Yoga for Chronic Pain

Worldwide, 1 in every 5 adults suffers from chronic pain (Breivik, Hattori & Moulin 2005). In the United States, the number is even higher. A recent survey found that more than half of Americans live with chronic or recurring pain that interferes with their mood, sleep, ability to work and enjoyment of life (ABC News 2005). The National Institutes of Health (NIH), citing pain as the number-one reason Americans seek medical care, estimates that the annual total cost of pain in the U.S. is more than $100 billion in health care and lost productivity (NIH 2003). To address this growing problem, Congress officially declared 2000–2010 the “Decade of Pain Control and Research.” Halfway through this 10-year period, yoga has emerged as a powerful tool to help relieve the suffering associated with chronic pain.

Chronic pain triggers vary broadly and include traumatic injury, autoimmune disorders and musculoskeletal problems. Whatever the initial cause, all chronic pain shares a common effect: the frustration it causes to both sufferers and healthcare providers. By its very definition, chronic pain—pain that lasts 3 months or longer—has not been successfully managed through medical treatment or self-care. Individuals with chronic pain have typically tried—and found little relief from—an exhausting number of remedies, including over-the-counter and prescription medications, massage, chiropractic care and physical therapy.

What makes chronic pain so difficult to treat? One important factor is that many suffer from neuropathic pain, meaning that the pain they experience is not in proportion to identifiable tissue damage or current injury (NPC & JCAHO 2001). Instead, the pain results from changes in how the nervous system processes sensation. These changes are often triggered by an injury, such as trauma to the spinal cord, or an illness, such as multiple sclerosis or diabetes (Galluzzi 2005). The nervous system, including the sensory nerves, the spinal cord and the brain, can become hypersensitive to pain perception (Katz & Rothenberg 2005). Sensory receptors in the joints or muscles, for example, may send signals to the brain that amplify and exaggerate actual painful stimulation. Another possibility is that the areas of the brain that interpret sensation may develop a bias toward interpreting nonthreatening sensation as painful.

On top of these changes in the nervous system, psychological factors such as expectations, coping strategies, stress, depression and anxiety (Hansen & Streltzer 2005) influence how pain is perceived. This doesn’t make the pain any less real, and it doesn’t mean that it is “all in the patient’s head.” It simply means that the physiological and psychological causes of chronic pain are complex and difficult to treat. Any successful treatment will need to take into account the mind as well as the body.

Because chronic pain is a mind-body phenomenon, many researchers and chronic-pain sufferers are turning to yoga for pain relief. Yoga integrates physical movement, which can play an important role in pain recovery, with mindful practices that address the cognitive and emotional components of pain. Studies show that yoga can reduce not only the experience of pain itself but also the emotional distress and physical disability associated with it, as well as the use of pain medication (Kolasinski et al. 2005; Garfinkel et al. 1998; Gaur et al. 2001). Two recent clinical trials demonstrated the benefits of yoga for back pain, the most commonly experienced form of pain among adults in the U.S. (ABC News 2005).

In one study, 101 adults with persistent low-back pain were randomly assigned to a 12-week yoga intervention; a 12-week exercise intervention; or a home study/educational book intervention (Sherman et al. 2005). The yoga program included weekly 75-minute group classes and home practice guides. The classes followed a gentle Viniyoga approach specifically designed for back pain (see the sidebar “Designing a Yoga Practice for Chronic Pain” on page 54). A physical therapist designed the therapeutic exercise intervention, which included education about biomechanics, along with cardiovascular and strength training exercises. Participants in the yoga group showed the greatest improvement in back function at the end of the intervention. Although all groups experienced some improvement in symptoms during the intervention, only the yoga group showed sustained and continued improvements in symptoms at a 3-month follow-up. The yoga group also reported less use of pain medication at 3 months than the other two groups.

Another study that focused on yoga for chronic pain in the low-back found that participation in once-weekly yoga classes was associated with significant and sustained reductions in pain intensity, functional disability and pain medication (Williams et al. 2005). Specifically, 88% of participants assigned to a 16-week yoga intervention reported decreasing or stopping pain medication by the end of the program, compared with only 35% in a control group that received lectures and handouts on self-care for chronic pain in the lower-back pain. The yoga classes in this study were based on the alignment-focused Iyengar style of yoga. Early in the 16-week intervention, classes emphasized restorative, passive poses to teach participants how to relax muscle tension. Subjects were gradually taught poses that gently stretched muscles attached to the spine and pelvis. They also learned standing poses that balanced flexibility and stability of the hips and core muscles. The authors concluded that the intervention would have been even more effective if it had focused on “doing fewer and less challenging poses.”

Effective yoga for chronic pain interventions tend to incorporate a wide range of traditional yoga practices. Researchers at the Pain Management Center at Texas Tech University Health Sciences Center in Lubbock, Texas, modeled their 10-week intervention on the Mindfulness-Based Stress Reduction Program developed by Jon Kabat-Zinn, PhD (Kabat-Zinn 1990). This program teaches participants breath awareness, body awareness (see the sidebar “Body Scan” on page 55), meditation and gentle hatha yoga. In a study of the program at Texas Tech University, 78 adults with habitual pain attended a 2-hour yoga and meditation class once a week and practiced meditation at home for 45 minutes a day, 6 days a week. All participants first received standard medical care for their pain and related conditions. The initial course of medical treatment did not improve participants’ symptoms, but they did report improvements following the comprehensive 10-week yoga intervention. Participants sustained these improvements at three follow-up points, including 1 year postintervention. Although the study group found all of the practices helpful, they ranked breathing and body awareness as more useful for managing pain than the yoga postures (Randolph et al. 1999).

Yoga practices that target emotional experience may play a unique role in reducing chronic pain. One example is the traditional loving-kindness meditation, which focuses on feeling love, compassion and forgiveness for specific individuals. A study by researchers at Duke University Medical Center found that participants who practiced loving-kindness meditation experienced both immediate and long-term reductions in chronic low-back pain and emotional distress (Carson et al. 2005). Other yoga practices that cultivate a sense of connection, including attending supportive group classes, may have similar benefits for reducing pain and the emotional distress that accompanies it.

Research suggests that self-efficacy, the belief that you can cope with the stress and challenges of a specific situation, is an important part of recovering from, or adjusting to, chronic pain (Turner, Ersek & Kemp 2005). Greater self-efficacy is associated with less pain-related disability and depression, even when controlling for pain intensity. Self-efficacy also predicts individuals’ willingness to use physical exercise and stretching as a way to manage pain.

Individuals often come to yoga for pain relief only after exhausting a long list of therapies. Many have tried everything from prescription drugs to acupuncture—none of which successfully resolved the pain. For this reason, the self-efficacy of a student entering a yoga class for the first time is typically very low. According to Ginger Garner, MPT, a physical therapist in Emerald Isle, North Carolina, who specializes in yoga for chronic pain, “Overcoming the hurdle of hopelessness is the biggest obstacle. People in chronic pain are often jaded toward health care and fitness, categorizing all of it as something they’ve tried that didn’t work.”

Garner recommends creating an immediate environment of success by having clients begin in a comforting, safe position (such as sitting in a chair, lying supine in relaxation pose or lying on the side with props for support) and teaching them how to breathe. Add movement later, she says, once clients experience success with basic breathing practices. Garner recommends keeping things simple, especially in the first few sessions. “Don’t discourage [clients] by giving too many poses or breathing exercises. People in chronic pain already feel overloaded with information—from doctors, therapists and their own bodies.”

Individuals in chronic pain tend to have low levels of fitness and experience greater perceived exertion during physical activity than pain-free individuals (Harding, Simmonds & Watson 1998). This is another reason why people with chronic pain will benefit from a gentle approach that encourages gradually increasing physical activity. Julia Payne, a registered nurse who teaches yoga in a comprehensive pain management program in Wheeling, West Virginia, advises, “Start slowly, listen to the students, and do less than you had planned.” Payne also gives students easy homework, such as a breathing exercise to practice for a few minutes each morning and evening. Simple instructions can create a sense of self-efficacy for people with chronic pain, who can be overwhelmed by elaborate advice. Success with basic homework will encourage them to continue with classes and home practice.

Chronic pain and fear of pain can become part of a vicious cycle: Fear leads to avoiding any activity that might trigger pain, and inactivity leads to greater physical disability and pain (Boersma & Linton 2005). Research shows that breaking this cycle, and being willing to engage in activity, is an important predictor of improvements in both physical function and emotional suffering (McCracken & Eccleston 2005).

“People with chronic pain need to develop safety and security in their bodies,” says yoga therapist Robin Rothenberg, a certified Viniyoga therapist and director of The Yoga Barn in Issaquah, Washington. “The only consistent message they get from their bodies is pain.” People with chronic pain need to learn that not all activity is dangerous and that not all movements will cause pain.

A “pacing” approach shows chronic-pain sufferers how to incorporate small periods of activity throughout their day or week so that being active is less likely to trigger an episode. Encouraging students to practice a little bit of yoga every day can help break the classic overactivity/underactivity cycle in which individuals avoid activity in general, overdo it when they feel relatively pain-free, and are then forced to spend several days or even weeks recovering. To help students develop the habit of gentle movement, give tangible “how-to” support for home practice, including handouts or audio instructions that describe poses and exercises learned in class.

In yoga, mindfulness is the ability to notice sensation, to focus attention on the present moment and to move with conscious intention. This turns out to be incredibly important for individuals with chronic pain, as they learn to face their fear of activity and develop new ways of being present in their bodies. Along with avoidance, many individuals have learned to rely on distraction as a coping strategy. Distraction makes it possible to ignore pain and perform an activity in the short term. However, people who use distraction as a coping strategy during activity experience more pain afterward than those who stay mentally engaged (Goubert et al. 2004).

Neil Pearson, MSc, a physiotherapist and specialist in yoga for chronic pain who lives in Port Moody, British Columbia, explains: “People with chronic pain become masters at distraction, but it’s the last thing you want to do during exercise. You won’t know the pain alarms are going off until you ‘come back’ mentally, and then they may be screaming.” By practicing yoga for pain relief, individuals learn how to be aware of sensation without overreacting to it. “You should not ignore pain signals, but you also have to stop overreacting to them, stop having the emotional catastrophizing reaction.”

Mindfulness allows individuals to feel sensation and determine what level of discomfort is acceptable as they try a new activity. Being mindful of sensation also helps people discover that there are, in fact, many movements that do not cause pain. When teaching mindfulness, it’s important to focus on the actions and sensations of a movement or pose and not on goals, such as touching your toes, or what the pose is supposed to look like. You want to give students an internal focus, such as the sensations of breathing, where they might feel a stretch, and the quality of their movements.

Yoga teachers and students often worry that chronic pain is such an individual problem that it requires individual instruction. No study has directly compared group and individual yoga instruction, and all of the published clinical trials on yoga for chronic pain have used group instruction. However, yoga teachers who work with chronic-pain sufferers report that there are clear benefits to both.

According to Payne, “One-on-one, you can focus on their specific issues. They often feel that for the first time, someone is taking their problems seriously. But in a group, they develop a sense that they are not alone in their suffering.” Garner requires every client to begin with a few private sessions, but she also encourages group class attendance. She has observed that in addition to providing support, group classes can create a sense of accountability. “Oftentimes, people need a little external motivation to stay committed to breaking free of their pain.”

Ideally, group classes should be designed specifically for individuals with chronic pain, even if the pain source and type vary. Many instructors have been successful teaching group classes that include students with chronic back pain, arthritis, autoimmune disorders and accident-related injuries. In such classes, it is even more important not to apply a one-size-fits-all yoga practice. Rothenberg advises, “The common thread is always the breath. When in doubt, just have them do more breathing and simple exploratory movement. You don’t need to teach everyone one form, one way to do a pose.”

Chronic pain is a complex and frustrating phenomenon. The good news is that effective yoga for chronic pain classes do not need to be either complicated or overwhelming. Research and experience suggest that the most beneficial interventions distill the practice of yoga to its core lessons: how to breathe; how to take care of yourself through conscious movement and a balance of rest and activity; and how to make peace with the present moment. These, of course, are useful lessons for all of us—not just those in chronic pain. But for those in pain, the lessons of yoga may mean the difference between the usual moment of suffering and the much-sought-after moment of ease in mind and body.

Breathing is the foundation of any yoga practice and is particularly important for participants taking yoga for chronic pain. Neil Pearson, a yoga therapist at the Orion Health Vancouver Pain Clinic and faculty member at the
University of British Columbia School of Physical Therapy, describes breathing as the key to disrupting the patterns of nervous system activation that create the experience of pain. “As soon as something triggers
the pain response alarms, the breath changes. It might be shallow breathing, hyperventilation or holding the breath. There’s nothing in the pain-alarm response that includes relaxed breathing. If you want to
calm the pain and stress, start with relaxed breathing.”

Relaxed Diaphragmatic Breathing is a healthy pattern of breathing in which the abdominal muscles relax during inhalation. This allows the diaphragm to descend and the lungs to expand with minimal effort. Individuals with chronic pain may habitually “brace” their abdominal muscles. This inhibits movement of the diaphragm, resulting in shallow, tense breathing. To teach relaxed diaphragmatic breathing, simply encourage students to relax the abdominal muscles and experience an attitude
of patience toward the breath. Relaxed diaphragmatic breathing does not require effort or power;
it is more about letting go of chronically held tension, and resting attention on the breath.

Instructions: “Begin in a relaxed, supported position, sitting or lying down. Notice where you are holding tension in the body: shoulders, hands, jaw. Relax as much as possible. Bring awareness to your breath. Close your eyes, if that helps you focus. Notice every inhalation and exhalation, without trying to force a particularly deep breath. Simply notice your belly rise as you inhale, and
fall as you exhale. You can place your hands on your belly to feel
this movement. Let the belly relax. You don’t need to do this movement on purpose or with effort. If your mind wanders, just bring it back to the breath. Feel the ease and spaciousness of observing the breath. If you are in pain, you can imagine the breath washing over and through the area of your body that is in pain. Practice for 5–15 minutes.”

Robin Rothenberg, a certified yoga therapist in Issaquah, Washington, recommends the following teaching strategies when designing a yoga program for chronic-pain sufferers. Rothenberg designed and taught the classes for a recently published randomized clinical trial of yoga for chronic pain in the lower-back (Sherman et al. 2005). This was the first large-scale study to compare the benefits of yoga and traditional exercise for chronic pain. The researchers found that a yoga practice using the following guidelines was more effective than traditional exercise. For the study, each class had a specific focus (such as relaxation, strengthening the hip muscles or customizing
a personal practice), and included a question-and-answer period, an opening and closing breathing exercise, five to 12 adapted yoga postures, and a guided deep relaxation.

1. Start with relaxed breathing in a supported position, such as lying down. As you introduce movement, go slowly, and structure the class to include plenty of repetition and rest.

2. Break down complicated classical yoga poses into simple movements and stretches. Individuals with chronic pain may hold tension in many areas of the body and have many pain triggers. They need the opportunity to explore basic movements that do not cause pain. For example, have students lie on their backs and lift and lower one arm. Ask them to notice where they feel tension: in the neck, shoulder, back? Does one side feel different from the other? What can they do that does not cause pain? Include a few “whole-body” poses near the end to help students integrate the isolated movements.

3. Encourage students to explore a movement rather than hold a pose for a long time. Focus on moving in and out of poses with the breath. Rehearsal creates greater ease and confidence and can reduce the fear of movement so common among individuals with chronic pain.

4. Use props, such as blankets or chairs, to make poses more accessible. Students learn to notice how they chronically hold tension in the body and how they can release that tension using support.

5. Know basic principles of yoga alignment, but do not force students with chronic pain into preconceived ideas about what a pose should look like. Look at the student in front of you and what he or she can do. Be willing to create an intelligent adaptation, and allow different students to practice a pose or movement in different ways.

The body scan practice develops sensation awareness with body acceptance—an important aspect of learning to cope with chronic pain. The practice can also induce a feeling of relaxed well-being. The following instructions are adapted from the mindfulness-based stress reduction program developed by Jon Kabat-Zinn, PhD, and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School (Kabat-Zinn 1990). The body scan can take up to 45 minutes and may be practiced daily. It can also be adapted in a shorter form to begin or end a yoga class. Have clients practice in a comfortable, lying-down position, with eyes closed.

Preparing: “Notice your breath, and feel the sensations of your belly rising and falling as you breathe. Notice the ‘whole sensation’ of your body, including your position, how your body makes contact with the floor, and any sensations (including pain) that arise. Practice simply being present to sensation.”

The Body Scan: “Direct your awareness to the toes of the left foot. Feel the sensations in the toes. If you cannot feel the toes, simply imagine them. Imagine breathing in and out of the toes for a few breaths. Then relax this focus and return your awareness to the sensations of the breath. Move on to the left foot, the left leg and then the pelvis. Repeat this process of feeling sensations. Imagine breathing in and out of each area of the body, and return your awareness to the sensations of breathing. Move on to the right toes, right foot and right leg. Move through the belly, back and chest; through the shoulders, arms, hands and fingers. Finish with the neck, head and face. If pain arises that competes for your attention, spend more time breathing in and out of the painful area without trying to distract yourself or striving to get rid of the pain. Finish the body scan by imagining the breath moving through the whole body, from head to toes.

For Adapting Yoga Poses to Individuals

Kraftsow, G. 1999. Yoga for Wellness: Healing With the Timeless Teachings of Viniyoga. New York: Penguin Arkana.

For Using Props and Support in Yoga

Iyengar, B.K.S. 2001. Yoga: The Path to Holistic Health. London: Dorling Kindersley.

Lasater, J. 1995. Relax & Renew: Restful Yoga for Stressful Times. Berkeley, CA: Rodmell Press.

For more information on yoga for chronic pain, including research and training opportunities, visit these websites:

International Association of Yoga Therapists, www.iayt.org

The Center for Mindfulness in Medicine, Health Care, and
Society, at the University of Massachusetts Medical School, www.umassmed.edu/cfm

For more information about chronic pain, visit the following sites:

American Chronic Pain Association, www.theacpa.org

American Pain Foundation, www.painfoundation.org