First published in What Doctor’s Don’t Tell You Magazine.
Chronic pain is one of the most difficult symptoms to describe. Pain is subjective to some extent and we cannot feel the experience of another. Living with chronic pain of any kind is a source of internally generated stress that can also create external challenges as people struggle with daily life and everyday tasks others might take for granted.
Some of the most common causes of pain are conditions such as migraines, arthritis, osteoporosis, fibromyalgia, endometriosis, auto-immune conditions like lupus and bladder problems. Back pain makes up a large proportion of sufferers and most yoga and pain focusses on chronic lower back pain. The Office for National Statistics (ONS) reported that 31 million days of work were lost in 2013 due to back, neck and muscle problems, with sedentary habits – particularly sitting on chairs – at the heart of the problem.
The physiology of pain
Pain can be somatic, from inflammation (part of the stress response), visceral from Irritable Bowel Syndrome or hyper-sensitivity at the gut wall or directly from tissue damage or neuropathic, where autonomic functions like blood flow may be altered. Often the cause is not known and medication the only offered treatment. The stress of pain can exacerbate it by fight-or-flight factors like blood vessel constriction and build-up of toxic muscle metabolites from increased energy for perceived physical response.
Multiple pathways in the central nervous system are involved in the experience of pain. Through the emotional limbic system (via the amygdala), whether a sensation is perceived as pleasurable or not, determines whether stress may create fear, panic and anxiety. Pain can have the effect of continually sounding a bell in the brain to react.
Chronic pain is described as “Pain without apparent biological value that has persisted beyond the normal tissue healing time” (IASP), rather than pain on a usual level that acts as protection e.g. not putting weight on a sprained ankle or attending to a wound. There is a large cross-over with chronic pain and mood-related issues; low levels of neurotransmitters such as mood-regulating serotonin and nervous system calming GABA (gamma-amino butyric acid) have been implicated and the NHS cite that 65% of people with depression also experience pain. Pain itself can also create difficulty sleeping, low energy, anxiety and poor concentration and may lead to substance abuse and addiction, both pharmaceutical and recreational.
Mindful yoga for pain
Yoga has shown to benefit all of these aspects, as movement and as a meditative, mindful and contemplative practice (Complementary Therapies in Medicine, 2013: 313-23). Researchers are exploring that the ‘stilling of the mind’ at the heart of yoga is related to its ability to raise GABA levels in the body (Journal of Alternative and Complementary Medicine, 2010: 1145–1152). GABA reduces the incoming signals of peripheral and central nervous system sensitisation, meaning lowered pain transmission from nerves and higher pain thresholds. These practices have shown to create brain alterations through neuroplasticity that have both immediate effect and then with regular practice have a cumulative effect to build resilience and less stress-inducing responses to stimuli like pain (Evidence Based Complementary and Alternative Medicine Journal, 2014: epub).
Research has shown mindfulness helps reduce and change perception of pain, with smaller brain activity in the amygdalas of experienced meditators (World Journal of Radiology, 2014: 471-9) – this is the brain region where first response to stimulus occurs; lower activity here shows greater threshold and handling of strong stimuli. Another review reported, “interventions such as meditation not only decrease pain but also have powerful protective effects on brain grey matter and connectivity within pain modulatory circuits.” (Nature Reviews Neuroscience, 2013: 502-11)
An accessible solution
Yoga offers a self-controlled, modifiable and accessible route to pain management. Women with fibromyalgia practising a 75 minute yoga class twice weekly for 8 weeks showed not just pain reduction, but also lowered catastrophising about the pain, increased acceptance and mindfulness, and lowered stress hormones (Journal of Pain Research, 2011: 189–201). Movement, slow breathing and flexibility training all help to reduce pain by removing toxic build-up, engaging the calming parasympathetic nervous system, making more oxygen available to body tissues and releasing mood-enhancing endorphins that reduce pain intensity and increase tolerance.
Whilst many living with chronic pain may avoid movement through fear and exhaustion, coaxing new levels at a pace that feels safe may help to create change with increased feelings of hope – vital for the mood issues that commonly run besides chronic pain.
A recent review paper stated that “Because chronic pain affects the whole person (body, mind, and spirit), patient-centred complementary and integrative medicine (CIM) therapies that acknowledge the patients’ roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management” (Pain Medicine, 2014: S40-53).
Yoga Sequence to Help Prevent and Relieve Chronic Pain
This sequence combines movements and stillness to encourage both fluidity and the ability to be with strong sensations with less fear and reaction. Listen to your body above all and feel free to play with what feels right and back away from that which does not.
Joint loosening movements
These simple movements are called pavanamuktasana ‘wind-relieving’ movements in some yoga schools. They help keep the synovial fluid that cushions and allows movement in joints to stay fluid and not become viscous and sticky. This can help people with pain or limited mobility in joints, but also encourages freedom of movement that stops tensions building in muscles located near those joints. Moving joints first allows stretches through them to be beneficial rather than adding to strain.
Practice slowly and mindfully, feeling each part of the experience and breathing space and compassion into areas where you meet any pain. Explore how you might be able to move in towards it with an inhalation at times and, at others, just play around the edges; using full and releasing out-breaths to invite pain to change and move through. This kind of attunement can help you learn to be with pain with less reaction and stress, whether in movement or stillness.
Do these lying if possible (with legs bent, feet hip-width or wider on floor) so your whole body is supported by the ground and effort is therefore isolated into the joint moving. Support your head with a folded blanket to ensure no neck tension present. Choose another comfortable position if you need.
- Open and close hands to open out across all of the finger joints.
- Make fists and rotate into your wrist joints, one direction and then the other.
- Hold your arms comfortably out to the side palms up, then draw hands into towards your shoulders and back again, through elbow joints.
- With ankles still, wiggle and moves toes, opening them out as best you can and moving up to the top and bottom of your foot.
- Move your ankles in full circles, one way and then the other.
- Point and flex your toes, feet in same pattern as each other and then alternating for added focus; squeeze toes together as you point, spread them out as you flex.
- From legs bent, feet hip-width on the floor, draw one knee into the chest at a time and lift the foot up and down for movement through the knee joint, focussing on feeling the movement equal through insides and outsides of knees to support their natural range of movement.
- From legs bent, lying down let one knee drop out to the side. From here, either drawing it back in to open into the hip joint or (if fully happy for your lower back) once out, keep it rotated outwards and lengthen out, then rotate it in to toes pointing up to ceiling and draw back up to the start position. Do this movement about ten times on each side.
- Move your jaw around and scrunch into your face to release tension and habits of expression there – note if pain is created when holding a frown or clenched teeth and even exaggerate these to direct muscles to let go where they’ve been locked in contraction.
If movement is limited in any area, imagine making the movement. Your brain and nervous system experience movement along the same communication pathways by visualisation, helping create connection and bringing back a sense of the whole to our mind-body.
Much pain can originate from muscular patterns that don’t support the spine up from gravity and may compress nerves, compounded by daily habits of hunching. With hip, spine and shoulder issues, sitting upright on the ground can be difficult. Sitting consciously on a chair – with ears above shoulders and shoulders above hips – allows uplift with more space between vertebral discs.
In the beginning this may feel straining or sore as muscles adjust, but this can change as new postural habits settle in. Fully breathing and paying attention to creating strength with ease can keep the shoulders released, face soft and breath dropping down into the belly. This is crucial to keep the calm nervous system tone needed to change pain responses.
Helping to release the tension of pain held up into the shoulders can help our ability to allow our breathing to drop down into the diaphragm and belly, not just stay confined to upper chest and shoulders, which holds us in stress mode.
Breathe attention and looseness into your shoulders, then inhale to bring them forward and up towards your ears. As you exhale then draw them back and down, creating full circles that you can feel deep into the shoulder girdle, meeting any tensions and crunchy bits with smooth breath and a soft jaw.
Long-term pain and tension can both originate and end up in the top of the back and neck. These neck rolls also provide an antidote to compression at the top of the neck common with habits of hunching and then looking up, e.g. at a desk, looking at a computer.
Take your chin to your right shoulder, keeping both shoulders soft. Inhale here:
Then exhale your chin down in a semi-circle past your breastbone and up to the left shoulder. Inhale there and reverse back up, exhaling back to the right.
Continue this movement just behind long and spacious breath to feel an opening at the top of the neck. Continually lift the spine and release into shoulders and trapezius muscles at the top of the back as you exhale.
These can be done seated (figs 1 and 2) or if hips and knees don’t feel happy there on a chair (figs 3 and 4). Then if we follow the natural rhythm of the breath – rounding the back as the lungs empty on the exhale and arching as they fill on the inhale – we can open the back and then front of the spine to create movement and flexibility that helps free compression that can add to pain. Include the neck as part of the spine, reaching up through the sides and back particularly as you arch. Use your breath to create the body awareness needed to gauge the right range of motion for you, noticing that this can change daily.
Figures 1 & 2
Figures 3 & 4
Matsyendrasana (sage twist pose) supported standing or chair variation
Stand feet hip-width apart behind a chair and lift up one leg onto the seat, raising up from the standing leg. Lift your arms to lift your spine and twist towards the bent leg, bringing the opposite hand across it. Take the other hand to the back of the pelvis, pointing down to allow that shoulder to drop and collarbones to open. On the inhale create length upwards from the ground to the crown of the head and allow rotation with least compression on full out-breaths. Repeat on the other side.
If standing is too strong or creates lower back pain, a seated version with knees and feet together can help. This is also a great pose for relieving back pressure at a desk.
Balasana (child pose) variation on chair
This is a great version for those who feel foot or knee pain in the pose on the floor. It also lets the head drop beneath the hips to fully release the back of the neck and open the upper back. From legs 90 degrees apart, start with elbows onto thighs to find how far your body is happy to come down. You may stay there (especially if you tend to dizziness) or drop lower, even with hands on blocks to come halfway. Roll up head last to come up.
Setu Bandha Sarvangasana (bridge pose) – variation to chair
This version is softer on the upper back than regular bridge pose and is also a shoulder stand alternative with less weight on the neck, yet still benefiting from a circulation supporting inversion. Start back on the ground, close enough into the chair to fully grab hold of the front legs. Bring the feet onto the very front of the seat and, keeping them hip-width apart, lift up the pelvis on an inhale, opening the chest. Soften your face and jaw to stay opening your heart with soft breath, rolling down to rest when your body signals.
Savasana (corpse pose) variation with chair
Lying for the final relaxation with legs up onto a chair creates length into the lower back that can relieve compression there and help avoid lower back pain. With legs above the heart, lymphatic flow from the lower to top body can fall down with gravity, encouraging relaxation as the heart needs to pump less as blood simply drops down too. Stay a while with any mindfulness practice that works for you or try the “Golden Thread Breath” exercise below.
Golden Thread Breath
This is a very simple practice that gives you a focus to observe any thoughts, feelings or bodily sensations that you wish to let go off or change in nature – including pain. Step back from expectation or labels of ‘good or bad’, ‘pleasant or unpleasant’ that may arise, to allow yourself to simply feel and invite letting go. This is sometimes easy, sometime not, but try to notice that everything is always changing in order to bring acceptance to each moment.
- Breathe with a focus on the out breath, with a full emptying of the lungs – without force or pushing, simply what is easily on offer at any time.
- Then visualise a golden thread leaving your nostrils, riding on your exhalation and moving in a beautiful flowing line out of your body. Simply let this vessel carry away whatever you are ready to release, watching with curiosity to notice how your body feels as these changes happen.
- Step back from expecting a result, solution or outcome from this practice, rather use the lovely image of the golden thread to cultivate release without labelling what you don’t need as ‘bad’.
To come out, roll to whichever side feels most safe and take your time coming up.
Heal your body
Join Charlotte in her weekly yoga classes, aimed to heal and restore strained, tired and hurting bodies. Focusing on a mindful, connected practice, Charlotte guides her students at a pace that suits them best, with the only “outcome” to be present. For prices and more information visit this page.
Unsure you’ll meet your body’s full needs at a group session? Charlotte also offers private one-on-one yoga tuition, allowing her to tailor the entire session to your wishes. Whether it’s a one-off or regular occurrence, more information can be found here.