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.

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.

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