearning to ride a bike when we have fallen off in the past and done some serious damage but now have the desire to get back on the bike. But where to start? With all activities it is helpful to imagine the activity first before attempting it. So, if you had some yoga poses that you used to do that gave you pleasure, start with those. I would set myself up in a position of comfort where I was warm and felt safe, and then I might mentally begin the practice using only my memory. After a while of envisioning the pose, I would try it just a little bit. If I felt scared that I was going to hurt myself, then I would stop and leave it and try again tomorrow.

If this type of mental re-entry into yoga doesn't work for you, then you might re-contact your teacher (if you had one) and ask to talk about your concerns about returning to a class. If you don’t have a teacher anymore, look for someone in your local area who has experience with working with individuals with neck injuries and discuss your concerns about re-entering a class. If that isn’t possible, look for a class either for people recovering from injuries or with a gentle focus, and, again, approach the teacher with your concerns. Going back to a class has to feel safe for you, and in order to feel safe you have to be able to trust the teacher to not make you do more than you are comfortable with. Don’t be afraid to be frank about your needs and to have the ability to keep yourself safe. If you still can't find a teacher who fits this profile, contact the International Association of Yoga Therapists and ask for a teacher in your area or near to you that you can work with. They keep a registry on file for all members.

 And finally when you do begin to practice I would follow the motto of “less is better” because more than that might spiral you back into a flare-up cycle and put you off of yoga for quite a while. Poses that I particularly like when my own neck is feeling fragile are more passive poses like Viparita Karani (Legs Up the Wall pose) or a passive backbend over bolster with neck and head support. Active practice like standing poses with arm motions often make my own neck feel worse, so go easy on those. Learning to twist again without using arms for leverage also is important. I also like Chair Shoulderstand with a bolster under my upper back and no weight on my neck.

You mention only the physical aspect of asana but as you can see on many of the posts on our blog, that is only one small part of the practice of yoga. I might use this opportunity to re-visit some of the other limbs of yoga, especially some pranayama or basic breathing practices. The ability to fully breathe is a gift in learning to manage chronic pain and stiffness because it's like doing a massage from the inside out. I suffer from major neck issues myself, and I find that my neck will often let me know when I am overworked or overly stressed because the littlest things can set off my own pain cycles. There is no quick fix, but there are many pieces to the puzzle in learning how to manage ourselves in life.

—Shari

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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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