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).

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.

For The Young and The Old: Back Care

by Baxter

Back in the day, say 20 years ago or so, when I was a Family doc back in Cincinnati, every day someone came into my office with the problem of low back pain. And if it was your average run-of-the-mill, muscular strain-style back pain, regardless of what I had to offer, things usually got back to normal in about six weeks. However, for the smaller percentage of patients whose pain did not resolve in that time frame, difficulty often lingered for much longer, and there were a myriad of possible underlying causes to account for the situation.

My tools at the time included medications, referrals to physical therapists, and finally consultations with specialists like orthopedic or neurological surgeons. The latter two groups were often interested in offering surgery as a solution, since that was their main “tool” of healing. However, the results rarely matched the billing, and often these same patients would return following a procedure with little or no change in their baseline symptoms.

To say the least, I found myself very frustrated with the repeating scenario I was a part of. What I had to offer did not seem to be very effective; the patients were also frustrated, anxious and worried about what the future held for them. At that time, in my community, hatha yoga was not mainstream, and certainly was not looked upon as a possible therapeutic option for addressing chronic pain of any sort.  Fortunately, the winds of change started blowing at just the right time!

From Yoga: The Poetry of the Body by Rodney Yee with Nina Zolotow

As I began to explore yoga personally and eventually transitioned into teaching and using it therapeutically with my students, it became very clear again and again how helpful yoga practice is in addressing not only the root anatomical, kinesiological issues in back pain, but also in providing prompt benefits for the mental and emotional issues that arise due to chronic pain: anxiety, depression, frustration and disappointment. I suspect that we will return to talk about back pain a lot over the coming weeks, months and years, so today’s post is really an opportunity for me to give you some background thoughts on low back pain and chronic pain in general, with an eye to expanding and addressing more specific issues as we travel along together. Update: See here for further information (and a sequence of poses).

In the meantime, I recommend you read Brad's post from last week (see here). He makes some very important observations regarding the research that has been done to date on this issue, and again reminds us all that ultimately we need to do our own personal study of yoga on our health, sometimes with the caring and expert guidance of our yoga teachers and sometimes on our own.


There are a more and more good books available to all of you out there to get you started on applying hatha yoga techniques to healing your back pain. Now classics are Mary Pullig Schatz, MD’s 1992 Back Care Basics, which is grounded in the Iyengar tradition, and TKV Desikachar’s The Heart of Yoga, which is not specifically a back yoga book but introduces a different and equally powerful method of working with yoga and your body. And if you find yourself in the San Francisco Bay Area, please join me any Monday night at Piedmont Yoga Studio (see here) for my ongoing series of Back Care Yoga. Until the next time, happy backs to you!