Interview with Shari and Bonnie on Yoga for Chronic Pain

by Nina, Shari, and Bonnie

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

Grasses and Reflections by Brad Gibson

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

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

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

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

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

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

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

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

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

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

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

NINA: Why is yoga particularly helpful for chronic pain?

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

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

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

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

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

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

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

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

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

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

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