Movement, and exercise generally, are crucial aspects of effective pain management in the case of long standing pain conditions.
Pain is a vital aspect of the body’s defence mechanism. However, when pain responses occur beyond normal physiological healing times, this type of pain is counterproductive [1].
A rapidly expanding body of research is demonstrating that mind-body exercise, specifically yoga, can be immensely beneficial for managing persistent pain [2-8].
Improving function (e.g. one’s ability to engage in daily household tasks, work, socializing etc.) through mindful exercise has profound beneficial ‘flow-on’ effects, including reduced disability, reduced depression and improved physical conditioning and increased subjective quality of life.
Yoga, health and pain management.
Here are some of the evidence based benefits associated with yoga and mindful-exercise:
Improved general quality of life [9-11]
Improved general health (cardiovascular, musculoskeletal, cognitive) [12-15]
Improved mood (especially depression) [16]
Improves immune function (your body’s ability to fight infection or illness or stress) [17-19]
Helps regulate sleep patterns [20]
Reduces stress [21-22]
Increases access to your own natural pain modifiers (Endgenous opiates, .i.e endorphins) [23-26]
Helps with weight control (important if you have additional chronic disease like diabetes or heart disease) [27-29]
Helps turn the ‘pain volume’ button down and reassure you that some pain with movement is normal and does not mean more damage [30], [31]
The science of beginning yoga with persistent pain
Sometimes, pain gets in the way of a patient commencing a yoga practice. Here are some of the factors that can influence an individuals ability to move, exercise and do yoga when they have pain:
Beliefs: what patients believe about pain can have a very big impact on their recovery. If patient have helpful beliefs (for example, “some pain is part of recovery and does not mean more damage”; “it is safe to move”), then they are less likely to experience ongoing pain. If unhelpful beliefs dominate (“hurt equals harm”; “I am doing more damage”), then recovery is likely to be slower and patients are more susceptible to getting persistent pain [31], [32]
Beliefs of the patients healthcare professional can also negatively and positively impact recovery. Consistent advice from the health professional team to start moving and exercising in a sensibly paced way, with clear instruction and guidance is required [33].
Catastrophizing or negative thoughts (cognitions) and mood (depression/anxiety) responses to anticipated or actual pain, mean that patients tend to magnify the threat value of pain and can cause them to feel helpless in the context of pain [34]. If the patient recognise this response, pain management education is required.
Fear of pain or ‘fear-avoidance’: here patients may stop moving because they feel pain when they move and they may interpret this pain as doing more damage. The reality is that some pain is normal when recommencing exercise - this pain does not mean more damage. If patients are fearful of moving, this can slow recovery [35]. Again, pain physiology education is crucial in this context.
In some pain conditions (e.g.; low back pain), persistent pain can be associated with disruption or distortion of patients ‘virtual body maps’ [36]. Body and mind re-integration (or mind/body ‘re-training’) using neuroplasticity appears to be very important to helping treat pain in such cases [37]. An intelligent approach to yoga therapy capitalises on this re-training approach.
Commencing yoga if in pain
If a patient has avoided activity for a long period of time because of pain, muscles typically increase in stiffness, decrease in strength, and neuromuscular control becomes compromised.
When deconditioned individuals, who have avoided activity for a long time initially commence a yoga program, it is very common for them to experience a temporary increase in pain, body soreness or muscular stiffness. However, it is important that this is conceptualised as a ‘positive’, body re-training response.
Muscle soreness usually lasts 24 to 48 hours and is a normal response to unaccustomed exercise and this reduces as muscles adapt to new exercise. It is vitally important that the patient mentally reinforce that this does NOT mean more damage. A pain flare is a common response to starting a new exercise, especially if they have overdone the exercise. To avoid pain flares, patients need to make sure that they are aware of the pacing (gradually increasing the yoga sequence duration and intensity).
Pacing is explained in detail in the pacing section below.
Urges to stop
Regardless of your pain levels, continuing daily yoga, moving often and maintaining your activities is important. Like any new behaviour, yoga practice requires commitment. There will be times when it requires a lot of willpower to practice! Each practitioner need to take personal responsibility for accurately interpreting the need for a restorative session Vs a more challenging and demanding session, given the natural day to day fluctuations in energy. Working with a competent teacher will help patients navigate this space, and more clearly understand how to adapt the practice for personal needs and ability.
Pacing and mind body exercise
An evidence based approach to yoga therapy incorporates “Pacing” as an integral aspect of the practice. The general chronic pain guidelines in the medical literature advocate a ‘time-contingent’ approach to activity rather than a ‘pain-contingent’ approach [38]. In the context of yoga therapy, this means the yoga sequences are built up slowly according to the individual needs, temperament and capacity of the student.
This allows the student to build ‘exercise and activity tolerance’. As exercise tolerance increases, it improves the capacity of the student to engage in everyday tasks, which may have been limited by the pain.
Building an understanding and communicative relationship with a yoga teacher will facilitate the process of pacing the yoga practice, allowing it to gradually build in duration and intensity. Additionally, with practice and experience, the duration of the yoga practice can be gradually gauged by a receptive student, who is able to judge the limit of tolerance at any given point, and adjust the practice accordingly.
Helpful Tips for Pacing the yoga practice
Keep a record what practice you are doing and how much you are doing – write it down
On a bad day still try to do yoga, but remember to understand your limitations, and try to honestly evaluate if you are over or under doing it.
If you have had a flare-up, go back to a level that you can cope with and start pacing it up again.
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