In Focus: Yoga Therapy in Pain Care

Spring 2016

a publication of The International Association of Yoga Therapists Yo g a T h e r a p y To d a y Volume 12, Issue 2, $5 In Focus: Yoga Therapy in Pain Care

S Y TAR 2016 June 9–12, 2016 SYR 2016 Sept. 19–21, 2016 w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 Yo g a T h e r a p y To d a y Editor’s Note

PUBLISHER International Association of elcome to the second of Yoga Therapists our annual spring series EDITOR IN CHIEF Kelly Birch, E-RYT-500, PYT-500 WIn Focus issues in which LAYOUT/PRODUCTION Ken Wilson we investigate various health topics COPYEDITORS Lokiko Hall and Stephanie Shorter, PhD of interest to the yoga therapy com- Yoga Therapy Today is published in the spring, summer, and winter. munity. The topic of this issue is the role of yoga therapy in the manage- IAYT BOARD & MANAGEMENT ment of pain, in particular how yoga Dilip Sarkar, MD, FACS, CAP, President therapy can help our clients pro- Carrie E. Demers, MD, Vice President foundly change their relationship to Amy E. Wheeler, PhD, Secretary Eleanor Criswell, EdD, Treasurer their pain. Executive Director John Kepner, MA, MBA Advertising Manager Abby M. Geyer Pain is a major reason why people visit their healthcare Conference Manager Debra Krajewski providers and why they are frequently prescribed opioid medica- Accreditation Administrator Aggie Stewart, MA, E-RYT-500, CYT tions. As you will read in one of our Feature articles, opioids are Certification Manager Beth Whitney-Teeple, PhD, E-RYT 500 very effective in the short term but there is an epidemic of overuse. The Centers for Disease Control and Prevention recently MISSION IAYT supports research and education in yoga, and serves as a issued guidelines to physicians for prescribing opiate medica- professional organization for yoga teachers and yoga therapists tions, recommending, in addition to nonnarcotic medications, worldwide. Our mission is to establish yoga as a recognized and what amount to lifestyle modifications. I believe this provides a respected therapy. tremendous opportunity for yoga therapists to offer healthcare providers an alternative support for their clients coping with pain. MEMBERSHIP IAYT membership is open to yoga practitioners, yoga teachers, yoga therapists, yoga researchers, and healthcare professionals It's important to understand that chronic pain differs from who utilize yoga in their practice. acute pain. The latter is short term (days to weeks), may be related to tissue damage or injury, and the use of asana may be MEMBER BENEFITS limited in helpfulness for many types of injury; however, other • Subscription to the International Journal of Yoga Therapy tools of yoga such as awareness of thoughts and feelings, medi- • Subscription to Yoga Therapy Today tation and pranayama, and the therapeutic relationship, can be • Access to IAYT’s research resources and digital library • Professional recognition through IAYT’s online listings very helpful. In my own bout with acute pain from a lower-back • Discounted registration at IAYT conferences injury, I found these to be profoundly supportive—especially reaching out to family to soothe my sense of isolation. No one CONTACT could feel my pain for me, yet they could feel my fear and hurt, IAYT and their love helped to soothe and to keep me connected. P.O. Box 251563 Little Rock, AR 72225 Phone: 928-541-0004 (M-F, 10AM – 4PM CST) The power of social connection is equally if not more appli- www.iayt.org • [email protected] cable to chronic pain, as you will read in these pages, given the interplay of the vagus nerves and neurotransmitters such as HOW TO SUBMIT TO YOGA THERAPY TODAY oxytocin in the experience of social isolation or connection. Writers In this issue, we focus mainly on chronic pain (more than a few Email a query or completed article to [email protected]. months). A recurrent theme is that chronic pain is not necessarily Yoga Therapy Today relies on submissions from the membership. an indicator of actual injury and that the experience, or “story,” of Please submit reports and articles on training, views and insights pain is influenced by a myriad of internal and external factors, relating to the field and profession of yoga therapy, as well as on integrative practices and business practices. Review author guide- particularly our beliefs about it. lines on the IAYT website/Publications/YTT. Articles are reviewed and accepted on a rolling basis and may be submitted at any time. Unfortunately, many people conclude that they are being Advertisers told the pain is “all in your head” and this can be profoundly For advertising rates and specifications, contact Abby Geyer at 702- alienating. Who would want to be told that their pain isn't real, 341-7334 (M–F, 9 AM–3 PM, PST) or [email protected]. when it is a huge factor in their life? However, what might sound Editorial decisions are made independently of advertising like the bad news is also the very good news: the perception of arrangements. pain can be changed through yoga therapy, even if the pain REPRINT POLICY doesn't go away. This message is repeated in the various arti- IAYT's reprint policy applies to all articles in the International Journal cles in this issue with great skill and compassion by all of our of Yoga Therapy and Yoga Therapy Today. Fee: $1 per copy per writers, to whom I am extremely grateful for coming through all article. The policy works on the honor system, e.g., if two articles the demands I put on them for this issue to bring you this wealth are copied for 25 students, please send IAYT a check for $50 and of information and inspiration on the complex story of pain. YTT note “for reprints” on the check. Questions? Email Debra Krajewski at [email protected]. In service, Kelly ENVIRONMENTAL STATEMENT This publication is printed using soy-based inks. The paper contains Cover photo: 30% recycled fiber. It is bleached without using chlorine and the Cover models: Nancy Huestis (left) and Robin Rothenberg (right) wood pulp is harvested from sustainable forests. Photo credit: Maren R. Aberle, First Track Photography www.firsttracksphotography.com [email protected] 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g TableOfContents Spring 2016

2 Editor’s Note Members News 8 4 Matra Raj Returns to IAYT Board, By John Kepner, MA, MBA, Executive Director IAYT 4 2016 IAYT Certification and Accreditation Committees 6 Call to Action: Building Bridges between Licensed Healthcare Practitioners and the IAYT 6 Thank You New Donors 6 Welcome New 2016 Member Schools 53 Responsible Self-Regulation: Comments on the Recently Published Yoga Alliance Position on Yoga Therapy By John Kepner, MA, MBA, Executive Director IAYT

8 Science for the Yoga Therapist The Story of Pain is Physiological By Stephanie M. Shorter, PhD 12

Feature Articles 12 Neurobiology of Pain By Neil Pearson, PT, MSc, BA-BPHE, CYT, E-RYT500

18 Living Well with Chronic Pain through Mindful Yoga By Jim Carson, PhD, and Kimberly Carson, PMH, E-RYT

22 Opioids and Yoga Therapy: What You Need to Know By Frederick R. Taylor, MD, FAAN, FAHS, and Matt Erb, PT

26 Personal Narrative Exploring Inner Space: Reducing Pain through Yoga Therapy 26 By Barbara Stowe

32 Professional Development Yoga Therapy as a Creative Inquiry into Pain and Suffering By Matthew J. Taylor, PT, PhD

34 Case Report Yoga Therapy for an Individual with Persistent Pain By Shelly Prosko, PT, PYT, CPI

Yoga Therapy in Practice 40 Guidelines for Yoga Therapists Working with Clients for Pain Management By Lori Rubenstein Fazzio, DPT, PT, MAppSc, YTRX 46

46 Assembling the Pain Puzzle By Robin Rothenberg, CYT

48 How to Work with Knee Pain in Clients: Part 1 By Nicole DeAvilla, E-RYT 500, RPYT, RCYT

56 Review Overcome Pain with Gentle Yoga By Neil Pearson, PT, MSc, BA-BPHE, CYT, E-RYT500 and Shelly Prosko, PT, PYT, CPI Reviewed by Staffan Elgelid, PT, PhD

Yo g a T h e r a p y Today | Spring 2016 3 MembersNews Matra Raj Returns to IAYT Accreditation and Certification the IAYT Board Committees 2016 Retreat By John Kepner, By John Kepner, IAYT Executive Director IAYT Executive Director The IAYT Accreditation and Certification Committees held a combined retreat in e are honored that Matra Raj, OT, March at the Redemptorist Renewal Center in Tucson, Arizona. I can personally attest ERYT-500, from Palo Alto, Cali- to the conscientious care, intelligence, and plain hard work on the part of members. Wfornia, has rejoined the IAYT This is peer review at its finest! One of the advantages of a combined retreat is that board. Matra is a graduate of the the standards set by these committees can be well integrated; in other fields, the Kaivalyadhama Yoga Institute, in Lonavla, accreditation and certification agencies may have little communication or coordination. India, as was her mother, and she brings When you see these volunteers at SYTAR or otherwise on the yoga path, I encourage a deep sense of yogic direction to our you to thank them for their selfless service to our field. YTT association's governance. She also brings extensive nonprofit governance experience. Raj led our fundraising efforts that brought us back from the brink after the Great Recession of 2009, and she was instrumental in starting IAYT's annual audit, which we have published on our website since 2011. Raj still has many connections to India and has championed the Swami Kuvalyananda Scholarship Awards and Travel Grants for our Sympo- sium on Yoga Research. When you see her at our conferences or otherwise on the yoga path, please thank her for her service. As executive director, I can attest that IAYT might not be here today without her support and quiet leadership. YTT

IAYT 2016 Certification Committee Back Row, L–R; Amy Wheeler, John Kepner, Leigh Blashki, Dan Seitz Front Row, L–R, Swami Ramananda, Beth Whitney-Teeple, Clare Collins, Bev Johnson

IAYT 2016 Accreditation Committee Back Row, L–R; Sue Tebb, Robin Gueth, Hansa Knox, Dan Seitz, Molly McManus, Maggie Reach Left Row, L–R; Danielle Atkinson, Robin Rothenberg, Aggie Stewart, Janie Stover Schmitt Not Shown, Eleanor Criswell. (Members News continued on page 6) 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g

Members News c o n t i n u e d

Call to Action: Building Bridges between Licensed H e a l t h c a re Practitioners and the IAY T

AYT's continued professional development with the accreditation of schools Iand credentialing of yoga therapists has many members who are also licensed healthcare professionals won- dering about the place, differentiation, and recognition of licensed healthcare professionals who integrate yoga therapy into their work. Preliminary discussions have begun around this important topic between licensed healthcare professionals from a variety of fields and IAYT to explore the question of how to create clarity both for the public and within the field. This is yet another developmental step for the profession with the intention to sustain cohesion between IAYT, yoga therapists, and licensed healthcare professionals who integrate yoga therapy into their work. If you are a licensed healthcare practitioner interested in being part of these discussions, please contact Marlysa Sulli- van at [email protected]

Thank You to IAY T ’s New Donors Welcome New IAYT 2016 Member Schools 12/1/2015–2/29/2016 Amrit Yoga Institute (FL) UMN Center for Spirituality and Healing Arkansas Yoga Center (AR) (MN) $5000–$9000 $1–$99 Baltimore Yoga Therapy (MD) VT School of Integrative Yoga Therapy Mary Hilliker Sharon Atteh-Chi Body Balance and Wellness (AR ) (VT) Sherry Brourman Yoga Deza (AR) $100–$999 Robin Anchors Breath Yoga Therapy (GA) Yoga Foundations (NY) Olga & Chris Kabel Denise Lockett Center for Integrative Yoga Therapy Cathy Lilly Nikki Tehel (GA) Yoga Gyam Jyoti (IL) Shelly Prosko Amy Briggs Circle Yoga Shala (AR) Yoga Veda institute (Mexico) Leslie Bogart Julie Shaw Healing Movement Yoga (NY) Yoga Well (CA) Adrienne Blenderman Joanna Barrett Korean Healing Yoga Association Yoga Integrated Science Wellness Center Bev Johnson (South Korea) (KY) Claudia Cardin-Kleffner Yogatherapy Skyros (Greece) Raj Mashruwala Loknath Institute of Yoga (Chile) Elisabeth Rivasseau National Yoga Academy (VA) Paula Morris New Mexico School of Yoga (NM) Robin Glantz SCU (CA) Sue Mangala Loper-Powers (Members News continued on page 53)

6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g 2016 Sponsors SYTAR June 9–12 • Reston, VA SYR Sept. 19–21 • Stockbridge, MA

Diamond Sponsor (SYR Co-Presenter)

Gold Sponsors

Silver Sponsors

Piel Canela Peru Fair Exhibitors Trade Organization

Media Sponsors

Association & Affiliate Sponsors Academic Sponsors

For 2016 Sponsorship Opportunities, Please Contact Debra Krajewski at [email protected] S c i e n c e f o r t h e Yo g a T h e r a p i s t The Story of Pain is Physiological

By Stephanie M. Shorter scious, clients seeking yoga therapy will chronic pain,4 potentially leaving them with often not be able to articulate the full story an ever-increasing social divide and feel- hen we feel pain, it seems so well of their pain. It is much richer than the ings of isolation. Making the client feel localized to a particular part of the pain receptors are hardwired to reveal. cared for and seen while being a role Wbody. It hurts here. We can point model of empathy and compassion has to where it hurts. However, the pain is— Therefore, as a yoga therapist, what if significant currency beyond the in-person paradoxically, objectively—simply not you change your goal from solving a yoga therapy session time. Over time, this there. It's not there in the tissues of the client's pain to creating social safety in teaching of empathy and compassion (and body, despite feeling as real as can be. your time with the client? It is a relevant self-compassion, the most advanced The physical origin of pain is distributed— reframing question because there actually level!) can be imparted through observa- in some way we don't yet fully under- is an extensive neural pathway that allows tional learning and may catalyze physical stand—across the body, brain, and spinal for holding space, bearing witness, show- healing and social support outside of the cord. Wrapped on top of that is a layer of ing compassion, and the therapeutic bond therapeutic context. subjective psychological story, probably to be a source of healing. years in the making, and expectations about the pain.1 This psychological story gets created and re-interpreted through the anatomy, physiology, emotion, memory, cognitive biases, perceptual filters, and spiritual development of our entire being. Pain is shaped by an interaction of the current environment and all past learning. The perception of pain emerges from a fuller story, and that story is written out in the physiology of the body.

Pain receptors—specialized sensory inputs called nocioceptors—are better thought of as danger sensors rather than pain detectors per se. Nocioceptors are insufficiently wired to be able to localize the exact source of pain down to the level of organs and tissues. The function of pain is to grab your attention, to tell you how to keep yourself safe. At the most basic level, pain is a sign to do things dif- ferently; it is a signal to find safety. Such Serving like a metronome that sets But are these effects real? Although self-protective wisdom can arise from the pace of the most basic physiological controversial, there is a niche of the deep within the insular cortex, a part of processes of the body, the vagus nerves research literature that points to overlap in the paralimbic cortex that is folded deep track warning signs of the neuroception of the neural pathways underlying pain and within the brain's midline. The insular cor- danger.2 Conversely, these nerves also the pathways that signal social pain.5 The tex notably plays a role in consciousness, detect safety, and their activity increases implication is that taking pain medicine for self-awareness, and interpersonal relation- parasympathetic (rest-and-digest) activity, social pain—negative feelings from social ships by integrating many different types allowing healing to take place. By provid- rejection, loss, or being excluded—can of inputs from the body and the outside ing safety, the caring yoga therapist can alleviate the hurting. Some of the evidence world. It is primal and holds many of the modulate the pain experience and the in favor of this shared pathway is that tak- pieces of the story of who we are. Yoga unconscious sense of danger through ing an analgesic such as acetaminophen practice or, even more so, targeted yoga stimulating the vagus nerves. Allowing dis- (Tylenol) was correlated with fewer behav- therapy, modulates this filter of conscious- comfort and silence, rather than pushing it iors related to being socially hurt, as com- ness, making the individual better able to away because it is burdensome or not pared to a control group that took a place- see and feel sources of present danger, socially appropriate, offers a form of heal- bo for three weeks.6 In a second experi- correlate current sensations to past inci- ing in and of itself. Therapeutic bonding is ment reported in the same article, fMRI dents, and take action for future healing. associated with release of the neuropep- data showed that acetaminophen reduced tide oxytocin, which has been shown to the neural activity seen in response to Because much of this somatic intelli- alleviate the experience of pain.3 social rejection in the dorsal anterior cin- gence is not accessible to the language- gulate cortex and anterior insula, areas of related areas of the brain and the influenc- Empathy for pain in self and others is the brain that have been associated with ing events of the past may be uncon- diminished in individuals who suffer from the emotional experience of physical pain (continued on page 10)

8 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 9 Science for the Yoga Therapist c o n t i n u e d

in many other studies. The take-home recipe of the yoga therapist. I recommend Acknowledgement message is that acetaminophen, a simple coming back to this truism when the The author would like to thank Neil Pear- over-the-counter analgesic designed to specifics of the physical origin of pain and son for a helpful discussion that influ- work on the physical level, also works on the complexities of the perceptual layers enced the content of this article. the psychological level, corroborating that resting on top seem too intricate a story to there is overlap in the nervous system unravel and solve. YTT between the neural pathways of physical and social pain. References Stephanie M. Shorter, 1. Tracey, I. (2010). Getting the pain you expect: Mechanisms PhD, is a neuroscien- Taking it a step further, one is left to of placebo, nocebo and reappraisal effects in humans. Nature tist, behavior designer, wonder if a treatment—like yoga thera- Medicine, 16(11), 1277–1283. and expert on mind- py—that is based around building up a 2. Geller, S. M. & Porges, S. W. (2014). Therapeutic pres- body research meth- sense of psychological safety and comfort ence: Neurophysiological mechanisms mediating feeling safe ods. Trained as a in therapeutic relationships. Journal of Psychotherapy Inte- in the body can reduce the level of pain gration, 24(3), 178–192. behavioral neuroscien- experience at the same time. If social pain 3. Tracy, L M., Georgiou-Karistianis, N., Gibson, S. J., & tist and cortical electrophysiologist, she and physical pain are indeed the same (or Giummarra, M. J. (2015). Oxytocin and the modulation of published studies in visual perception, significantly overlapping) physiology, then pain experience: Implications for chronic pain management. attention, and movement control before perhaps the social intervention of estab- Neuroscience & Biobehavioral Reviews, 55, 53–67. shifting her focus to yoga research. lishing the therapeutic bond really can 4. Wang, J., Wang Y., Hu, Z., & Li, X. (2014). Transcranial Stephanie also serves IAYT as the manu- change the story of pain. direct current stimulation of the dorsolateral prefrontal cortex script editor for the International Journal of increased pain empathy. Neuroscience, 281C, 202–207. Yoga Therapy. She welcomes your feed- Pain is mysterious and not knowing 5. Eisenberger, N. I. (2015). Social pain and the brain: Con- troversies, questions, and where to go from here. Annual back about this science column and what how to “solve” it for the client can be intim- Review of Psychology, 66, 601–629. topics you would find most useful in your idating. Distilled to its essence, presence 6. Dewall, C. N., et al. (2010). Acetaminophen reduces social practice. You can reach her at smshort- that creates a sense of social safety is the pain: Behavioral and neural evidence. Psychological Science, [email protected]. fundamental ingredient of the healing 21(7), 931–937.

Member Schools with IAYT Accredited Yoga Therapy Training Programs (as of 4/1/16):

• Ajna Yoga Centre (CA) • American Viniyoga Institute (US) • Ananda School of Yoga and Meditation (US) IAYT congratulates its Member Schools whose • AUM hOMe Shala (US) yoga therapy training programs have been • Essential Yoga Therapy (US) awarded IAYT accreditation! • Functional Synergy Yoga Therapy (CA) • Guru Ram Das Center for Medicine and To date, 25 Member Schools have programs that Humanology (US) have earned this distinction by demonstrating • Hot Yoga Wellness/Yoga Qigong Academy (CA) • Inner Peace Yoga Therapy (US) compliance with the rigorous IAYT Educational • Integrative Yoga Therapy (BR & US) Standards for the Training of Yoga Therapists. • Kula Kamala Yoga (US) • Maryland University of Integrated Health (US) More accreditation decisions are in process! • Niroga Institute (US) Check IAYT.org for up-to-date information. • Phoenix Rising Yoga Therapy (US) • Prana Yoga School of Yoga and Holistic Health (US) • Soul of Yoga Institute (US) IAYT honors all our Member Schools who are • Spanda Yoga Movement Therapy (US) submitting their yoga therapy training programs • Stress Management Center of Marin (US) to this rigorous process. • Wellpark College of Natural Therapies (NZ) • YATNA (Yoga as Therapy North America) (US) Together, we are paving the way for making yoga • YogaLife Institute (US) • Yoga North International Soma Yoga Institute (US) a recognized and respected therapy worldwide! • Yoga Therapy International (CA) • Yoga Therapy RX LMU (US) I AY T. O R G • Yoga Vahini (IN)

1 0 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 1 F e a t u r eA r t i c l e N e u robiology of Pain By Neil Pearson Nociceptors are classified as A-delta sensors are. The signals they send are fibers or C fibers. Although both respond always influenced by activity in other What is Pain? to similar stimuli, they are quite different in peripheral nerves in the skin. For example, other ways. Because they are thicker and gentle stroking or applying soothing ain is complex. It can arise for no myelinated, A-delta fibers are able to send warmth over an area of pain can modify apparent reason; it can be attributed signals up to 20 meters per second. They nociceptor signaling when it reaches the Pto a specific event, an object or body primarily relay their information via the spinal cord.5 Activity in the autonomic part, or a physiological process or pathol- thalamus to the somatosensory cortex. C nervous systems, such as the increased ogy. Ask a group of people how to com- fibers are thinner and unmyelinated, so sympathetic nervous system activity dur- plete the sentence “Pain is …[blank]” or to they send signals more slowly—up to 2 ing a fight–flight response, can also answer the question “What is the opposite meters per second—and primarily relay enhance nociceptor reactivity. Even cen- of pain?” and its complexity becomes their information via the thalamus to the tral nervous system activity such as even more obvious. Pain is described as a insula. Recent research suggests that A- expectations has been shown to either symptom, a perception, the enemy, a delta fiber inputs are the sensory appara- enhance or diminish how nociceptive sig- teacher, a friend, and an experience; it is tus of the central nervous system, where- nals are transmitted from the peripheral labeled as invisible, horrible, necessary, as C fiber inputs are the sensory appara- neurons to the spinal cord.6 For example, inevitable, and disabling. The opposite of pain can be stated as comfort, the absence of pain as bliss, calm, and sometimes, peace.

Pain is both a complex experience and a complex biological process. Yet its complexities are rarely explored, especially when we are in the midst of it. Only recently has science provided a new understanding of the physiological processes related to pain beyond the long-held views that pain and tissue damage are directly related. Understanding the intricacies of pain will help us respond to it in more helpful ways, both as yoga therapists and when we experience pain ourselves.

Neuroception Sometimes Starts with Nociception

Pain exists when neural circuits conclude that danger exists and that action is required.1 As such, it is so much more than a symptom or a message telling us that there is something damaged or dis- tus of the autonomic nervous systems.4 believing that a posture will be painful or eased in the body. Pain is an experience. The significance of these different types of will aggravate an old injury can enhance It motivates us to stop or change our fibers is that when something potentially nociceptive signaling, while a gentle com- behavior.2 Known as the neuroception of dangerous occurs in the body, neurons forting hand on our back or a calming danger,3 the experience begins subse- can send signals to both the autonomic breath can diminish the activity and signal- quent to activity of special nerve cells and central nervous systems and create a ing through nociceptive neurons.3 In other (neurons) in the physical tissues of the multitude of both automatic and volitional words, each aspect of your nervous sys- body in response to potentially dangerous responses. tems can influence nociceptors and noci- mechanical, chemical, or hot/cold stimuli. ceptive signaling. In fact, all systems of These neurons are called nociceptors Nociceptors are found both internal- the body have an influence on these neu- because they are receptors (sensory neu- ly—for example, in muscle, joints, and rons, including respiratory, endocrine, car- rons) that respond to potentially noxious organs—and externally in the skin. Firing diovascular systems, and especially the stimuli, from the Latin word noci, meaning of nociceptive neurons is impacted by immune system. As such, it is important to “to injure or hurt.” Nociceptors are fasci- much more than what's occurring at the view nociceptive neurons as dynamic. nating and multifunctional cells. peripheral end of the neuron, where the Their sensitivity, receptiveness, and sig- (continued on page 14) 1 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 3 F e a t u r e Article c o n t i n u e d

naling is always in flux, either adapting to cells.7 The sophisticated interplay between allows us to bypass the details of an expe- (with less activity) or becoming hypervigi- both immune and neural cells and sys- rience in favour of a defensive response, lant (with more activity) to not only tems is beyond the scope of this article. regardless of stimulus details.9 mechanical stresses or hot/cold and However, given the potential links chemical stimuli, but to aspects of our between yoga techniques and the immune One key clarification is required here. internal and external environments. system, this is an exciting area for us to Although we observe similar brain activity observe as it develops. with acute nociception as with social rejec- Another fascinating aspect of noci- tion, this is not evidence that acute nociceptors is that they are always ready and Neuroception and the Brain ception is experienced in the person in able to send danger signals toward the exactly the same way as social rejection is spinal cord and brain, even when there When we feel acute pain, many parts of or that social rejection should be treated has not been any pain in a particular the brain become more active. The with the same medications as acute tissue region or tissue of the body for weeks, amount of activity and the period of injury. There are similarities and differ- months, or even years. Typically, cells that increased activity is as much dependent ences in these experiences, and scientists are not used will atrophy, so something on the intensity of pain as it is on our have not yet found how to observe differ- different must be occurring with nocicep- thoughts, emotions, past experience, pre- ences in how the brain encodes for the tors. One possible explanation is that the dictions of what this pain means for the multitude of events we experience as cells are continuously active, always send- future, our current internal physiological potentially dangerous. ing some signals to keep the nervous sys- milieu, and all aspects of our external tems apprised of the physiological state of environment. In other words, just like tis- Brain scans of individuals with persisting pain* often differ from those with acute pain.10-12 Differences are also The experience or perception of pain is observed related to differing pain condi- believed to occur when neural circuits conclude tions and how the experience of persisting pain has changed many aspects of the that danger exists and action is required. individual's life. However, since each part of the brain has many functions and each the body. This might lead one to wonder if sue damage and pain intensity are not works in concert with many other areas, it we should actually be in pain all the time. directly related, overall increases in brain is unwise to directly attribute specific However, these low-level signals can be activity are not directly related to pain changes seen on brain scans to the sub- inhibited by descending signals from the intensity. The nervous systems—and even jective experience of persisting pain. Pos- brain to the body, or they may be filtered more so, the entire organism—are far too sibly the most important thing to know out by brain mechanisms evaluating the intricately interconnected for such a sim- about the changes that occur in the brain importance or saliency of the signals. This plistic relationship. related to persisting pain is that they can is a similar situation to other physiological be reversed—they are not permanent inputs that don't typically require your Beyond complexity, what we know changes. Even those with disabling low- attention. For example, the brain is always about pain and the brain is that the brain back pain who improve either via surgical getting information about skin temperature does not have a pain center. When we intervention or with active rehabilitation and bladder distention, but you don't know experience pain, a network of brain areas show brain activity returning to normal about this information until your attention is engaged. Interestingly, researchers when pain and function normalize.13 is required and you need to act. This is have clearly demonstrated that this same important for two reasons: (1) it means network of brain areas is engaged during These changes in the nervous sys- that the experience of pain does not rely a number of experiences that can be theo- tems are referred to as neuroplasticity, solely on nociceptive signaling from the rized as important for defensive respons- which is defined as relatively enduring body but also on neuronal cellular activity es.8 When we experience acute pain, the changes in the physiology (functioning) and processing in the central nervous sys- thalamus, insula, anterior cingulate cortex, and structure (physical connections) of the tem and (2) it means that when we experi- dorsolateral prefrontal cortex, and primary nervous system. Learning something new, ence increased pain, it may be the result and secondary somatosensory cortices adapting to temperature variations, of more nociceptive signals, the brain typically become more active. Some increasing tolerance to a noxious smell, interpreting these signals as important for researchers have unfortunately referred to and becoming more skilled in body aware- attention, or fewer descending inhibitory this pattern of activity as the “pain neuro- ness or a breathing technique are all signals filtering the nociceptive inputs. matrix,” “pain network,” or “pain signa- associated with neuroplastic changes. ture.” However, it is not specific to pain. It is important to consider that noci- This same network becomes more active Research has shown neuroplastic ception and pain are not only related to when individuals experience potentially changes in many brain areas in persisting the activity of neurons. Neuronal activity is dangerous tactile vibration, noises, flashes pain, including important ones in the sen- supported by cells referred to as glia, of light, and experimentally induced social sory and insular cortices, the amygdala which were originally believed to be the rejection.8 In other words, this network is and hippocampus, and the dorsolateral cells “gluing” the nervous system together the saliency network—the network of brain *Persisting pain is often used as the preferred lan- (the term glia means “glue”). Neurons activity that occurs when some form of guage for patients and clinicians. Although it is syn- make up only 10% of the brain's cells, defensive response is required. Ianetti onymous with chronic pain, it is a hopeful word, rather while the majority of its cells are glia. goes so far as to state that this network than suggestive of even worse pain to come. These are considered to be neuroimmune (continued on page 16) 1 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 5 F e a t u r e Article c o n t i n u e d

prefrontal cortex.14 Changes in the sensory nerves. In his polyvagal theory, he apies and techniques used to create the cortices have been related to the experi- describes three functions of the vagus neuroplastic changes related to less pain, ence of pain spreading away from the nerves that serve to mediate our fight– greater ease of movement, and improved original body area over time and to distor- flight response (sympathetic nervous sys- quality of life: social acceptance, compas- tions of body awareness.1 The insular tem, SNS) and our freeze and social sionate listening, touch, music, smells, col- changes, like sensory cortex changes, are engagement responses (parasympathetic ors, fear, body awareness, body image, often considered as both related to nervous system, PNS). Engaging the PNS self-efficacy, and knowledge. decreased sensory acuity and to body inhibits the SNS and increases the neuro- schema distortions experienced by many ception of safety; this is related to greater The Role of Education in Changing with persisting pain. Thankfully, there is inhibition of ascending nociceptive the Experience of Pain evidence that the practice of body aware- signaling. ness leads to measureable neuroplastic Moseley and others have studied the dra- changes in insula cell density and cellular When we breathe calmly and when matic impact of knowledge on pain and interconnections15 and may be associated we soften tension in the muscles of the recovery.18-20 Findings from these random- with the benefits of decreased pain. face, vocal apparatus, and hearing, we ized controlled trials (RCTs) showed that when individuals understood the role of the nervous systems in pain, their pain Learning something new, adapting to temperature decreased, their ease of movement variations, increasing tolerance to a noxious smell, increased, and these immediate changes could persist for many months after just and becoming more skilled in body awareness or one session of education. a breathing technique are all associated with neuroplastic changes. To date, few studies have measured brain changes related to the effects of explaining pain, although preliminary find- Increased activity reported in the increase the neuroception of safety. Com- ings are promising. A case study report21 amygdala is usually described as related plex alterations in the neural circuitry of showed that immediately following a single to the increased hypervigilance and emo- the vagus nerve, the phrenic nerve,* the education session about pain neurobiolo- tion turmoil (anxiety, grief, anger) of per- autonomic nervous system, insular cortex, gy, brain scans of a woman with chronic sisting pain. Unfortunately, when the anterior cingulate cortex, and the dorsolat- low-back pain showed dramatic decreases amygdala is more reactive, it inhibits the eral prefrontal cortices have all been impli- in activity in the areas of the brain impli- hippocampus, one of the areas of the cated in the experiential changes, along cated in stress responses. Other findings brain involved in spatial awareness (that with measurable changes in neurochem- reported in studies looking at the effects of we know is distorted in some individuals istry, cardiorespiratory, and cognitive and education on pain neurobiology include with persisting pain),16 in turning short- emotional factors. diminished fear,22 catastrophic thinking,23 term memory into long-term memory, and and peripheral sensitization.24 In my opin- the ability to be present (temporal aware- Each of the factors listed below ion, when people understand how their ness). impact whether our neural circuits interpret pain is influenced by their thoughts and movement as safe or dangerous. They are beliefs, their patterns of activity, and their The dorsolateral prefrontal cortex is all highly interactive with the regions of the social support systems, it increases their associated with perceived control and with brain implicated in pain and the neural cir- neuroception of safety and, by extension, the brain's diffuse processes for inhibiting cuitry related to the neuroception of dan- it reduces their perception of pain. Adding nociceptive inputs (diffuse noxious ger and safety. The experience and inten- support to the power of appropriate educa- inhibitory control). The neuroplastic sity of pain may well be intimately related tion are the research studies that demon- changes of decreased activity in this area to the current balance or imbalance strate how education that focuses on on both the right and left hemispheres between factors that increase and pathology and fear-based language can have been associated with learned help- decreased the neuroception of danger: lead to increased disability and pain.25-26 lessness and with increased pain from a • the mechanical pressure and/or stretch These research findings on the power of diminished ability to inhibit nociceptive sig- education to change the experience of on the tissues naling via descending signals to the spinal pain have direct implications for your cord.17 • how we are breathing clients. You might consider developing • the tension in face, jaw, and tongue ways of incorporating pain education into Nociception and the Autonomic Ner- muscles your yoga therapy treatment plan. Many vous Systems resources and workshops are available to • how we are listening and aware assist with this. According to Porges,3 the neuroception of • what we are thinking danger, and therefore our experience of Yoga is Education through Move- • our emotional state pain, is impacted by activity of the vagus ment and Embodied Cognition

*The phrenic nerve provides motor and sympathetic Many other factors are also implicated Multiple RCTs and four meta-analyses supply to the diaphragm as well as sensory innerva- in the neuroception of safety. It is plausible tion to the fibrous aspects of the diaphragm, pericardi- studying yoga27-30 support the positive um, and pleura, whereas the vagus nerve supplies that each of these may play a role in ther- parasympathetic innervation to the heart and organs. (continued on page 52)

1 6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 7 F e a t u r eA r t i c l e Living Well with Chronic Pain t h rough Mindful Yo g a

By Jim Carson and Kimberly Carson training, and other complementary therapies.13 Central Sensitization hronic pain (CP) is pain that has Central sensitization is a set of changes persisted for 3 or more months.1 Our team recently conducted a unique in the central nervous system associat- Often, such pain is the result of international Internet survey of 2,543 C 14 ed with the development and mainte- multiple causes rather than a single type fibromyalgia patients. Of these, 59% had nance of CP.18 Specific anatomical alter- of disorder. Pain interferes with sleep in attended at least one yoga class and 80% ations, especially at the cellular level, most people, which compounds their pain wanted to try yoga. This data is consistent occur in the dorsal horn area of the and related fatigue. Activities are often spinal cord and in the brain. These strongly affected by this combination. changes result in three major abnormali- The net result is profound suffering that ties: 1) allodynia: the generation of pain often includes reduced mobility, loss of sensations from non-harmful stimuli, strength, immune impairment with such as light touch, due to substantive increased susceptibility to disease, long-lasting increases in the excitability dependence on medication, and reduced of spinal cord neurons and correspon- ability to carry out one's social roles as ding lowering of pain thresholds accom- family member, panied by reductions in pathways that caregiver, friend, and employee. act to inhibit pain; 2) hyperalgesia: heightened sensitivity to and prolonged The problem is widespread: at least aftereffects from painful stimuli; and 3) 116 million American adults are afflicted secondary hyperalgesia: the production by CP, more than the combined number of pain from non-injured tissue due to of those affected by heart disease, can- expansion of the receptive field of a set cer, and diabetes.1 Pain is the primary of neurons. The combination of these reason people seek medical care, and various changes leads to “wind up,” a the economic impact is enormous. CP is persistent state of high reactivity in the estimated to cost up to $635 billion each central nervous system that maintains year in medical treatment and lost produc- pain even after initial injuries may have tivity in the U.S.1 Yet FDA-approved drug with other studies showing yoga has healed. Central sensitization is not only therapies have limited effectiveness for drawn the interest of people with CP from a major contributing factor in conditions most CP conditions, and such medications many cultural backgrounds.15 such as fibromyalgia and irritable bowel are often accompanied by addiction syndrome, but is thought to be active to potential and other significant side Special Challenges in Teaching some extent in all CP conditions. effects.2,3 Yoga to People with Chronic Pain

An Opening for Yoga Therapy To effectively teach yoga to people with Additional influences, which research CP, it is crucial that yoga therapists under- indicates predispose individuals to develop Only recently have Western researchers stand the unique challenges they will CP, are prior experiences of trauma, begun to demonstrate yoga's effects on encounter with these students. CP is a abuse, or significant anxiety or depression. persons suffering from persistent pain, very complex experience that subsumes It is important for yoga therapists to under- including those with chronic low back many influences beyond tissue damage or stand that a history of trauma is much pain, fibromyalgia, osteoarthritis, musculoskeletal imbalance.16 The many more common in people who develop CP migraines, carpal tunnel syndrome, kidney complications of CP include central sensiti- than in the wider population.19 Moreover, failure, and cancer-related pain.4-12 As zation—neurological changes that lead to even in the absence of such prior experi- research-based evidence for yoga's abnormal, long-lasting sensitivity to and ences, the emotional, cognitive, and social potential for alleviating CP accumulates, amplification of pain—which is only one of impact of living in constant pain substan- receptivity to yoga therapy is growing variety of neuroplastic changes that are tially raises the risk of developing mental among MDs, nurses, physical therapists, related to the development and mainte- health disorders.20 Furthermore, due to and other standard medical treatment nance of CP. (See Central Sensitization neurological linkages, heightened emotion- providers. In fact, the prestigious Institute sidebar for details.) Leading scientific al reactivity amplifies somatosensory proof Medicine has recently emphasized the experts propose that CP should be under- cessing of pain.21 Other complications need for innovative approaches for coach- stood and treated as a distinct disease come from the fact that CP often impairs ing patients in pain self-management and process that is quite different from acute memory, concentration, and other cogni- coping skills, including yoga, mindfulness pain caused by tissue damage.16,17 tive processes and that kinesiophobia

1 8 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g F e a t u r e Article c o n t i n u e d

(fear of movement) is highly prevalent in week course called “Yoga of Awareness.” Being able to comfortably breathe again people living with CP, driven by concern We have conducted rigorous randomized was a huge relief for Paul. Next he signed that almost any movement will aggravate controlled trials of this program at Duke up for an eight-session Mindful Yoga their pain.22,23 An important finding of our Medical Center and Oregon Health & Sci- group program in which he was introduced survey of women with fibromyalgia was ence University. These studies have docu- to a series of very gentle modified asanas that such fear is a common reason that mented reductions in pain, more energy and a meditation practice that cultivates these women do not attempt yoga exer- for valued activities, better sleep, and last- the ability to rest in simple being (the cises.14 ing improvements in mood in people living familiar, immediate sense of just being with fibromyalgia and cancer-related pain.4- present at any given moment). A turning Mindful Yoga 7,29 Furthermore, a recent pilot study we point happened half-way through the pro- completed provided quantitative sensory- gram. During the asana portion of the ses- Appropriate asana practice is likely to be testing evidence of partial reversal of cen- sion our instructions focused on learning therapeutic for people with CP in several tral sensitization in fibromyalgia patients.30 to relate to all bodily sensations from a ways, including induction of the relaxation careful, accepting, nonreactive perspec- response,24 which can alleviate pain and Mindful Yoga as we teach it aligns tive. As Paul was going through a flow emotional distress, and by generating an with the practices of yoga therapy in that it movement, suddenly he was gripped by a invigorating effect on mental and physical doesn't just teach yoga asana but empha- very intense surge of pain. We asked him energies that can alleviate fatigue and sizes meditation and other practices to to pause just as he was and for a few improve balance and strength4,25—two cultivate mindful awareness in daily life. moments to do his best to let the sensa- functional deficits that are common in We explore traditional topics such as the tions arise and move in whatever way they people with CP. However, the manner of principles of simple being (sat), awareness might. As he did that, a huge wave of fear teaching asanas needs to be tailored to (chit), love (ananda), acceptance (tapas), arose, and an image of his father's face CP. and skill in action (karmasu kaushalam). flashed in his mind's eye. His father had often been physically abusive toward him. Tears flowed for a few moments, and then the pain dropped to a level that was much During a pause in the posture, we ask: easier to tolerate. The following week, dur- “What do you notice? What waves of sensa- ing the satsang portion of the class he shared that as he continued to practice tion, emotions of the heart, stories in the being with whatever was arising, he began to have insight into how his life-long mind?” When a limitation is encountered in guarding in response to fear of his father a posture, we suggest: “Can you—for a was contributing to his pain. Gradually over that week his pain levels dropped moment—allow this experience to just be significantly, he began to have more ener- here without resisting?” gy and to be able to do more, and his mood brightened considerably. He said, “I am learning how to be my own best friend. Beyond asana practice, there is a We also address modern concerns, such When I rest in simple being, I can let the great deal more that the yoga tradition as the physiological underpinnings of anxiety wave wash through and learn how offers that is very valuable. In Bhagavad mind–body stress reactivity and how yoga to ride it.” Gita: A New Translation, author Stephen may have beneficial effects on stress- Mitchell states: “Physical sensations—cold related problems. Paul’s story illustrates several impor- and heat, pleasure and pain—are tran- tant points about what ingredients are sient: they come and go; so bear them Applying Yoga Practices for Opti- required for Mindful Yoga to be deeply patiently.”26, p48 How does one really live mal Coping therapeutic. First of all, in this approach this teaching? And how can we convey asana practices are adjusted according to this wisdom in a practical, accessible way Paul had suffered a work-related injury the particular CP concerns of the individ- so that people with CP can discover more than a decade before we met him. ual or group. (See Modifications of Poses authentic relief? We believe that the deep- The injury led to unremitting chronic pain, for a Specific Condition: Fibromyalgia). er yogic teachings—including how to primarily in his back and hips, and eventu- Most often a titration process is needed, relate to difficult sensations, thoughts, and ally to permanent disability. He had under- starting with very easy, gentle movements emotions—are essential for yoga to be gone several extensive spinal surgeries and then very gradually building up the optimally effective for helping people to that actually worsened his pain, resulting strength, flexibility, balance, skill and confi- have fulfilling lives despite CP. in the diagnosis of “failed back syndrome.” dence necessary for more challenging In addition, he was in a motor vehicle acci- poses. We have often heard yoga thera- In the following paragraphs we will dent that injured his ribs several years pists say that the first time they taught a draw on examples from our Mindful Yoga after his work-related injury, after which yoga class to people with CP, they had no program that illustrate ways to weave every breath he took hurt. We began at idea that what they were asking students yogic wisdom into yoga therapy sessions. first to work with him one-on-one and to do was way too much. This is also In 2000, inspired by the work of Jon focused on very careful guidance to find a reflected in another finding from our Kabat-Zinn,27,28 we developed an eight- breathing rhythm that did not elicit pain. fibromyalgia survey: concerns about the w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 1 9 F e a t u r e Article c o n t i n u e d

physical demands of postures, including you notice? What waves of sensation, For people with CP, learning powerful yoga-induced pain, were frequently cited emotions of the heart, stories in the ways to cope is the key that allows them as reasons women quit attending yoga mind?” When a limitation is encountered in to keep pain at a manageable level and classes.14 To minimize negative reactions a posture, we suggest: “Can you—for a resume pursuing a rewarding and enjoy- in clients, yoga therapists need to closely moment—allow this experience to just be able life. A comprehensive yoga practice monitor and intervene when they notice here without resisting?” that includes meditation and study of facial expressions, verbal signals (such as yogic wisdom can re-unite us with an sighs or grunts), or awkward or inhibited Third, the most crucial element of unfathomable source of energy, and bring movement that indicate students are Mindful Yoga is that asana practice is about a truly liberating shift in how we struggling to execute instructions. complemented by substantive engage- relate to pain and life itself. YTT Modifications of Poses for a The prestigious Institute of Medicine has Specific Condition: Fibromyalgia recently emphasized the need for innovative In our first fibromyalgia clinical trial, we introduced a series of low-intensity, low- approaches for coaching patients in pain self- impact yoga poses that were modified management and coping skills, including for common pathophysiologic changes in fibromyalgia.31 The sequence included yoga, mindfulness training, and other com- self-massage, warm-ups, table, mountain, mountain with sun arms, breath of plementary therapies. joy, warrior 1 flow, chair pose, down- References ment in meditation and other yogic prac- ward-facing dog on chair, sphinx, modi- 1. Institute of Medicine (US) Committee on Advancing Pain fied locust, child's pose, supine core tices. Typically, each 2-hour session Research, Care, and Education Institute of Medicine. (2011). strengthening, supine pigeon, supine includes (1) approximately 40 minutes of Relieving Pain in America: A Blueprint for Transforming Pre- thoracic twist flow, bridge, knees to gentle poses; (2) 25 minutes of mindful- vention, Care, Education, and Research. Washington, DC: The National Academies Press. chest, and corpse. Students were also ness meditation; (3) 10 minutes of 2. Martell, B. A., et al. A. (2007). Systematic review: Opioid introduced to a restorative version of pranayama techniques (individual tailoring may be needed if breathing hurts); (4) 20 treatment for chronic back pain: Prevalence, efficacy, and legs-on-a-chair with pelvis support and association with addiction. Annals of Internal Medicine, a twist over a bolster. Modifications minutes of relevant didactic presentations, 146(2), 116–127. included minimizing eccentric and repet- including how to "ride the waves" and how 3. Russell, I. J., et al. (2008). Efficacy and safety of duloxe- itive muscle activities to reduce muscle to distinguish between actual events and tine for treatment of fibromyalgia in patients with or without micro-trauma, slow transition from lying stories our minds have created; and (5) 25 major depressive disorder: Results from a 6-month, random- minutes of satsang/group discussions of ized, double-blind, placebo-controlled, fixed-dose trial. Pain, to standing due to fibromyalgia-related 136(3), 432–444. changes in the autonomic nervous sys- challenges or insights experienced during the week. Emphasis on these additional 4. Carson, J. W., et al. (2010). A pilot randomized controlled tem, and adapting standing poses to sit- trial of the Yoga of Awareness program in the management ting or lying poses to minimize peripher- practices provides people with CP with of fibromyalgia. Pain, 151(2), 530–539. al pain generators such as knee many effective tools for learning to accept 5. Carson, J. W., Carson, K. M., Jones, K. D., Mist, S. D., & osteoarthritis. Foam blocks were used and learn from pain and other stressful Bennett, R. M. (2012). Follow-up of Yoga of Awareness for to reduce wrist pain or carpal tunnel experiences, so as to begin to recognize fibromyalgia: Results at 3 months and replication in the wait- list group. Clinical Journal of Pain, 28(9), 804–813. symptoms in certain poses. The yoga clearly what choices contribute to more wellbeing versus more suffering. 6. Carson, J. W., Carson, K. M., Porter, L. S., Keefe, F. J., & therapist highlighted the need for gentle Seewaldt, V. L. (2009). Yoga of Awareness program for practice when one's body is challenged menopausal symptoms in breast cancer survivors: Results by illness, and students were encour- Lastly, deeper yogic teachings are not from a randomized trial. Supportive Care in Cancer, 17(10), aged to work according to their limits left as abstractions. A variety of practical 1301–1309. rather than rigidly adhere to concepts strategies are introduced for applying 7. Carson, J. W., et al. (2007). Yoga for women with metasta- about how postures must be performed. these teachings to shifting ways of relating tic breast cancer: Results from a pilot study. Journal of Pain to pain, fatigue, emotional distress, and & Symptom Management, 33(3), 331–341. other difficulties. Examples of strategies 8. Garfinkel, M. S., Schumacher, H. R., Jr., Husain, A., Levy, 29 M., Reshetar, R. A., (1994). Evaluation of a yoga based regi- Second, the integration of mindful- for working directly with pain include men for treatment of osteoarthritis of the hands. Journal of ness cues and the application of other • Watching pain sensations in a nonreac- Rheumatology, 21(12), 2341–2343. yogic principles (e.g., noticing simple tive way to see if they shift or remain 9. Garfinkel, M. S., et al. (1998). Yoga-based intervention for being) into asana instructions ensures that carpal tunnel syndrome: A randomized trial. Journal of the the same. American Medical Association, 280(18), 1601–1603. yoga poses serve not simply as healthy • Breathing into the area where the pain physical movements but also as a forum 10. John, P. J., Sharma, N., Sharma, C. M., & Kankane, A. or discomfort is felt. for developing nonreactive awareness of (2007). Effectiveness of yoga therapy in the treatment of • Reconnecting clearly with simple being, migraine without aura: A randomized controlled trial. bodily sensations, including pain. This while letting the pain be as it is. Headache, 47(5), 654–661. enhances students' ability to gain insight • Engaging attention elsewhere in your 11. Williams, K., et al. (2009). Evaluation of the effectiveness into reactions such as fear of movement here-and-now environment—clearly and efficacy of Iyengar yoga therapy on chronic low back pain. Spine, 34(19), 2066–2076. or guarding in the musculature and to shift noticing what you see, hear, touch, or out of these often subtle patterns. During smell-without making any effort to push a pause in the posture, we ask: “What do the pain away.

2 0 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g F e a t u r e Article c o n t i n u e d

12. Yurtkuran, M., Alp, A., Yurtkuran, M., & Dilek, K. (2007). 21. Grachev, I. D., Fredrickson, B. E., & Apkarian, A. V. 30. Carson, J. W., et al. (2012, May). Modulation of pain pro- A modified yoga-based exercise program in hemodialysis (2002). Brain chemistry reflects dual states of pain and anxi- cessing in fibromyalgia patients with Yoga of Awareness patients: A randomized controlled study. Complementary ety in chronic low back pain. Journal of Neural Transmission, training. Paper presented at the 31st Annual Meeting of the Therapies in Medicine, 15(3), 164–171. 109(10), 1309–1334. American Pain Society, Honolulu, HI. 13. Schultz, A. M., Chao, S. M, & McGinnis, J. M. (2009). 22. Keefe, F. J., Rumble, M. E., Scipio, C. D., Giordano, L. A., 31. Jones, K. D., & Clark, S. R. (2002). Individualizing the Integrative Medicine and the Health of the Public: A Summa- & Perri, L. M. (2004). Psychological aspects of persistent exercise prescription for persons with fibromyalgia. ry of the February 2009 Summit. Washington, DC: National pain: Current state of the science. Journal of Pain, 5(4), Rheumatic Diseases Clinics of North America, 28(2), Academies Press. 195–211. 419–436. 14. Firestone, K. A., Carson, J. W., Mist, S. D., Carson, K. M., 23. Roelofs, J., et al. (2011). Norming of the Tampa Scale for & Jones, K. D. (2014). Interest in yoga among fibromyalgia Kinesiophobia across pain diagnoses and various countries. patients: An international internet survey. International Jour- Pain, 152(5), 1090–1095. nal of Yoga Therapy, 24, 117–124. 24. Vempati, R. P., & Telles, S. (2002). Yoga-based guided 15. Astin, J. A. (2004). Mind-body therapies for the manage- relaxation reduces sympathetic activity judged from baseline ment of pain. Clinical Journal of Pain, 20(1), 27–32. levels. Psychological Reports, 90(2), 487–494. 16. Melzack, R. (1999). From the gate to the neuromatrix. 25. Berger, B. G., & Owen, D. R. (1992). Mood alteration with Pain, (Suppl. 6), S121–S126. yoga and swimming: Aerobic exercise may not be necessary. 17. Apkarian, A. V., Hashmi, J. A., & Baliki, M. N. (2011). Perceptual & Motor Skills, 75(3), 1331–1343. Pain and the brain: specificity and plasticity of the brain in 26. Mitchell, S. (2000). Bhagavad Gita: A New Translation. clinical chronic pain. Pain, 152(3 Suppl.), S49–64. New York: Harmony Books. 18. Latremoliere, A., & Woolf, C. J. (2009). Central sensitiza- 27. Kabat-Zinn, J. (1982). An outpatient program in behav- Jim Carson, PhD, and Kimberly Carson, tion: A generator of pain hypersensitivity by central neural ioral medicine for chronic pain patients based on the practice MPH, E-RYT, live in Portland, Oregon. plasticity. Journal of Pain, 10(9), 895–926. of mindfulness meditation: Theoretical considerations and They have developed yoga and meditation 19. McAllister, M. J. (2012, October 23). High rates of trau- preliminary results. General Hospital Psychiatry, 4(1), 33–47. programs being researched at Duke Uni- ma in people with chronic pain. Retrieved from 28. Kabat-Zinn, J. (1990). Full catastrophe living: Using the versity Medical Center and lead national http://www.instituteforchronicpain.org/understanding- wisdom of your body and mind in everyday life. New York: yoga teacher trainings at Duke and Ore- chronic-pain/complications/trauma Bantam Books. gon Health & Science University focused 20. Dersh, J., Gatchel, R. J., Mayer, T., Polatin, P., & Temple, 29. Carson, J. W., & Carson, K. M. (Unpublished manu- on health challenges specific to cancer, O. R. (2006). Prevalence of psychiatric disorders in patients script). Mindful Yoga Professional Training Manual. with chronic disabling occupational spinal disorders. Spine, chronic pain, and aging (for more informa- 31(10), 1156–1162. tion visit yogaofawareness.org).

w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 2 1 F e a t u r eA r t i c l e Opioids and Yoga Therapy What You Need to Know

By Frederick Taylor and Matt Erb short-term interventions.8,9,10,11 The CDC In most cases, long-term use of opi- has recently published extensive new oids (three months or more) develops into e are in the midst of what some guidelines for clinicians treating clients tolerance, in which increasing doses of the are calling the worst public health with chronic pain in an effort to promote drug are required to achieve the desired Wdrug crisis in decades.1 That cri- more safe and effective treatments. In effect. In some cases, this will also lead to sis is in opioid treatment of chronic non- these guidelines, it states that “nonphar- increased sensitivity to stimuli that do not cancer pain. The Centers for Disease macologic therapies can ameliorate chron- normally produce pain (allodynia), and Control and Prevention (CDC) reported ic pain while posing substantially less risk eventually to an excessive pain response that in 2012 alone, U.S. providers wrote to patients. In some instances, other thera- (hyperalgesia), which will be discussed 259 million prescriptions for opioids— pies result in better outcomes than opi- further below. more than a pill bottle for every adult.2 In oids. These therapies include exercise 2011, the Obama administration referred therapy, weight loss, psychological thera- Physical dependence also develops to an epidemic of prescription drug abuse, pies such as cognitive behavioral therapy, with chronic use of opioids, characterized and in March 2016, President Obama said interventions to improve sleep …” It is not by the onset of withdrawal symptoms as that this epidemic is “costing lives and it's difficult to see how yoga therapists (YT) the drug effect wears off (Figure 1.). The devastating communities.”3 are positioned to play a critical role in pre- user “fixes” the symptoms with another venting, minimizing, and alleviating pain or dose. The time it takes to develop depend- Worldwide, the UN Office on Drugs simply supporting the pain patient. ence varies by individual, and it is possible and Crime estimates that between 26 and to be dependent without being addicted. 36 million people abuse opioids (use them Opioids and Pain Indeed, most chronic opioid users do not without a prescription, in a way other than have opioid addiction, but all are physical- prescribed, or for the experience or feel- Current Environment ly dependent. Addiction, or substance use ings elicited), with an estimated 2.1 million disorder, is a more severe behavioral syn- people in the United States suffering from A 2015 Medscape survey reported that drome of repeated, compulsive seeking prescription opioid substance use disor- 88% of providers prescribed narcotics and (psychological dependence) or use of a ders in 2012.4, 5 63% of surveyed patients admitted to substance despite adverse social, psycho- using them. The majority was for acute logical, and/or physical consequences, Opioid overdose deaths have doubled pain, 28% for chronic non-cancer pain, along with the physical need for an or tripled in many U.S. states in the past and 2% for cancer pain. While the majority increased amount of a substance over decade and risk of overdose increases as of patients received important information time. the dose increases. Prescription opioids about opioid use, only about 25% were and illegally-made prescription fentanyl screened for personal history of past and illicit drugs like heroin are now the abuse/addiction or family history of addic- Early Late tions. Only 19% of patients surveyed largest contributing cause of injury death • Agitation • Abdominal in the United States today, occurring reported using mindfulness/mind–body pain/cramping across all age groups but with a concen- techniques to help manage their pain. tration between 25 to 54 year olds.6 • Anxiety • Diarrhea The Science • Muscle aches • Dilated pupils Opioids include opiates, natural deriv- • Increased tearing • Goose bumps atives of opium, and synthetic drugs such An opioid is a chemical that binds to three as hydrocodone and oxycontin. Opioids, different types of receptors (mu, delta, and • Insomnia • Nausea also known as narcotics, have been used kappa) that are important mediators of • Runny nose • Vomiting as analgesics for centuries as well as most known neurotransmitters and hor- used recreationally. Opioid analgesics are mones. Each opioid receptor mediates dis- • Sweating extremely effective therapies when used tinct effects. For instance, while all three • Yawning properly—for short-term acute pain and receptors mediate spinal pain, mu opioid terminal cancer.7 The evidence base, how- receptors mediate pain from higher levels. Figure 1. Opioid Withdrawal Symptoms ever, has increasingly suggested that Opioid receptors are particularly intriguing long-term opioid use for chronic pain car- because they are activated both by inter- ries substantial risks and uncertain nally produced endorphins and by exter- Adverse Drug Events/Side Effects benefits. nally administered opioids. Pain relief results from a complex series of interac- An adverse drug event (ADE) is injury or How can yoga therapy help? Thus far, tions, which ultimately results from synergy harm caused by or from the use of a drug four meta-analyses support the use of between reducing the pain threshold and and is a preferred term for side effects, the yoga for chronic pain treatment, with facilitating emotional detachment from the latter which tends to normalize the con- some evidence for benefit from even pain.12 cept of injury from drugs. Prevention of 2 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g F e a t u r e Article c o n t i n u e d

ADEs is a national priority. In a systematic Chronic Non-Cancer Pain and Opioids — We encourage you to avoid suggest- review of opioid-related ADEs, whites are The Evidence ing to a client that their use of opioids is a most at increased risk. However, few stud- barrier to improvement in their wellbeing. ies provided adequate standardization, Several systematic reviews have conclud- If your client shows signs of dependence controlled for confounders, or were specif- ed that opioids have limited overall effec- or addiction, or if a client expresses inter- ically designed to evaluate racial or ethnic tiveness for reducing chronic pain long- est in reducing or going off of their opioids, disparities.13 Common opioid ADEs include term and for improving the patient's level this warrants appropriate referral to a constipation, sedation, and nausea. of function.14,5,16 In addition, they have a knowledgeable medical provider, because Potentially more serious ADEs include poor safety profile with high risk of side these processes require medical monitor- depression, hormonal changes, and wors- effects.17,18,19 ing. If your client does not broach the ening of pain. The risk of depression topic, we suggest you remain neutral starts as soon as a person begins taking Opioids, Pain, and Yoga Therapy about your client's opioid use or address it opioids and increases significantly as the indirectly, such as in the use of functional duration of opioid prescription increases. Yoga therapy fundamentally reflects an education (“just the facts”) and the use of Opioid-induced androgen deficiency integrative biopsychosocialspiritual motivational client-centered interviewing (OPIAD), a reduction in hormone secre- approach. This is important for all people (“What changes would you like to make?”). tion by the testes or ovaries, can occur seeking care through yoga, but may be Pain, defined as an unpleasant sensory through alteration of the hypothalamic- even more important for the persistent pain and emotional experience associated with pituitary-gonadal/adrenal axes in both client on opioid management, which often actual or perceived tissue damage, must men and women. The symptoms (Figure reflects a strong external locus of control in be differentiated from the pain experience 2) are often not recognized as being linked to opioid use. Opioid-induced hyperalgesia is another chronic exposure Opioids have limited overall effectiveness for reducing state most broadly defined as increased pain caused by external opiates. It is rec- chronic pain long-term and a poor safety profile with high ognized by a paradoxical response where- by pain becomes more widespread than risk of side effects. originally present and responds more sen- sitively to stimuli. Complex pain facilitatory relationship to the pain experience. That is, (PE), which is a behavior pattern involving mechanisms (sensitization of nociceptive long-term users of opioid painkillers often factors such as restricted breathing, abnor- mechanisms) in the central nervous sys- feel that they are not able to help them- mal posturing, guarding, holding patterns, tem are known to contribute to opioid- selves with their pain and tend to rely on emotional distress, deconditioning, abnor- induced hyperalgesia. This can occur in outside sources such as medication and mal sleep, negative thoughts, and chronic pain states independent of opioid surgery. This is an important area in which social/family impact. All of these are use but is believed to be amplified by yoga therapists can help clients in chronic impacted by opioid use. We suggest that exposure to long-term opioid use. You can pain, because the emphasis in yoga on you work with the overall PE by address- suspect opioid-induced hyperalgesia when self-awareness, self-discipline, and effort ing contributing lifestyle factors rather than opioid effectiveness seems less evident, can help to instill and cultivate a client's focusing on the pain per se or on the topic particularly if found in the context of lack sense of self-efficacy—a crucial compo- of opioid use itself. It will usually be more of disease progression, unexplained pain nent in the process of learning functional useful to cultivate the client's awareness of reports or diffuse skin sensitivity (allody- ways to manage pain. the pain experience and to develop the nia), especially when unassociated with therapist/client healing relationship. Upon the pain as previously reported by the As a YT, it is important to be sensitive intake, in addition to assessing pain levels client. to the complexities that inform the experi- and opioid-use history, contemplation of ence of a client who shows up for yoga “yellow flags” as part of the pain environ- Symptoms Physical findings therapy on chronic opioid therapy. We rec- ment (attitudes and beliefs, psychologic ommend being cautious about giving distress, illness behaviors and social/envi- • Impaired sexual • Reduced facial advice, and reserve your judgment. Focus ronment focused around the PE) is useful. function and body hair on establishing a healthy understanding This contributes formation of a more com- • Decreased libido • Anemia and compassionate relationship with the plete picture of the client with chronic opi- • Irregular menses • Decreased client and all that informs their pain experi- oid therapy and areas within the scope of 20 muscle mass ence. As always in yoga therapy, a funda- yoga therapy needing the most attention. mental tenet of care is to remember you (Figures 3 and 4.). • Infertility • Weight gain are working with a person, not a diagnosis, • Hot flashes • Osteopenia/ nor an “opioid user.” Meet the person Opioids, Emotion, and Yoga Therapy osteoporosis where they are and serve as a gentle edu- cator and guide. Understand that pain trig- Opioid science informs that in addition to • Night sweats gers do not occur by themselves—they mediating the perception of physical pain, • Depression occur in a living system, in a life. Also centers involved in emotional processing • Fatigue remember that change is hard. are also affected by opioids, which can lead to emotional changes, including Figure 2. Opioid-Induced Androgen Deficiency Symptoms. w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 2 3 F e a t u r e Article c o n t i n u e d

Cognitive: Beliefs, thoughts, judgments Unhelpful beliefs about pain condition: Environment & Social Engagement Indication of condition as Illness Behaviors uncontrollable, expectations of poor Emotional Distress treatment outcome, negative thoughts, Attitudes & linked to nocebo effect Beliefs Emotional distress Worry, fear, anxiety, also linked to Pain nocebo effect Unrecognized or unexpressed grief, sadness, shame, etc. Illness behaviors/ Avoidance of activity/movement pain coping strategies Over-reliance on passive treatments Maladaptive use of opioids and other medications, progression of use Figure 3. Pain Environment Conceptual Figure 4. Example “Yellow Flags” Model

increased aversion to uncomfortable sen- feelings of social comfort but they also does not activate the pain/alarm system. sation and numbing of emotion.21 In addi- decrease motivation to seek out social The key here is that opioid use would tion, clinical practice informs that persons contact. Cultivation of a safe and empa- serve a supportive rather than a leading on chronic opioid therapy for persistent thetic relationship with the client is funda- role in treatment, but this should only be pain may have poor or heightened emo- mental and may in itself activate the undertaken with continuous guidance from tional awareness and you should consider endogenous opioid system,23 contributing a medical provider. strategies for working with either. In a sim- to the goal of pain relief. We also encour- ilar way, if the client has comorbid anxiety, age you to facilitate client self-expression Conclusion even benign sensations can increase anx- through verbalizing, drawing, writing, iety and avoidance, whereas comorbid imagery, movement, and similar tools, and Opioid medications are helpful for those who desire them while recovering from an acute injury, following a painful surgery This is an important area in which yoga therapists can help allowing the restoration of movement, or with terminal cancer pain. However, long- clients in chronic pain, because the emphasis in yoga on term use of opioids for chronic non-cancer self-awareness, self-discipline, and effort can help to instill pain is problematic. and cultivate a client's sense of self-efficacy—a crucial Fear of pain is often worse than the pain itself and ultimately pain is less component in the process of learning functional ways to painful when we are confident that we are safe. Opioid use can become a maladap- manage pain. tive behavior rooted in the innate drive for safety. Yoga therapists are uniquely suited depression may link sensation to remember to normalize the client's experi- to aid in pain prevention, management, increased negative thoughts. Yoga thera- ence. Stress, anxiety, and depression are and healing by facilitating clients with pain py tools bring clients' awareness to these not reflective of a weakness or character and opioid use towards an experience of effects as well as supporting emotion reg- flaw, nor is opioid use, even when it may safety that is equally nurturing as empow- ulation and cultivation of positive mental not reflect the optimal strategy for coping ering by facilitating awareness and states. However, if signs of clinical with one's experience of pain and life in change in all levels of human experience. depression or other serious mental illness general. Opioid dependence or addiction YTT present, please do not presume that yoga are best understood as chronic medical therapy is sufficient but discuss appropri- disorders just like hypertension, diabetes, References 1. http://www.nytimes.com/2016/03/16/health/cdc-opioid- ate referral. or schizophrenia and requires a compas- guidelines.html sion-informed whole-person approach. 2. Opioid painkiller prescribing. (2014). Retrieved February 16, 2016, from http://www.cdc.gov/vitalsigns/opioid-pre- Opioids have also been shown to scribing inhibit the physiology of attachment anxi- Integrated Care 3. http://www.nytimes.com/2016/03/16/health/cdc-opioid- ety (fear of abandonment), which is also guidelines.html 22 4. United Nations Office on Drugs and Crime. (2012). linked to anxiety/panic disorder. Thus, Consider finding medical providers in your Retrieved February 16, 2016, from opioid use is often medicating more than area with an understanding of the impact http://www.unodc.org/unodc/en/data-and-analysis/WDR- 2012.html just physical pain. In addition, it's impor- of opioids on pain management, especial- 5. Volkow, N. D. (2014). America's addiction to opioids: tant to understand that clients, especially ly those who offer assistance with an exit Heroin and prescription drug abuse. Retrieved February 16, 2016, from https://www.drugabuse.gov/about-nida/legisla- those reducing their opioid use, may have strategy should a client be motivated to tive-activities/testimony-to-congress/2015/americas-addic- higher than average sensitivity and reac- reduce or eliminate use. In some cases, tion-to-opioids-heroin-prescription-drug-abuse tivity to emotional stress, necessitating 6. Levi, J., Segal, L. M., & Martin, A. (2015). The facts hurt, short-term utilization of opioids can be a state by state injury prevention policy report. Retrieved mind–body self-regulation training as a helpful to assist with the goal of a client February 16, 2016, from http://healthamericans.org/ priority. Opioids may temporarily increase learning how to experience movement that assets/files/TFAH-2015-InjuryRpt-final6.18.pdf (continued on page 53) 2 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 2 5 P e r s o n a l N a r r a t i v e Exploring Inner Space Reducing Pain through Yoga Therapy

By Barbara Stowe sion after chemotherapy for Hodgkin's Dis- I read that book over and over again. ease in my late 20s. I couldn't live with The explanations about the latest theories that kind of hopelessness again. of how pain worked were intriguing, and I looked down the hotel corridor. The pain tried the methods suggested. I'd ask my in my neck and between my shoulder brain, "Is this really dangerous?" when the blades was screaming so loud, I could Out of the blue, I was offered the I pain shot up while I was reaching for a hardly think. Three heavy-duty painkillers chance to teach creative writing at a col- glass in the cupboard. My brain was hard (Cymbalta, Lyrica, and Baclofen, a daily lege. I'd transitioned out of dance into writ- to convince, but I felt the possibility of regimen) dialed it down a notch, but still ing in my 40s, earning a master of fine change. I couldn't absorb all the material, the dining room, roughly 60 yards ahead, arts degree. I liked teaching; in the past I'd though. I lacked a scientific bent. My seemed impossibly far away. "This is taught dance and had developed my own brother, a neurologist, was the "brain" in going to hurt," I thought. form of laughing yoga, and this offer felt like a lifeline. It would provide a desper- our family. It was the body and the feeling, nonverbal world that interested me. ately needed boost to my self-esteem and A dancer in my teens and 20s, I used allow me to contribute to society again. to explode into the air in grand jetés, whirl But how was I going to stand in front of a Around this time, coincidentally, around a stage en pointe, and throw a leg class for three hours when I was spending another PT also introduced me to Neil's up over my head. But in my early 20s, I most of my time lying down on a heating work. On my way to an appointment with started to experience pain in my upper pad? her at the University of British Columbia back. It got worse and worse, and I kept cutting activities out of my life because they hurt too much. I went to numerous physical and massage therapists and tried all kinds of exercises. Now, at age 54, I couldn't even walk down a corridor without feeling like I was climbing Mount Everest. I despised the weakling I'd become.

Yoga and physical therapist Neil Pearson seemed like my last hope. I'd flown up to Penticton from Vancouver for four appointments with him. The pain clinic at St. Paul's Hospital in Vancouver had given up on me. Minimal exercise sent my upper back into spasm. Injections with steroids proved somewhat helpful, but when the pain increased after an injection, the pain doctor stopped this treatment. The thing that had helped most in over three decades of increasing pain was trac- tion in a harness that pulled the back of my neck up—but the relief was fleeting, and I'd been told since that physical therapists didn't "hang people up" like that anymore, because it was too dangerous. I had to get better. One morning, Hospital one day, I was in too much pain slumped at the kitchen table in my to focus and went to Emergency instead. When tailbone pain began, the PT bathrobe, feeling sorry for myself, I decid- The physician said there was nothing he and OT shook their heads. "If you can't sit ed to google Neil Pearson. The PT at the could do. "I think if you just go home and properly, there's nothing more we can do." pain clinic had given me the manual that relax, you'll feel better," he said. I went home and lay down on a heating later became his book, Understand Pain, pad. For 2 weeks, I tried accepting that Live Well Again: Pain Education for Peo- The PT was outraged when she this was my life. I could feel myself teeter- ple in Pain. "You like to read," she'd said heard this. "Lie down," she said gently. ing dangerously close to the edge, falling with a shrug. "Maybe this will help you." "I'm going to play a CD for you. Have you into a depression. I'd weathered depres- ever done body scans?" I followed the

2 6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g Personal Narrative c o n t i n u e d

directions of the soothing voice and while The many PTs I'd consulted since my 10–minute periods of exercising, challeng- the pain did not go away, it receded some- early 20s were always running in and out ing the edge of pain while watching alter- what. I was curious. I'd used relaxation of cubicles, stressed. As I watched them nately my breath, body, the pain, and my techniques, but this "body scan" was dif- manage the patient load required to run a thoughts; body scans; and finding time for ferent. The voice, too, was different; I clinic, I understood. But because I always both joy and grieving. Finally, I had to couldn't detect color or personality, but saw the interior of people more than the challenge my fears, every day. neither was the tone cold or detached. superficial aspect, I reacted to the tension What was going on here? and frustration in their voices more than Calm breathing lessened the pain by their directions, adding these emotions to allowing me to see where and when and the blame I'd internalized and intensifying Neil's body scan CD and book were how I was tensing in response to pain, the only materials that seemed to be help- my shame and despair. Neil modeled the enabling me to let go of some of that ten- ing. When I googled him, I was surprised attitude of calm acceptance and scientific sion. Doing tai chi barefoot on the grass in curiosity I needed to find in myself, in to see that he, too, lived in British Colum- the backyard, I'd watch my breath, body, bia. I emailed him, asking if I could come order to begin my recovery. the pain, and thoughts (and emotions, see him at his clinic. I didn't know how to which I added in to this cycle) and gain progress further on my own. He agreed. At the second appointment, Neil information of how these all connected, taught me calm breathing. For 5 minutes, affecting each other. And when I reached Neil's first task was to re-introduce he instructed me to breathe slower, for a glass, instead of thinking, "This is me to my body, to help me make friends smoother, longer, and with equal length on going to hurt," I'd think, "This will be inter- with it again. He started by listening to my the inhale and the exhale. It was unnerv- esting, I'm just going to explore," which story. Then he patiently answered all my ing to have someone sitting beside me put me at one remove from pain, paving questions. Deep down, I was still hoping watching me breathe! But his gentle, the way for change. for a traditional surgical fix, even though attentive manner allowed me to relax, and I'd been told there was none. I knew Neil's I found the exercise profoundly soothing. It Besides lessening physical pain, these mindfulness exercises infused my life with joy. My senses were heightened: And when I reached for a glass, instead of think- food tasted exquisite when I slowed down and paid attention, sounds were over- ing, "This is going to hurt," I’d think, "This will whelming, and touch ... I had no idea how "out of touch" I'd been. As I took the time be interesting, I’m just going to explore," which to look more closely at the hummingbirds at the feeder, to savor a meal, to really put me at one remove from pain, paving the way feel, a deep peace suffused me, some- for change. thing I can only describe as bliss.

went deeper than the physical, penetrating Slowly, over the ensuing months, the yoga therapy work involved retraining the pain in my upper back lessened and I was brain and calming down the nervous sys- somehow to the core of my being. I was able to do more. Where once walking 60 tem, not surgery, but my intellect still shocked that a mere change in breathing could do that. My mind struggled to cope yards had seemed daunting, after 6 regarded yoga therapy with suspicion, and months I could get on the treadmill at the it fought for supremacy with my intuition. I with this information. gym and walk for almost 20 minutes. peppered him with queries about past Whereas before I couldn't carry a knap- injuries and X-rays that showed a spondy- I went back to the hotel room with sack or even wear a hoodie because any- lolisthesis, spinal stenosis, and mild scol- homework: one 5-minute calming-breath thing pulling on my neck and shoulders iosis. I had some reason to be confused. session every hour for the rest of the day. hurt, I started to be able to do both of The doctor at the pain clinic had looked at I also had a CD to listen to, with recorded these again. And when I went back to the my scans and warned, "Just don't ever get body scans. It was an intense immersion pain clinic to thank the PT for introducing in a car accident." My brother, however, that suited my nature. I liked to get my me to Neil's work, she agreed that I was had said, "There's nothing unusual in your teeth into something, accomplishing, doing fine on my own. Now, I could man- scans. At your age, spinal stenosis is achieving. Pain had prevented that. age my own pain. ubiquitous, and the scoliosis is mild." Putting on his physical therapist's hat, Neil By the time I left Penticton 2 days agreed. Their opinions calmed my fears, The effects of the program Neil pre- later, I had a plan in hand. It included what reassuring me that my body was not as scribed went much further, however. Neil called the four "Ps": practice, Besides introducing me to a "way in" to fragile as other medical professionals had patience, persistence, and compassion. led me to believe. joy and bliss whenever I let myself slow "You have to become an Olympic athlete down and become mindful, yoga therapy of pain management," he told me. It was a led to the conquering of a lifelong phobia Neil's calm, compassionate attitude daunting schedule: 5 minutes of calm of wasps. Had it not been for Neil's exer- opened the door to all that was to follow. breathing, five times a day; three (continued on page 30) w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 2 7 2 8 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 2 9 Personal Narrative c o n t i n u e d

cises, I never would have learned how to I still do too much. Even as I write the most extraordinary phrase that came calm my mind, open my heart, and chal- this, I am driven by an excitement that to mind during this journey was "saving lenge my fear until it receded so far that makes me tense, forget my posture, and my soul." I remain deeply grateful for the my brain could no longer deny the bene- forget to breathe. But more often now I extraordinary, life-changing lessons this fits of yoga therapy, or refute the intimate can see that happening and can make work has afforded me, and for Neil's com- and profound connections between body, myself either stop or stay aware and con- passionate, centered care. I know that mind, and spirit. tinue in a mindful manner. Neil himself would pass on this thanks, saying only—as he once told me—"I had Several months after seeing Neil in My ongoing challenge is to continue good teachers." YTT Penticton I attended a 3-day workshop he to work the program Neil prescribed, to gave at Salt Spring Centre for Yoga, which attend deeper to the exercises and see For anyone interested in Neil Pearson's helped further cement my commitment to where they will take me. Also, I have work, his website is www.lifeisnow.ca. He this work. Since seeing Neil in 2012, I am recently begun studying Svaroopa® yoga is not taking any new patients right now, not completely cured. I still have pain in with Eschara McNab, a wise teacher in my but is currently creating more online my tailbone and upper back. But it is con- area. I have come to accept my excitable, resources in order to help more people. siderably lessened, and I am stronger and driven, imperfect self more, and to under- can do a great deal more. Besides writing stand how to calm that self down. My and teaching creative writing, I also teach forceful intellect remains skeptical, critical, Barbara Stowe, a for- gentle exercise, incorporating mindful- and judgmental of spiritual healing such as mer professional ballet ness, breathing practices, and laughter yoga therapy. But it cannot deny the heal- and modern dancer yoga into a Maintain Your Independence ing of a phobia, and so while I remain with a Masters’ in Cre- program for seniors. I have learned to lis- grateful for my inner security guard, I ative Writing, teaches ten to my body more, to take breaks, and laugh at that critical voice when it is not mindful exercise and to attend to my breathing. Reducing pain helping, knowing that it has only my best creative writing. Her medications took time, but 4 years later I interests at heart. fiction and nonfiction has been published am off Cymbalta and have dropped down in literary magazines and national news- to the lowest possible dosages of the Although I am not religious, and "soul" papers. other two. was never a word used in my upbringing,

3 0 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 3 1 P r o f e s s i o n a lD e v e l o p m e n t Yoga Therapy as a Creative Inquiry into Pain and Suff e r i n g By Matthew J. Taylor relates to professional practice followed by This means that suffering depends on the how it may be applied with CI to alleviate stories we author about the presence of “Yoga therapy is the process of empow- chronic pain. pain from any of our koshas. As humans, ering individuals to progress toward we are always creating stories about our improved health and wellbeing through YRx involves experience, including the experience of the application of the teachings and pain. Whether these stories add to or sub- practices of Yoga.” 1 • Process. This is not an event, but an tract from the pain output requires dis- ongoing relationship of discovery with cernment (viveka) by both the individual e are a community co-creating the self as well as with the therapist. and the therapist. So how will you and the profession of yoga therapy to • Empowerment. Our profession restores your clients know whether the current cre- W“make yoga a respected and rec- the power of the process back to the ation of specific responses is therapeutic? 1 ognized therapy.” I'm sure we can all nod individual, rather than promoting a pas- in agreement that there are more than a sive, “fix me” relationship. Where Does CI Fit in This? few stereotypes of modern yoga that represent barriers to achieving this mission. • Improved health and wellbeing. Our If we start using the words duhkha, vive- To establish the respect and recognition philosophy is that health is our natural ka, and vrittis in our modern Western soci- that a therapy to relieve pain and suffering state, unlike the pathology-based mod- ety, we will lose before we've even start- demands, we need a way to entice and els that grounds most other professions. ed. However, if we begin with inquiring educate potential clients and referral We do not diagnose pathologies or pro- into what the person has tried so far and bases to answer the question, “How is pose to cure them. why the person is still not better (has not yoga therapy appropriate for chronic • Teachings and practices of yoga. The found a creative solution to date), we are pain?” I believe describing yoga therapy inquiry into the tenets of yoga carries initiating CI as a form of action research (YRx) as a creative inquiry (CI) can bring equal weight with the practices, each as described by its primary proponent, us a long way toward answering such informing the other through experience Alfonso Montuori, PhD.2-5 Such language important questions of our profession. and discovery to arrive at a creative new is far less scary and feels secure com- self-understanding. pared to classical yoga terminology in First, some background perspective Sanskrit, even if the listener doesn't really on the short definition of YRx, and then a Now, how do we effectively communi- yet understand what CI or YRx means. So practical example for your use on how CI cate this to our potential clients and refer- let's do some translation from the yoga- and YRx are appropriate terms within ral sources so they can appreciate how speak in the paragraph below in order to modern society. uniquely YRx can ease their or their explain YRx to potential clients using CI. patients' pain and suffering? How many Background on the Definition of people understand that those last two In yoga, we have the kleshas that YRx words aren't synonymous? outline the causes of suffering. Through viveka, together we discover the cause(s) The IAYT board of directors spent over a The Need for Relief of pain and suffering, and then work to year researching, petitioning definitions, weaken or eliminate those causes. We and then creating a short, functional defi- People in pain seek relief from both pain understand the experience of duhkha as nition to present to the public. The target and suffering, and YRx invites just that. valuable because it points us toward our audience included potential clients, health- "Heyam duhkham anagalam," Yoga Sutra, ignorance of the causes of suffering. care professionals, regulators, and II:16. Future suffering can be avoided. We Duhkha literally means “bad space,” also researchers. Our intention was to mark work together with the individual to avoid discomfort or suffering in our citta (heart- out what YRx is as well as how it differs the future duhkha. mind). Using the teachings and practices from other therapy professions. In order to of yoga yields insightful information about gain recognition and respect, the definition Modern science now understands ourselves that might have been hard to needed to be culturally congruent so that pain to be an output of the human nervous get through other therapies. The core of even a novice or a bureaucrat can grasp system. This output is a highly contextual- these practices includes tapas (effort), its essential meaning. The recent develop- ized matrix of assessments unique to each along with svadhaya (self observation/ ment with the Yoga Alliance prohibition of individual and circumstance, including all study), and isvara-pranidhana (faith/letting the term “yoga therapy” in their registry of the koshas. Therefore, any remedy or go). Much of this duhkha arises due to highlights the very real importance of such prevention of a pain output must be a change and our resistance to it, as well as a definition as well and of our ability to unique, creative set of therapeutic from wanting what we want and what we communicate effectively across social responses. Additionally, suffering has been are used to and not wanting what we milieus. Here is a way to conceptualize described as “Suffering = Pain x Resis- have. There are at least four steps we go IAYT's definition of yoga therapy as it tance” or “Suffering = Pain – Meaning.” through in YRx. 1. Identify the

3 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g P r ofessional Development c o n t i n u e d

symptoms/duhkha. 2. Find the cause(s). Do you hear and feel the difference? yoga as a therapy. As a profession, we 3. Set intention to eliminate the cause(s). can insist there is some purist form of 4. Put into the practice the means of elimi- More about CI practice—and by doing so reach the 15% nating the cause(s) from all the koshas. of the population that are early adopters CI is a form of research that can be used and befuddle the rest—or we can trans- We can, however, also phrase the with individuals and groups. It consists of form our story as practitioners in order to same strategy in this way: “In YRx we a process of relieve our collective suffering of not being believe each individual's pain and suffer- 1. Learning new skills and perspectives recognized and respected. We do this by ing to be unique to that person. Working about pain and suffering; creating an accessible next evolution of together, you and I will creatively inquire yoga that invites a much greater propor- into and search for a deeper understand- 2. Practicing and paying attention to the tion of our communities to experience, ing of where they come from. Modern sci- outcomes; and then explore, and then promote YRx as the ence says that pain is very complex and 3. Re-assessing and modifying practice profound therapy that we all know it is. made up of the many parts of our lives and teachings based on those discov- while suffering is the story or narrative we eries. Our future suffering is avoidable just have been told or have told ourselves like that of our clients. Your creative inquiry into how best to fulfill our mutual mission as yoga therapists promises to yield the joy, wonder, passion, hope, and conviviality we all earnestly seek. Do the tapas of birthing something new rather than accepting the easy momentum of habit. By inserting these concepts of CI and YRx into your marketing, conversa- tions, and referral source interactions, you will be able to invite many others into the inquiry. YTT

References 1. Taylor, M. J. (2007). What is yoga therapy? An IAYT definition. Yoga Therapy in Practice, Dec 2007, p. 3. 2. Montuori, A. (2008). The joy of inquiry. Journal of Trans- formative Education, 6:1, 8–26. 3. Montuori, A. (1998). Creative inquiry: From instrumental knowing to love of knowledge. In J. Petrankar, (Ed.), Light of Knowledge. Oakland: Dharma Publishing. 4. Montuori, A. (2011). Creative inquiry: Confronting the challenges of scholarship in the 21st century. Futures, 44(1), 64–70. 5. Montuori, A. & Donnelly, G. (2013). Creative inquiry and scholarship: Applications and implications in a doctoral degree. World Futures: The Journal of Global Education, 69(1), 1–19. about our pain. In YRx, we have many Because CI is focused on making gentle methods of creating new ways of change in the individual's unique real-life moving, thinking, sensing, and story-telling circumstances, the person develops the in order to understand not only how you ability to alter pain and suffering through have arrived at this bad space of pain and this empowering process. The cycles of suffering but also how to change it. change experienced within CI are charac- Together, we will research and test if terized by joy, wonder, passion, hope, and these new ways alleviate your pain and conviviality.2 Matthew J. Taylor, PT, your suffering. These same processes of PhD, is past president discovery can then also be used by you to CI and YRx are not some drudgery of of the IAYT board, avoid or lessen future suffering and future fixing or self-help. They mark out a way of owner of a yoga- pain. YRx teaches you invaluable strate- being human that embraces and address- based rehab clinic, gies for living a richer, higher quality life es the age-old problems of pain and suf- and editor of the text- no matter the situation. In effect, you then fering. The language of CI is familiar, com- book Fostering Cre- can create your responses to life with this monsensical, and removes the barriers to ativity In Rehabilitation. He also directs self-care science of discovery we call cre- modern society recognizing and respecting www.smartsafeyoga.com . ative inquiry. w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 3 3 C a s e R e p o r t Yoga Therapy for an Individual with Persistent Pain

By Shelly Prosko • transferring to and from chair ments and he does not feel the need for • moving around in bed additional interventions at this time. eter* is a 56-year-old male with a diagnosis of longstanding persistent • activities of daily living requiring forward Occupational, Psychosocialspiritu- Plow-back pain that was complicated bending or twisting al, and Nutritional History by a recent lumbar vertebral fusion (L4–5) • difficulty sleeping due to pain, waking at surgery. His orthopedic surgeon recom- least every 2 hours, and achieving less Peter holds a manager position that prima- mended physical therapy rehabilitation to than an average total of 5 hours of rily consists of sitting at a computer. He commence 4 weeks after his operation. sleep per night has been off work collecting a nominal Peter chose my services because he amount of disability insurance for almost 1 • pain exacerbated when stressful situa- wanted to try adding yoga to his physical year. He reports that although his job can tions arise: particularly related to finan- therapy rehabilitation and he knew that I'm be stressful, he still enjoys it and has been cial burdens and the inability to con- a physical therapist and Professional Yoga feeling his life lacks purpose and produc- tribute to household physical work Therapist1 who integrates medical thera- tivity since being off work. He also misses because of his "disability" (his term) peutic yoga1 into my physical therapy ses- the camaraderie of his staff and cowork- sions. He also knew I specialized in the ers. He realized during our interview that He states his pain controls him. He area of chronic pain. The initial subjective he was feeling somewhat isolated from his does not have any strategies to help interview took approximately 45 minutes. friends since he has been off work and reduce his pain other than the medication I included open-ended questions with unable to participate in his usual recre- that is occasionally, minimally, and tem- mindful listening and an empathetic and ational activities such as fishing, golfing, porarily effective. motivational interview approach2 that and hunting. He is not affiliated with any helped to expose aspects of Peter's life religion, but states he is spiritual and feels SF-36 Health Survey4: Physical Com- that have been influenced by his persist- most connected to spirit when he spends ponent Summary (PCS) = 21.7, Mental ent pain and also helped to reveal factors time in nature. He also feels the financial Component Summary (MCS) = 26.3 (0 = that may be influencing his pain experi- strain from not acquiring his usual income total disability; 100 = no disability; scores ence. I also included questions to deter- and expresses motivation to return to work <45 are below average for general popu- mine Peter's level of readiness to change.3 on a part-time basis. He has a supportive lation.) wife and two adult children that have History of Present Complaint Stage of Change3 = Contemplation recently moved away from home. He reports his memory has declined and his Peter currently complains of constant, per- Past Medical History and brain has become "foggy" over the past sistent neck and lower-back pain that is Interventions few years. generalized across both sides but varies in location and intensity. He states he is Co-occurring chronic neck and back pain Peter states he is a "meat and pota- never free from pain and cannot remem- for over 20 years without any specific toes" person who also enjoys locally ber being free from pain for over 20 years. mechanism of injury noted. Four partial or grown fresh seasonal vegetables and Constant numbness is present on the left full discectomy/fusion surgeries over the berries. He is a nonsmoker and rarely dorsum of foot and first digit as well as last 7 years. Medications are Tramacet, drinks alcohol anymore because he says intermittent paraesthesia to right anterior Lyrica, Indomethacin. "it does not mix well with my pain medica- thigh. He complains of feeling weak "all tions." He typically eats three meals per over," particularly in his legs, with low Past Interventions consisted of physi- day, but says his chronic pain has reduced energy throughout the day. cal therapy for approximately 12–16 his appetite and joy for food over the past weeks following the first three surgeries, year, particularly since his recent surgery. Aggravating Factors: including enrollment in specialty pain and occupational rehabilitation programs, and Physical Observations • maintaining a position for more than 5 regular sessions with a psychologist in minutes (mostly sitting or standing) 2010 and 2012 (1–2x/month) for approxi- Some of the specific assessment tech- mately 1 year for mild depression and niques that I use as a physical therapist • walking anxiety surrounding unmanaged pain. (such as a specialized biomechanic evaluation, neurological clearance tests, and * In order to adhere to patient confidentiality and Peter states that his past physical screening for differential diagnoses) are Health Insurance Portability and Accountability Act therapy and psychology interventions not within the scope of practice for a yoga laws, the client's name was changed to “Peter.” were valuable and beneficial. He has had therapist, so these will not be discussed in Some details of this case report have been inten- some pain science education in the past this report. It is a good idea to communi- tionally omitted to avoid client identification. The when attending the pain clinic and occu- cate with the surgeon and work closely client gave verbal consent to disclose all docu- pational rehabilitation programs. He cur- with a physical therapist to ensure adher- mented information included in this case example. rently is not undergoing any other treat-

3 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g Case Report c o n t i n u e d

ence to any specific precautions or con- apy because he wanted a more mind-body Breath-Control Practices traindications and promote continuity of approach to his rehabilitation and he had care. Physical observations that are within heard yoga was good for overall health. He The next step after breath awareness scope of practice for the yoga therapist, wanted to learn how to meditate because was to implement breath-control prac- such as the quality and patterns of breath he had heard it might help his pain. His tices. Some of the methods we used that and movement, positions and movements goals were as follows: Peter found beneficial were 1:2 ratio of of ease and discomfort, and balance inhale:exhale, nadi shodana (alternate • Reduce and successfully manage his capabilities, are outlined as follows: back pain and leg symptoms. nostril), transversus abdominus-assisted thoracodiaphragmatic 5,6 breath with • All general mobility, including gait and • Reduce or eliminate pain medications. ujayii (victorious), and dirga (three-part) transitions, are performed with exagger- • Improve overall body strength and pranayama. Breath visualizations such ated guarding, muscle tension, and pro- endurance. as imagining the breath entering and tective motor patterns with reduced exiting various parts of the nostrils and body awareness and proprioception. • Improve and restore level and quality of incorporating a longer, smoother, and function including activities of daily living • Performance of movements elicits an softer pattern also appeared to be valu- such as being able to bend over to put on able for reducing Peter's pain and mus- extremely protective posture with his socks and shoes independently, get in reduced mobility throughout entire spine cle tension and promoting generalized and out of bed with ease, tolerate pro- calming effects. and pelvis. longed walking and sitting for at least one • Abdomen is continuously held rigid and hour each, return to part-time work, fish, Another effective visualization and sucked in because he reports he has hunt, golf, perform yardwork, and engage breath-control technique that Peter used been taught to "protect his spine" by in sexual activities. to reduce pain and muscle tension was using his core. • Incorporate a regular home yoga practice to bring his awareness to an area of his • Breath pattern is shallow and rapid at into his lifestyle to sustain gains made in back that did not hurt and try to keep his 18 breaths/minute with reduced thora- therapy and help prevent future surger- focus on that area with a long, smooth, co-diaphragmatic and costal expansion, ies. and soft breath pattern while visualizing reduced length of exhalation phase, and the breath surrounding that area without excessive use of accessory muscles of Peter's Treatment Plan letting his attention be drawn to the respiration on inspiration. painful area of the back. Once he was Breath and Body Awareness Practices successful at keeping the focus on the • Frequent breath holding and jaw clench- non-painful area, he would then gently ing exhibited when performing most The first step to changing the nervous sys- shift his focus to an area on his back that movements, particularly during gait, tems is awareness. We first must introduce was painful, continuing with the long, transitioning from one position to anoth- practicing breath and body awareness tech- smooth, and soft breath pattern and visu- er, and when attempting to balance on niques before introducing movement pro- alizing the breath massaging that area. one leg. gressions that challenge the nervous sys- This technique can be used with a vari- • Unable to perform one-leg standing tems. ety of body parts. without upper-extremity support and exhibits poor balance reaction strate- Breath and body awareness practices Introducing Movement and gies due to overall rigidity and lack of that helped calm the nervous systems were Progressions movement in the trunk, pelvis, and completed in supported and tolerable posi- ankles. tions with adequate props for optimal com- We know that introducing and progressing movement is essential if we want to • Unable to lie unsupported in any posi- fort to ensure Peter felt safe so that the help our clients move with more ease tion without aggravation of symptoms; threat to the nervous systems was mini- mized. The positions varied depending on and improve function.7 But how do we however, he briefly tolerates (less than help our clients move when they are 5 minutes) being in prone position with Peter's level of comfort each session, but supta baddha experiencing pain and when most move- folded blanket under the hips and shins, were primarily supported konasana (reclined cobbler), savasana ment causes more pain? There is no a supine position with hips at 90° and makarasana simple answer to this. However, current legs supported by a chair, and support- (corpse), (crocodile), or a sup- virasana pain science would suggest that we ed balasana (child's pose) with bolster. ported/modified (hero). Peter's breath awareness practices included shouldn't use pain as our only guide.7 • Standing tolerance is approximately 2 abdominal diaphragmatic or belly breathing Solely relying on pain scales, such as a minutes before needing to change posi- while I observed the quality of his breath, visual analog pain scale from 0–10, to tions secondary to increased back pain including temperature, texture, rate, depth, guide clients while they are attempting to and lower extremity symptoms. length of inhale versus exhale, and how the move in the face of pain may not be as breath moved the body. I also used guided valuable to use with the persistent-pain Peter's Goals body-scan meditations, visualization tech- population as one would think. Pain-sci- niques, yoga nidra, and progressive mus- ence research confirms that the location, Peter was interested in this therapeutic cle-relaxation methods to heighten intero- intensity, and severity of pain is not an yoga approach integrated into physical ceptive awareness. accurate indication of the state of the therapy instead of traditional physical ther- tissues or tissue damage.8 Pain neuro- w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 3 5 Case Report c o n t i n u e d

science also tells us that the nervous sys- guidelines as stated above. The move- • Client use of yamas and niyamas while tems of people who have been suffering ments can vary from person to person, but moving with pain (ahimsa: interact with from pain over a prolonged period of time, the four guidelines remain the same. The pain with compassion; satya: truthfully can change in a variety of ways. For following are examples of some of the admit "this does hurt"; asteya: do not example, the signals carried by certain poses and movements included over the allow the pain to steal the peace you nerve cells from the tissues can become course of treatment: want to feel from yoga; brahmacharya: hypervigilant, or "over sensitive," sending • Supine: lower-trunk rotation (windshield (moderation) do not push too far past danger signals to the spinal cord and pain, but do not avoid it; aparigraha: wipers) with lateral spinal articulation,5,6 brain, resulting in an exaggerated output reclining knee to chest with hip tele- nonattachment to your pain (stay curi- of the brain that contributes to the pain ous and open to your pain changing); scoping,5,6 knee flexion/extension range experience. Inputs to the system, like cer- of motion (ROM) with proprioceptive sauca: purity of awareness (be cog- tain movements or positions, that never neuromuscular facilitation methods, nizant through which filter you may be used to be considered a threat or to result bilateral knees to chest, two-foot pos- practicing awareness); santosha: in a pain response, now do, even when acceptance of present situation and ture,5,6 modified bridge, reclined modi- there is no real threat. Therefore, the fied pigeon alternate with piriformis pain (not right or wrong or good or bad); physical sensations and emotional experi- dynamic stretch, modified happy baby tapas: dedicated self-discipline to com- ences of pain may no longer be a normal- and half happy baby mit to change; svadhyaya: introspection ly functioning protection mechanism of the (be aware of thoughts/emotions and if individual's system, as it once was. This • Prone: arm/leg lifts (contralateral); modi- they are in line with your values); ish- certainly does not mean we encourage fied locust vara pranidhana: balance fighting/resist- our client to ignore the pain; in fact, it is • Four-point kneeling: weight shifting all ance with surrender, letting go, and essential that we guide them to monitor planes, spontaneous/creative move- trusting. the pain throughout the movements, oth- ments, cat/cow, arm/leg lifts (contralat- • Discussed importance for Peter of time erwise the system will try even harder to eral), arm abduction to/from thread nee- spent in nature. He started performing "turn up" the danger signal. dle dynamic flow, extended and sup- some of his home yoga program out- ported child's pose, child's pose with doors and going for short, frequent However, we do not use pain as the diagonal ROM, child's pose with spinal walks to feel more connected to himself, only guide, nor do we make blanket state- rotation ROM nature, and therefore spirit. ments such as "Stop if you feel pain." We can't improve ease of movement and • Half-kneeling: alternating PNF tech- • Discussed importance of cultivating that function if we always stop as soon as we niques: psoas to/from hamstrings, social connection he had lost: he con- feel pain. What we want to do is help spinal rotation (modified revolving tacted a friend to start joining him on his reduce the amount of threatening signals extended side angle) walks. in the system. • Standing: mountain; mountain with • Ended each session with five gratitude spontaneous, random, creative move- statements (silently on his own) and he As yoga therapists, we have a variety ments; mountain to/from fierce pose started keeping a daily gratitude journal of tools to promote this threat reduction (dynamic flow); fierce pose with spinal at home. and can use our knowledge and expertise rotation to/from mountain (dynamic 9 in conjunction with these effective evi- flow); warrior 1 and 2 with movement Every day, Peter made a Daily Plan 7 to promote success each day. He made a dence-informed guidelines from Life is (front knee flexion/extension and bilater- Now Pain Care9 to help our clients move al spinal rotation dynamic flow); tree; sheet for each of these three categories of and progress movement safely, with less tree to/from warrior 1 (dynamic flow); activity: respite, calming, and challenging. Under each category, he outlined activities pain, and more ease: crescent lunge to/from warrior 3 (modified); triangle to/from half moon (modi- that are related to each. Each day, he Mindfully, compassionately, and slow- fied) made a plan, based on how many units of ly, encourage the client to move to the each activity he thought he could tolerate edge of pain with these instructions: Sessions always started with a breath that day. 1. Ask yourself, "Do I feel safe? Will I and body awareness meditation and • We discussed the importance of nutri- regret this later?" It is essential that ended with supported savasana (chair or tion and strategies for healthier eating clients feel safe and believe that what bolsters under thighs and blankets under and not skipping meals. they are doing is not doing any harm arms and head). • He realized how his inability to control or that they will pay for it later. his pain and his feelings of isolation and Other aspects of treatment: 2. Keep your breath calm and relaxed. sense of loss of purpose may be related to his feelings of depression and anxiety 3. Keep your muscle or body tension low. • Client education (Implemented pain and could be contributing to his pain 4. Monitor your pain. neuroscience education and shared experience. We discussed the possibili- resources: research shows this has ty of pursuing professional psychologi- As we introduced gentle and slow positive effects on pain, disability, cata- cal intervention, and he returned to see- movements into Peter's sessions, I made strophization, and physical performing his psychologist regularly during sure he followed the four movement ance.)10,11 weeks 3–10 of our time together.

(continued on page 38)

3 6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 3 7 Case Report c o n t i n u e d

Nineteen Sessions and 9 Months • Appetite and energy levels have What did not work well for Peter: with- Later improved; prepares three meals per day in the first two months, any prolonged and focuses on eating unpackaged, positions aggravated his pain and muscle • SF-36 Score: PCS = 41.2, MCS = 59.3 whole foods. He and his wife are now stiffness, so the breath and body-scan (significantly improved), MCS is no enjoying time spent cooking together. awareness practices were less than 3 min- longer below average range for general utes in length. He worked his way up to approximately 20 minutes very comfort- population. • Sleep quality has improved, with 6–7 hours of uninterrupted sleep most ably resting in one position. He also did not do well with sustained active poses, so • Significant improvement observed in nights. Usually experiences pain when adding dynamic flows or micro-movements movement patterns, with more natural going to sleep, but uses breath and within the active pose, in timing with the gait and general mobility patterns with body awareness techniques to help get breath cycle, helped him tolerate the improved pelvis and spinal movements to sleep. movement and improve ease of breath throughout. and quality of movement tremendously. • Reports feeling more in control of his YTT • Able to perform steps, sit to stand, pain. He now has some techniques he transfers, bed mobility and asana with uses to reduce pain, and often times he more fluidity of movement and calmer, can get rid of it. However, he still more rhythmical, and more natural reports times when he cannot control or Peter's Testimonial: breath pattern. reduce it as much as he would like, "What helped me the most was learn- mostly when he is stressed. • Holds breath less during movement; still ing how to breathe and paying atten- has tendency to retain breath when • He no longer is on any prescription pain tion to it more often. I realized I was almost always holding my breath learning more challenging asanas and medication. He takes Extra-Strength when I moved because I thought that transitions. Tylenol on occasion (approx. 2x/month). would actually protect me, but it did- n't, it actually made my pain worse. • Improved one-leg balance: able to per- • Back and neck still feel “stiff and sore” Shelly helped me understand this. form tree pose without upper extremity upon arising, but improve after morning That was a game changer. The other support and with improved breath pat- yoga routine. thing that really helped me was to tern and less muscle tension. Peter still trust myself and my spine and know • Still has not tried golf, hunting, or heavy has habit of using accessory muscles of that my body wasn't going to break. I respiration during balance poses or yard work. used to think I needed to always pro- when practicing a new challenging tect my spine, and so I always tried to • Unable to perform any heavy lifting or movement. keep it straight and was afraid to prolonged sitting for more than one bend it. Yoga helps me practice let- • Significantly improved in body and hour. ting go and move more freely and I breath awareness. can feel that immediately helps my • He independently and safely practices pain. I never realized how tense I • Able to walk for 1–1.5 hours almost yoga (which includes meditation) daily used to be all over. Now I am more daily; sometimes walks 30 min, 2x/day. at home, following the Pain Care guide- aware and know when I'm tense, and lines.7 He does not practice the same I can change it and then my pain • Engages in regular sexual activities, but sequence daily, rather, he performs one changes. It's amazing how much wishes his stamina and overall perform- of the movement sequences and medi- more in tune I am with my body. ance were better. tations that he feels is appropriate for Shelly (yoga) has taught me how I him each day. He also follows one of can help myself, and not just rely on • Went fishing a few times, with ease. the Overcome Pain with Gentle Yoga12 others to fix my pain. I've also learned to be more aware of my boundaries. I video practices about 1–2x/week in • Has returned to part-time work on modi- know when it's time to stop and when place of his individual program. fied duties and is happy to be back at it's time to push now and that has really helped me be able to progress." work with co-workers and friends. • Both Peter and the orthopedic surgeon were beyond pleased with his progress • Able to dress self independently and Overall, Peter agreed he was more and the goals that were attained with ease. confident in his ability to move and through a combination of yoga therapy his ability to control his pain. "The and physical therapy. pain doesn't control me anymore. I feel like I'm more myself again. It feels really good, and hopeful."

(continued on page 54)

3 8 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 3 9 Yo g a T h e r a p y i n P r a c t i c e Guidelines for Yoga Therapists Working with Clients for Pain Management

By Lori Rubenstein Fazzio types of pain so as to be able to guide ated with actual or potential tissue dam- patients safely back into movement. It is age, or described in terms of such dam- 1 orking with clients in chronic pain also very helpful to know what clients age.” How does acute pain become can be daunting. However, the understand about their condition. If a chronic pain? According to the IASP, Wmore we as yoga therapists client believes that his or her spine has chronic pain is pain that continues when it understand about chronic pain, the less degenerated and associates pain with should not. The IASP further defines it as overwhelming it will be to work with such clients. Pain is a stressor, and stress can contribute to the experience of pain. Yoga therapists offer many tools for stress management, and these tools are often very powerful when working with those in chronic pain. When a body has been in pain for a long time, the body has been in a stressed state for a long time. This often results in susceptibility to more health issues; thus clients in chronic pain often present us with a list of their medical diagnoses and medications. At a minimum, it is important that you know what the diagnoses mean, precautions and contraindications associated with such diagnoses, and potential side effects of any medications.

Working with Medical Diagnoses

As yoga therapists, we do not treat medical conditions; rather we use yoga practices to help support patients who may have them. We need to know what conditions our patients have so that we can best support them and, above all, so that we do no harm (ahimsa). Patients do not come to us to cure them; they come to us to feel better. It is important that we recognize what the patients' goals are for their yoga therapy. In achieving these goals, clients may also alleviate some of their comorbid health conditions. Say a client has had multiple surgeries; we need additional harm, then educating about pain and “pain, lasting beyond the usual course of information in order to better understand working to reduce fear of movement will acute illness or injury or more than 3 to 6 what movements this person can safely be most beneficial in helping the person months, and which adversely affects the 1 do. What kind of surgery? Are there any become more active again. individual's wellbeing.” When pain per- long-term postsurgical precautions? It is sists beyond the expected time frame, an often helpful, with the client's permission, Understanding Types of Pain all-too-common response is fear, stress, to speak with his or her physician, sur- and worry that something is really wrong. geon, or nurse to discuss precautions or In order to understand chronic pain, one However, chronic pain is not actually cor- contraindications for yoga therapy. must first understand the nature of pain. related to the severity of injury or dis- Pain is often misunderstood as being ease.2,3,4,5 One of the biggest risk factors Oftentimes, a physician will tell his or indicative of the extent of injury to the for developing chronic pain is a person's 5,6 her patient to let “pain be the guide.” With physical body. According to the Interna- coping strategy. State of mind is a acute pain this may be helpful; however, tional Association for the Study of Pain stronger predictor of chronic pain than the 5,6,7,8 with chronic pain this can be detrimental. (IASP), pain is defined as “an unpleasant severity of the injury of illness. T h i s It is important to be able to distinguish sensory and emotional experience associ- does not mean that pain is “all in the mind,” (continued on page 42) 4 0 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 4 1 Yoga Therapy in Practice c o n t i n u e d

but it does mean that the mind affects the Subjective Evaluation or Intake for the patient. Types of pain and their experience of pain. The good news is that patterns include nociceptive, radicular, yoga therapy offers many practices that The subjective evaluation helps you to get referred, and central pain. can shift the pain experience, reduce fear to know clients, understand their medical • Aggravating and easing factors. 9 and stress, and shift states of mind. history, their pain experience, their goals, Knowing what makes the pain better or Understanding the science of pain, and their lifestyle, and—most important- worse will guide you in selecting which explained in other articles in this issue, ly—to develop a relationship with the types of movements to start with and enables the yoga therapist to wisely patient. Establishing a safe and trusting which to be cautious with. May also choose and adapt these practices. relationship is crucial when working with highlight emotional or situational trig- any client. The most important aspect of gers. A Yoga Therapy Approach to • 24-hour pattern. Medical practitioners Chronic Pain Management use this to help determine types of EAR acute pain. With chronic pain there is A key component of the IASP's definition EYES often no clear pattern, but one example of chronic pain that calls to yoga thera- of a common pattern in chronic pain is pists is that it “adversely affects the indi- UNDIVIDED that the pain worsens as the day pro- vidual's well-being.” Mentoring yoga thera- ATTENTION gresses. This is often due to weakness py students in a chronic pain clinic, I often and fatigue and can guide us to focus find that the students are trying to “fix” the HEART on helping the patient build strength and patient. These patients have often learn how to pace activity. Pay close endured years of unsuccessful attempts to attention, because sometimes pain at a fix them, which only contribute to their particular time of day may be related to self-concept of “brokenness.” As yoga this is listening. Listen attentively with what the patient is doing then or even therapists, we hold the space for patients interest, with compassion, and without how they may feel about what they are to safely become aware of their current judging. One of the Chinese characters doing. condition as a multidimensional experi- for "listen" is made up of ears, eyes, open • Lifestyle. Educating patients about ence, to soften their neurophysiological heart, and undivided attention. healthy lifestyle practices can be very response to pain, and to gain an aware- beneficial, yet it is important to remain within our scope of practice. General State of mind is a stronger predictor of chronic lifestyle advice on things such as water intake, balanced diet, sleep habits, body pain than the severity of the injury of illness. mechanics, stress management, and healthy relationships are all helpful This does not mean that pain is “all in the mind,” interventions. Many people in chronic but it does mean that the mind affects the pain tend to do too much on the days they feel better only to end up in bed experience of pain. recouping on the following days. By applying lessons from the gunas (ele- ness toward that part of themselves which Listening in this way can guide you in ments of our nature): rajas (movement), is beyond the pain. In doing so, the pain how you may best help the client. Your job sattvas (balance/harmony), and tamas often dissipates. is to know what questions to ask, to listen (inertia/dullness), we can help patients to the answers, and to be able to discern recognize unhealthy lifestyle patterns SOAP Format for Yoga Therapy what the answers tell you. It is likely that and help guide them towards a more Client Evaluation your client has seen many doctors and balanced lifestyle. therapists and has shared his or her histo- • Social factors. What kind of sangha In Loyola Marymount University's Yoga ry repeated times. Employ viveka (dis- (community or support system) do they Therapy Rx Level IV clinical internship, we cernment or intuitive discrimination) to have? Pain can increase a sense of iso- document in the patients' medical record help guide you in your questioning, to help lation. Spending time with supportive with standardized SOAP notes. Our evalu- determine how deep to go with question- family, friends, pets, a yoga therapist, or ation format is guided by this medical ing on this first session, and to help you to attending a gentle group yoga class can approach to evaluation and includes understand how the pain experience is all help to soothe that sense of isolation. • Subjective evaluation or intake. affecting the client's life. Your compassion- As yoga therapists, we help clients to • Objective/physical examination ate attention and presence can profoundly find ways to connect with their sangha composed of influence your clients' ability to unwind as well as with themselves. o Breath assessment and their experience of pain. o Movement assessment: asana Questions to Ask Your Clients Useful evaluation topics include assessment for range of • What meaning does your pain have for motion, strength, coordination, • Pain pattern. Being able to identify the you? balance, pain. type of pain the client is experiencing • Why do you think your pain has persist- • Assessment including all koshas may help you to know when to refer to ed? What do you believe is necessary (sheaths, bodies, or layers of our another healthcare practitioner or how for you to feel better? being). much and which kind of activity is safe • Plan. (continued on page 44) 4 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 4 3 Yoga Therapy in Practice c o n t i n u e d

• How much of your life is impaired by Breath Assessment ahimsa (non-harming). Be honest with your pain? How would your life be dif- Breath assessment is a key component in patients about your experience level. ferent without it? What practices are you skilled to offer this the evaluation of all patients, particularly • How much better do you believe you in those with chronic pain. Because peo- person and when is a referral to another practitioner beneficial? Some clients may can feel? ple in chronic pain are often living in a state of heightened sympathetic nervous benefit from referral to a yoga therapist • Did you discover anything about your- who has additional training, especially if self through being in chronic pain? system activity, they often present with short, shallow breath patterns. Many tend your patient is not progressing at all or if you are having difficulty finding practices • What is your emotional response to to hold their breath in response to pain or pain? brace with their abdominal muscles, that the patient is able to do safely without increased pain. In any case, if a patient • What brings you joy? What inner resulting in decreased diaphragmatic mobility and excessive use of the acces- presents with new persistent symptoms, resources do you have? always refer them to a medical practitioner sory breath muscles that may contribute • What are your goals? to chronic neck pain. Below are some for diagnostic evaluation. • Do you have any previous yoga experi- questions to answer during a breath Plan ence? What is your understanding of assessment. yoga therapy? • Where do you see movement? Where The yoga therapist's toolbox for chronic do they initiate movement? Belly? pain may include asana, pranayama, Objective/Physical Examination Chest? Ribs? meditation, chanting, lifestyle management, bhavana (visualization), relaxation, The objective examination is often • What difference is there in breathing at yoga nidra, Swara Yoga, ayurveda, and referred to as a physical examination. This rest and during activity? How much patient education. Depending upon your will largely be dictated by the client's accessory muscle activity do you training as a yoga therapist, you may capabilities, pain level, and type of condi- notice? focus more on one area or another. tion. We evaluate and re-evaluate patients • How much movement? Deep or shal- Choose practices based on what your each time we see them to monitor and low? clients need. As explained in other articles recognize progress and to alter the pro- in this issue, the brain and nervous sys- gram as needed, so focus on what is • How many breaths per minute? tem adapt when someone is in chronic helpful for you to know about the patient • What is the ratio of inhale to exhale? pain, resulting in a lowering of the pain during each session rather than putting • Is the quality smooth or erratic? threshold. Pushing through the pain does the patient through all kinds of movement Relaxed or labored? not usually help. Start with lifestyle educa- assessment on the first day that could tion and practices such as relaxed breath- potentially increase the pain experience. Extended exhalation is a key to ing, extended exhalation, yoga nidra, or Again, use viveka to discern what move- reducing the sympathetic state and guided imagery to stimulate the relaxation ment assessment will best guide you in increasing parasympathetic activity. How- response. When the patient is in a relaxed developing a program tailored for the indi- ever, many patients are unable to volition- state, start gentle and pain-free breath vidual you are working with. ally extend their exhalation. You should with movement. Keep the movements simple. Know how to modify asana, give clear instructions, and empower the Your compassionate attention and presence can patients by helping them to learn how to profoundly influence your clients’ ability to unwind move without pain. This may entail layer- ing practices such as relaxation with their experience of pain. movement, breath with movement, and visualization. As a general rule, the more know how to evaluate breath and how to complex the client's situation, the more General guidelines for physical then teach appropriate practices. It is simple the practice should be. examination equally important that you be able to iden- Assess active range of motion for pain, tify when a patient is not responding to a Working in a Team quality of movement, movement patterns, practice and know how and when to adapt emotional response to movement, and or use alternative practices such as culti- Patients with chronic pain often benefit body awareness. Movement, balance, vating positive mental states. from a team approach. Working as part of strength, and coordination can all be a team requires its own skill set. Stay assessed through asana or a functional Assessment within your scope of practice, never movement exam. Observe how the client undermine another practitioner's treat- moves, walks, sits, stands, and talks. How Once you have gathered this information, ment, and communicate with one another. much effort is needed? Does the client take some time to review your notes and It is also a great way to build a referral exhibit pain behaviors, fear of movement, summarize your findings. Using the kosha network. Most importantly, it may be what guarding, ease of movement? If the client model, you can outline a picture of how is best for the patient. appears fearful of any movement, your the patient is coping physically, energeti- physical examination should be cautious cally, emotionally, mentally, and spiritually. (continued on page 54) and limited. The physical examination will This is also a good time for svadhyaha help you in choosing safe asana and in (study, self study), viveka (discernment, recommending appropriate lifestyle habit intuitive discrimination), satya (truth), and modifications.

4 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 4 5 Yo g a T h e r a p y i n P r a c t i c e Assembling the Pain Puzzle

By Robin Rothenberg inevitably along the lines of “Keep asking limitations imposed by pain? How has questions, and listen for the answers from the chronicity of pain impacted self- hen I was a little girl, one of my the client.” While clients may walk in look- esteem, relationships, and her sense of favorite self-directed activities ing to us for the answers, the truth is they who she is and how she moves through Wwas assembling jigsaw puzzles. are the ones who have been living with the the world? I'd spend hours playing on my own, pain, the duhkha (suffering and stress), the thrilled by the mystery of how seemingly dis-ease. Regardless of what we have Sometimes the onset itself is blurred random puzzle pieces could fit together studied, they are the experts on their expe- because of all the subsequent chapters. and make a whole. Organizing outliers rience. In his Yoga Sutra 1:7, Patanjali By the time a client ends up at the yoga that didn't seem to obviously fit into therapist there has usually been the gestalt gave rise to ambiguity, a large cast of characters giving and it wasn't always clear how to input with their diagnoses, opin- proceed. Sometimes it required ions, and treatment protocols. stepping back, giving my eyes and Some of these may have yielded mind a rest, and then returning with temporary relief, but obviously a fresh perspective. One thing was not entirely or the client wouldn't certain, if I narrowed my focus and be continuing to search for sup- fixated on trying to find the perfect port. This part of the story is fit, I inevitably ended up frustrated often confusing for the client and and defeated. Back then, I had no for us as well. How do we make idea that I was training myself for a sense of seemingly random career in yoga therapy! pieces of the puzzle? For example: a 6-month stint in physical Every day in my yoga therapy therapy (PT) that seemed to practice I have a similar jigsaw- help, followed by a flare-up and puzzle experience. Typical sce- then another 3 months of PT that nario: a client enters asking for didn't appear to make a differ- assistance in alleviating pain. ence; an MRI report that Although pain can show up in a describes an anomaly, but which variety of places in the body, heart, doesn't quite fit with the patient's or mind, objectively speaking “pain” experience of pain; contrary is not a complete descriptor of the opinions from different medical experience any particular person professionals that the client may may be having at any particular or may not be interpreting as time. Even if the client points to a intended. Although the client specific area on her back and says may be grasping and even des- the pain here averages a 7 on a perate for “the answer,” this is 1–10 scale, this still doesn't provide precisely the time for us to step enough information for me to back and ask more questions to assess how to begin our work gain a larger perspective. together. It's rather like she arrived with the puzzle still in its box. My I view the intake form and job as a yoga therapist is to open the box states that pratyaksha pramana is “valid process as a launch pad for a rich and and begin a process of facilitation, sup- proof through the direct experience of an revealing conversation. Questions like porting each client in putting the pieces of object via the mind and the senses.” Pain “How do you have fun?” or “How well do her own puzzle together. If I do my job is perceived by the client and the interpre- you nourish yourself?” may not seem to well, the client comes to understand what tation of that pain requires input from the be directly linked to the resolution of this pain signifies in her life and defines perceiver in order to understand the proper pain; however, they help me better her own individual path to healing. course of action. understand how this person is relating to life, not just to the pain. I watch the Where to Begin: Know the Pain is usually accompanied by a client's facial expressions and body lan- Questions story. There's a time before the pain, espe- guage closely, noticing where there is cially in the case of an accident or injury. levity amidst the expressed challenges As my colleagues and I mentor yoga ther- Who was this person before the onset? and where there is deep sorrow that was apy trainees, one of the most commonly How did she perceive herself? What activi- not conveyed by the ink on the page. expressed concerns is, “What if I don't ties were an integral part of identity? What Each of these nuggets are pieces of the know what to do?” Our response is does it mean to the client to no longer be puzzle that's helping to fill in the picture able to do those activities because of the of the person in front of me.

4 6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g Yoga Therapy in Practice c o n t i n u e d

What Gets in the Way—Beliefs and perspective is in fact our greatest asset, night she awakened without the usual the Mind and it's also the most demanding part of pinch and grab in her lower right quad- our practice. It would be far easier to lock rant. Most importantly, she realized that Beliefs can drive pain. I've often heard in on one aspect—poor posture, a negative she had been externalizing her experi- clients state, “My back is just like my attitude, a lack of spiritual connection—to ence, looking for the “experts”—including dad's” or “My friend had this same exact thing, and she had to have surgery.” Beliefs can foster a sense of impotence Truth be told, while I review all the MRI about the capacity to change the status reports carefully, I am still far more inter- quo, even more so than genetics or other contributing factors. I recently worked with ested in the clients’ own experiences and a yoga teacher who believed her back pain was directly linked to the findings on relationship to their condition than in the an MRI report that showed disc degenera- information on the pages. tion and a possible tear. I observed that she had a highly flexible body, but not much stability in her pelvis. For years she explain away the pain. However, I've rarely me—to tell her what the problem was. had practiced a fairly vigorous asana seen pain arising from just one of the She said that in the two years she'd been style, one that has a strong association mayas. Poor posture may in fact be linked searching for the answer, she had never with sacroiliac joint (SIJ) dysfunction. to poor self-esteem or depression. I've had stopped and just felt into her body and When I queried her about the possibility of clients who are deeply connected to their explored what it wanted and needed. In SIJ involvement, she shot back that she church community and who radiate joy but the end, it wasn't so much that her back had a disc issue and not an SIJ problem, are unable to sit or stand comfortably for pain had been resolved but that, in her as “proven” by the report. any period of time. We have to be willing to words, she “didn't feel lost any more.” play with the pieces: to observe, question, Clients often come to my office armed and support our clients in developing more We need to remember that our job with their MRI reports as if the reports interoceptive awareness. The more we can isn't to fix anyone's pain, but rather it is to hold the key to their quest. Truth be told, inspire them to be curious about their own guide a process of discovery through while I review all the reports carefully, I am pain puzzle and embark on an inward jour- which clients can come to know them- still far more interested in the clients' own ney, the more we are truly practicing and selves better. Armed with self-awareness experiences and relationship to their con- teaching yoga. and clarity about the relationship between dition than in the information on the choice and consequence, pain ceases to pages. Overuse of medical interventions The yoga teacher with the disc issues have the same bewitching power over the such as MRIs for conditions like nonspe- had been suffering for two years when I mind. This is the unique gift of yoga ther- cific low-back pain has been identified as met her. She was depressed and frustrated apy and a never-ending source of intrigue a considerable problem. The drive to that no one had figured out what to do for the puzzlers among us. YTT screen is prompted in part by patients' about her pain. The worst time for her was expectations as well as physicians' con- the pain she felt upon waking in the morn- References cerns about legal issues. Studies have ing. I listened to her story, noting “pieces” 1. Emery, D. J., Shojania, K. G., Forster, A. J., Mojaverian, shown that there is low correlation where the edges seemed to match up and N., & Feasby, T. E. (May 13, 2013). The overuse of magnetic between MRI findings and symptoms of where they diverged. At one point, I sug- resonance imaging, The Journal of the American Medical Association Internal Medicine, 173(9), 823–5. pain experienced by patients in the lumbar gested that perhaps she might have more 2. Jarvik, J. G., Hollingsworth, P. J., Haynor, D. R., Boyko, 1 area. In fact, depression has been shown than one issue going on—SIJ dysfunction E. J., & Deyo, R. A. (July 1, 2005). Three-year incident of to be a much more relevant predictor of and the lumbar disc problem. While at first low back pain in an initially asymptomatic cohort: Clinical low-back pain than findings on an MRI resistant to this idea, as we continued to and imaging risk factors. Spine, 30(13), 1541–8. report.2 So, if the pain isn't on the screen, explore together, through breath, move- then where is it and what can we do ment, supportive relaxation positions, and about it? core work, she gradually became more accepting of this as a possibility. Some- Knowing our Tools: Working with times I made suggestions, but mostly I Robin Rothenberg is the Whole Person asked her again and again to to notice how an internationally rec- the practices were affecting her and to ognized yoga therapist, One of my teachers frequently taught that describe her experience so that she could teaching in hospitals to be a yoga therapist requires that we are hear herself as “the one who knows.” and clinics in the Seat- tle area. She offers an one part coach, one part counselor, and RY T-500 teacher train- one part spiritual guide. It's true that the By the end of our time together she ing and comprehensive panchamaya model, the mutidimensional identified that the SIJ and lack of core sta- yoga therapist training teaching that informs our work in yoga, bility were the bigger issues for her. She for experienced teachers. Robin is the author of The Essential Low Back Pro- reminds us that the physical, emotional, recognized that her twisted sleep position gram: Relieve Pain & Restore Health, a n d and spiritual dimensions are always inter- was particularly aggravating to her SIJ, and Soothing the Spirit: Yoga Nidra to Reduce relating and impacting one another. This that by consciously propping her pelvis at Anxiety (CD). w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 4 7 Yo g a T h e r a p y i n P r a c t i c e How to Work with Knee Pain in Clients Part 1

By Nicole DeAvilla gives the quadriceps its mechanical advan- cartilage will be able to locate an exact tage. This system is referred to as the pain point. The most common cartilage client comes to you and asks, “I extensor mechanism. tears are to the meniscus, which some- have some knee pain and I don't times can heal on its own and sometimes Aknow what's causing it. Is it inactivi- An aberration of the extensor mecha- needs surgical intervention. Yoga therapy ty, is it misalignment, is it arthritis, is it nism (often referred to as chondromalacia, can be part of the rehabilitation process aging, is it all of these? Should I walk, do runner's knee, or quadriceps insufficiency) in either case. yoga, ride my bike, go swimming, or lie can have several causes: a blow or a fall, down on the floor and cry?” When you ask overuse injuries that happen over time, Because the ligaments provide some her if she has seen a doctor, she says: atrophy (underuse), and degeneration of of the main support of the knee joint, “For my knee pain the bone doctor said, the cartilage and/or bones. The pain is usu- when they tear, we will feel instability and 'Looking at your MRI, well, you might have ally felt in the front of the knee but in a looseness but not necessarily much a torn meniscus but you might not.'” somewhat diffuse manner. It tends to be a pain—at least not until we try to move

How can you safely and effectively help this client and others with their knee pain? First, let's review a little knee anatomy and physiology and some common issues that cause knee pain.

Brief Anatomy of the Knee Joint and Common Causes of Pain

The knee is not only the largest joint in the body, it is also one of the most complicated. Superficially, it appears to be a simple hinge joint. However, besides bending, the knee can also twist, move side to side, and withstand immense pressure. The joint requires a delicate balance of flexibility and strength—a wide range of motion and stability—to do all of the tasks that we ask of it (Figure 1.).

Most of this happens quite naturally. It's when we go beyond the normal range that we get into trouble. When we do go beyond the safe range due to lack of attention to alignment or what the body is telling us, it can result in immediate pain Figure 1. or lead to injury over time. pain that worsens over time and is felt after and the knee starts moving in all sorts of The knee cap (patella) protects activity. directions it was not intended to move! A against a blow to the front of the knee tear can be a serious injury and probably joint from either a fall or an outside force. Any of the tendons of the knee can a reason to refer your client to a doctor if Its prime function, however, is that of a become inflamed if they are overused, you suspect a torn ligament or do not see lever—a lever so effective that it enables abused, or otherwise injured. With patellar results with standard yoga therapy inter- the quadriceps muscle to lift 30% more tendonitis, for example, there will be a pain ventions. weight than it could without it. The quadri- specifically at the point just below the ceps consolidates into a tendon that runs patella. Pain in the knee area can sometimes through the knee joint and attaches to the be referred pain, such as from sciatic tibia. The patella actually resides within Whereas extensor mechanism or over- nerve problems. Working with a medical this large tendon and prevents it from rest- use injuries tend to have more diffuse and diagnosis can be helpful to rule out other ing on the joint surface underneath; this varying places of pain, someone with a torn causes of knee pain, such as a sciatic

4 8 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g Yoga Therapy in Practice c o n t i n u e d nerve issue, tumor, or other uncommon If the doctor or a physical therapist their seated alignment in a chair and conditions. A medical diagnosis can also gave the client exercises, ask the client encourage them to not stay stationary for give you clues to watch for alignment what they are. Looking at the type given long periods of time. issues, what other muscles might need to will help inform a course of yoga therapy, be strengthened in addition to the vastus such as whether they are strengthening or Yoga Therapy Approach to Knee medialis (VM), or which may need to be stretching or both. Also ask if the client has Pain stretched. been doing the prescribed exercises and if he or she finds them to be helpful. In some Alignment Working with a Medical Diagnosis cases, clients who are not inclined to do therapeutic exercises on their own or who Alignment is key in both preventing and When clients tell you they have a particu- are unclear about their alignment will bene- rehabilitating knee injuries. Consistently lar knee problem such as a torn anterior fit from doing their prescribed exercises in practicing yoga (or other activities) with- cruciate ligament or a torn meniscus (two your presence so that you can check for out proper alignment can destabilize the common knee injuries), ask them who proper alignment and body mechanics, as knee joint and create extensor mecha- gave them the diagnosis. Often people will well as offer encouragement. nism injuries that may stimulate an self-diagnose by thinking they have what inflammation response. Once injured, their friend had or they will go online and Some clients who have been pre- misalignment will continue to stress the think they have figured out their problem. scribed drugs or cortisone shots may hesi- knee and not allow it to recover fully. Never trust these self-assessments! tate to take them, preferring natural solutions. In some cases, natural solutions such In one workshop, I had a student as rest, ice, compression, and ele- with knee pain and chronic knee hyperex- vation (RICE) and yoga therapy tension and with very little upper leg mus- may do the trick. On the other culature. For her, the effort of putting her hand, if the swelling is extreme legs into proper alignment felt like phase (especially if it prevents normal one of utkatasana (chair pose); her knees range of motion), if the joint cannot also felt bent to her. However, she could fully bear weight, or if the pain level feel right away how this new position took is moderate to high, encourage the the stress off her knee joints, and it client to take the counsel of their brought a smile to her face. Many clients doctor. Likewise, if a client has any may say that they feel that their leg is of these more extreme issues and bent when you place it in proper align- they have not seen a doctor, advise ment. Let them know that as they contin- them to see one as soon as possi- ue to practice correct alignment, the new ble. You may still work cautiously position will soon feel like the straight with such a client, focusing more on position that it actually is. practices such as pranayama and meditation to reduce pain, suggest- Other alignment issues manifest ing RICE, and trying non-weight- when the weight of the foot is improperly bearing isometric strengthening at placed and the knee position is compro- low levels. mised or when the flexed knee is not aligned straight ahead with the foot, Assessment and Intake rolling instead to the left or right. Contrary to popular instructions that the knee mov- Perform a thorough intake to help ing forward beyond the ankle is danger- evaluate clients' pain. Ask them to ous, this is not a problem in and of itself. touch where it hurts; ask them On the other hand, the amount of force about the quality of the pain (sharp on the knee joint is great when the knee Figure 2. and pinpoint, diffuse, a feeling of is flexed and moves beyond the ankle instability, etc.) and when do they joint, so it does become imperative that If they do in fact have a medical diag- feel it (after sitting for long periods of time, students are in proper alignment and nosis, people don't always remember it after activity, constantly, etc.). Was the bend only to the extent that they have the accurately. If your client is wavering on onset of pain sudden or did it happen over muscular integrity to maintain the position what the doctor told her or him, simply ask time? What are they doing for the pain if safely. the client to call the doctor's office to get the doctor's actual diagnosis and report anything (medication, RICE, exercise, back to you. etc.)? Has it affected their daily activities The importance of the Vastus Medialis (can't fully bear weight, can't drive, or limit- With or without a diagnosis, if clients ed in length of time driving, etc.)? Asking An imbalance in strength or flexibility can have seen a doctor for their knee pain, clients about their range of motion (ROM), destabilize the joint (See Figure 2.). Typi- ask them what type of doctor they saw; rather than having them show you, is usual- cally, the VM is the muscle that most like- what were they told they should or should ly a safer way to evaluate ROM. ly needs to be strengthened to help bal- not do; what medications, if any, they are ance and optimize the functioning of the taking; and if they were prescribed an Check their standing alignment care- extensor mechanism. In Peak Condition,1 orthopedic device or physical therapy. fully. If they sit a lot during the day, check w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 4 9 Yoga Therapy in Practice c o n t i n u e d

James G. Garrick, MD, and Peter Radet- Aging and Lifestyle Walking can be healthy for knees if sky state that simply strengthening the VM walking body mechanics do not stress the can solve about three quarters of all knee Aging in and of itself does not cause knee knee and one walks on even surfaces to problems. Isometric strengthening of the pain. However, as we age, wear and tear avoid potentially twisting the knee. Bike VM is the safest, though it may take some on the knee can increase, especially with a riding is often very helpful for people with time and assistance from the yoga thera- lifetime of poor alignment and body knee pain because it can help to pist for the client to locate the muscle. mechanics, poor diet, past injuries, and so strengthen the VM and other knee stabi- forth, which can make it appear as though lizing muscles. However, for some indi- Strengthening the Extensor Mechanism the aging process causes knee pain for viduals (usually due to alignment issues) some individuals. This is where you can bike riding might not be helpful. I would All of the muscles of the extensor mecha- work with your clients' lifestyles: helping not recommend swimming for someone nism need to be strong for the knee to them to have sleep positions that don't with an instable knee because of the risk work properly and help relieve pain. Give stress the knee joints, ensuring that their for twisting the knee. However, swimming asanas that strengthen the upper legs. walking and other daily movement are not or walking or running in water may gener- ally tone the muscles for the knees and be helpful. The one activity that has People will self-diagnose by thinking they never been proven to help knee pain is lying down on the floor and crying as have what their friend had or they will go asked by our theoretical client! In other online and think they have figured out words, even though we may need to rest a knee injury from weight-bearing or their problem. Never trust these self- usual activity, we need to also be building strength. So doing nothing isn't a good assessments! plan.

The safest ones are probably salab- stressing the knee joints, encouraging them Reducing Inflammation and Stress hasana (locust pose), which strengthens to have a healthy diet appropriate for their to the Knee Joint the hamstrings and utkatasana leaning constitution and avoid possible food aller- against the wall, with only a little flexion to gies that may cause inflammation, and giv- • Apply the concepts of RICE to injuries. begin with (never go beyond a right ing them techniques for managing stress in • Restorative yoga positions that bring angle), which strengthens the quadriceps. their lives. Stress is known to increase the knees higher than the heart can (Please note that full chair pose varia- pain; so dealing with stress can help relieve reduce inflammation, fulfilling the rest tions, especially if it involves squatting, knee pain as well as other pain. and elevation aspects of RICE. might be harmful to someone with an injured knee.) Dos and Don'ts of Working with • Do not stress the knee in extreme posi- Knee Pain tions; especially avoid complete flexion Arthritis with knee injuries. In all movements, we want to keep the sen- • Avoid twisting such as in garundasana Arthritis of the knee can be tricky; howev- sations out of the knee joint itself. Clients (eagle pose). er, reducing inflammation and stabilizing should feel effort in the muscles around the the extensor mechanism can be helpful knee, but if they are feeling something— • Avoid unstable balance poses that with arthritis. Ask clients whether their even if it is not pain—in the joint itself, most stress the knee as a person tries to doctor has said that it is safe for them to likely the joint is being stressed even maintain or catch their balance. exercise with their type of arthritis or not. though they may not feel the pain there • Either avoid poses on the knees such The challenge can be knowing when until an hour to 24 hours later. The knee as table pose or try to cushion or prop clients are stressing their knee unduly joint will not get stronger by experiencing the joint so as not to stress the knee. when we ask them not to do anything that pain or discomfort; in fact, it will get weaker • Give stress-reducing practices such as they feel in the knee joint and they say from being destabilized. Feeling sensations pranayama and meditation. that their knee joint always feels uncom- in the joint is not the way to become more fortable or painful. Go slowly, and have flexible either. Again there will be a grey • Pranyamas with longer exhalations are your students give you feedback not only zone in that it will be hard to determine if effective in helping to reduce inflamma- in the moment but the hours and days fol- what a client is feeling is (a) the effort or tion. lowing their yoga sessions. If the pain stretch of the muscle and tendon that • For more yoga interventions for knee feels worse any time between one and 24 attach to the knee joint, or (b) the ligaments pain, see Part 2 of this article in the hours later, it is possible (if they didn't do holding it together, or (c) the other tissues next issue of Yoga Therapy Today. You other potentially irritating activities) that that comprise the knee joint. When in might also want to read my article in some part of the yoga practice irritated doubt, back off. Strength and flexibility can the International Journal of Yoga their knee. be gained without going into an extreme Therapy.2 position. Teach your clients to be like the tortoise: slow and steady to get results, instead of fast and impatient, which invites injury. (continued on page 54)

5 0 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 5 1 F e a t u r e: Neurobiology of Pain continued from page 16 effects of practicing yoga on pain and work of a lifetime. Taking the time to learn 18. Moseley, G. L., Nicholas, M. K., & Hodges, P. W. more about the neurobiology of pain is a (2004). A randomized controlled trial of intensive neuro- function. To date, evidence suggests ben- physiology education in chronic low back pain. Clinical efits for specific yoga practices provided great place to start—the anatomy and Journal of Pain, 20(5), 324–330. to people with osteoarthritis, rheumatoid physiology of neurons, the spinal cord, the 19. Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. arthritis, low-back pain, whiplash-associat- autonomic systems, and the brain. The (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. ed pain, irritable bowel syndrome, and added benefit of this knowledge for many Archives of Physical Medicine and Rehabilitation, 92(12), fibromyalgia. Given the complexity of pain is that it makes pain more tangible. When 2041–2056. and the nervous systems, it is probable we understand more about the neurobiolo- 20. Van Oosterwijck, J., et al. (2011). Pain neurophysiology education improves cognitions, pain thresholds, and move- that there are many reasons that yoga can gy of pain, we begin to truly know it as a ment performance in people with chronic whiplash. Journal be effective for decreasing pain, improving body–mind–spirit experience rather than of Rehabilitation Research and Development, 48(1),43–58. ease of movement, and helping people only a psychological phenomenon. This 21. Moseley, G. L. (2005). Widespread brain activity during live well again. It is possible that a large opens doors to more innovative applica- an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic portion of yoga's benefits for people in tions of yoga for people in pain and to low back pain. Australian Journal of Physiotherapy, 51(1), pain arises from its powerful experiential greater compassion for the people we 49–52. and physical experiences. For many, the serve in yoga. YTT 22. Fletcher, C., Bradnam, L. & Barr, C. (2016). The relationship between knowledge of pain neurophysiology and most impressive and believable changes fear avoidance in people with chronic pain: A point in time, arising subsequent to any therapeutic References observational study. Physiotherapy Theory Practice, 6,1–6. intervention are those that are experi- 1. Butler, D., & Moseley, G. L. (2003). Explain pain. Adelaide, 23. Wideman, T., & Sullivan, M. (2011). Reduced cata- Australia: NoiGroup Publications. enced physically. The experience of func- strophic thinking associated with pain. Pain Management, 2. Moseley, G. L., & Vlaeyen, J. W. S. (2015). Beyond nocicep- 1(3), 249–256. tional improvements can feel more real to tion: The imprecision hypothesis of chronic pain. Pain,156(1), 24. Van Oosterwijck, J., Meeus, M., Paul, L., De Schryver, some than the experience of learning new 35–38. M., Pascal, A., Lambrecht, L., & Nijs, J. (2013). Pain physi- ideas and concepts. 3. Porges, S. W. (2011). The polyvagal theory: Neurophysio- ology education improves health status and endogenous logical foundations of emotions, attachment, communication, pain inhibition in fibromyalgia: A double-blind randomized self-regulation. New York, NY: W.W. Norton & Company. controlled trial. Clinical Journal of Pain, 29(10), 873–882. Adults learn in many different ways. 4. Craig, A. D. (2014). How do you feel?: An interoceptive 25. Lin, I. B., O'Sullivan, P. B., & Coffin, J. A. (2013). Dis- Explaining pain through discussion and moment with your neurobiological self. Princeton, MA: Prince- abling chronic low back pain as an iatrogenic disorder: A experiential lecture creates change prima- ton University Press. qualitative study in Aboriginal Australians. BMJ Open 2013; 5. Mancini, F., Beaumont, A., Hu, L., Haggard, P., & Ianetti, G. 3: e002654. doi:10.1136/bmjopen-2013- 002654. rily through cognitive experiences and D. (2015). Touch inhibits subcortical and cortical nociceptive 26 Darlow, B., Dowell, A., Baxter. Mathieson, F., Perry, M., cognitive shifts. Similarly, many of the responses. Pain, 156(10), 1936–1944. & Dean, S. (2013). The enduring impact of what clinicians techniques of yoga seek to create change 6. Atlas, L. Y., & Wager, T. D. (2012). How expectations shape say to people with low back pain. Annals of Family Medi- pain. Neuroscience Letters, 520(2), 140–148. cine, 11(6), 527–34. through both physical and cognitive expe- 27. Bussing, A., Osterman, T., Ludtke, R., & Michalsen, A. riences, especially through the experience 7. Watkins, L. R., Hutchinson, M. R., Milligan, E. D., & Maier, S. F. (2007). “Listening” and “talking” to neurons: Implications (2012). Effects of yoga interventions on pain and pain- that change has occurred in physical func- of immune activation for pain control and increasing the effi- associated disability: A meta-analysis. Journal of Pain, 13(1), 1–9. tioning. Each time a yoga student experi- cacy of opioids. Brain Research and Review, 56(1), 48–169. 28. Cramer, H., Lauche, R., Haller, H., & Dobos, G. (2013). ences greater safety, whether this results 8. Mouraux, A., Diukova, A., Lee, M., Wise, R., & Ianetti, G. D. (2011). A multisensory investigation of the functional signifi- Systematic review and meta-analysis of yoga for low back from a cognitive and/or physical experi- cance of the “pain matrix”. Neuroimage, 54(3), 2237–2249. pain. Clinical Journal of Pain, 29(5), 450–460. ence, the new experience is inconsistent 9. Liang, M., Mouraux, A., & Ianetti, G. D. (2012). Bypassing 29. Holtzman, S., & Beggs. R. (2013). Yoga for chronic low with the brain's interpretation of danger. primary sensory cortices—A direct thalamocortical pathway back pain: A meta- analysis of randomized controlled trials. for transmitting salient sensory information. Cerebral Cortex, Pain Research and Management, 18(5), 267–72. The practices of yoga can provide an doi:10.1093/cercor/bhr363. 30. Ward, L., Stebbings, S., Cherkin, D., & Baxter, G. D. opportunity to repeatedly experience more 10. Wood, P. B. (2010). Variations in brain gray matter associ- (2013). Yoga for functional ability, pain and psychosocial safety and less danger in the body, lead- ated with chronic pain. Current Rheumatology Reports, 12(6), outcomes in musculoskeletal conditions: A systematic 462–469. review and meta-analysis. Musculoskeletal Care, 11(4), ing to positive neuroplastic changes. Each 203–21 experience in which we move while 11. Roussel, N. A., et al. (2013). Central sensitization and altered central pain processing in idiopathic chronic low back breathing calmly, decreasing body tension, pain: Fact or myth? Clinical Journal of Pain, 29(7), 625–638. Neil Pearson, PT, and quieting the mind, may be the perfect 12. Van Oosterwijck, J., Nijs, J., Meeus, M., & Paul, L. (2013). MSc, BA-BPHE, CYT, (re)education our nervous systems need Evidence for central sensitization in chronic whiplash: A systematic literature review. European Journal of Pain, 17(3), E-RYT500, is a to learn that movement and being in the 299–312. physical therapist, a body are not so dangerous. 13. Seminowicz, D. A., et al. (2011). Effective treatment of clinical assistant chronic low back pain in humans reverses abnormal brain professor, and a anatomy and function. Journal of Neuroscience, 31(20), The effectiveness of yoga for people 7540–7550. faculty member for with chronic pain likely relates to many 14. Apkarian, A. D., Sosa, Y., & Sonty, S. (2004). Chronic back international yoga therapist training factors beyond the nervous systems— pain is associated with decreased prefrontal and thalamic gray programs. He is the recipient of national including every other physiological system matter density. Journal of Neuroscience, 24(46), 10410–10415. Canadian awards in pain education, and and their tissues, cells, and even their 15. Hölzel, B., et al. (2011). Mindfulness practice leads to physiotherapy pain management, as well DNA. And the positive impacts of yoga on increases in regional brain gray matter density. Psychiatry as the founding Chair of the Canadian each of these likely relate to a wide array Research, 191(1), 36–43. Physiotherapy Pain Science Division. of factors found in each of the paths of 16. Andrews-Hanna, J. R. (2012). The brain's default network and its adaptive role in internal mentation. Neuroscientist yoga, including meditation, social connect- 18(3), 251–270. edness, breath, movement, awareness, 17. Wiech, K., Kalisch, R., Weiskopf, N., Pleger, B., Stephan, safety, and ritual. K. E., & Dolan, R. J. (2006). Anterolateral prefrontal cortex mediates the analgesic effect of expected and perceived control over pain. Journal of Neuroscience, 26(44),11501–11509. Understanding pain through all of its complexities is important—indeed, it is the

5 2 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g F e a t u r e: Opioids Members News continued from page 24 continued from page 6 7. Jammal, W., & Gown, G. (2015). Opioid prescribing pit- entitled “Current Illustrative falls: Medicolegal and regulatory issues. Australian Pre- Responsible Self- scriber, 38(6), 198–203. Standards for Yoga Therapists” 8. Bussing, A., Osterman, T., Ludtke, R., & Michalsen, A. written in 2003. That is a far cry (2012). Effects of yoga interventions on pain and pain-asso- Regulation: from our actual and extensive ciated disability: A meta-analysis. The Journal of Pain, 13(1), 1–9. Comments on the Recently “Educational Standards for the 9. Cramer, H., Lauche, R., Haller, H., & Dobos, G. (2013). Training of Yoga Therapists” Systematic review and meta-analysis of yoga for low back Published Yoga Alliance published in 2012 and our first pain. Clinical Journal of Pain, 29(5), 450–460. draft Scope of Practice just 10. Holtzman, S., & Beggs, R. (2013). Yoga for chronic low Position on Yoga Therapy back pain: A meta-analysis of randomized controlled trials. published this year. Pain Research & Management, 18(5), 267–272. By John Kepner, IAYT Executive • The YA-financed legal analysis seems 11. Ward, L., Stebbings, S., Cherkin, D., & Baxter, G. D. (2013). Yoga for functional ability, pain and psychosocial out- Director to lack awareness of the widespread comes in musculoskeletal conditions: A systematic review Published on the IAYT website* acceptance of yoga therapy and IAYT's and meta-analysis. Musculoskeletal Care, 11(4), 203–217. comprehensive efforts towards respon- 12. Ghelardini, C., Di Cesare Mannelli, L., & Bianchi, E. (2015). The pharmacological basis of opioids. Clinical Cases e at IAYT were as surprised as sible self-regulation. It also lacks aware- in Mineral & Bone Metabolism, 12(3), 219–21. everyone else to learn that Yoga ness of the normal development 13. Baehr, A., Peña, J. C., & Hu, D. J. (2015). Racial and eth- sequence for emerging healthcare pro- nic disparities in adverse drug events: A systematic review of WAlliance (YA) had taken a formal the literature. Journal of Racial & Ethnic Health Disparities, organizational position on yoga therapy, fessions and is thus unduly alarmist 2(4), 527–536. following the publication of a legal analy- about what is actually a normal evolu- 14. Noble, M., Treadwell, J. R., Tregear, S. J., Coates, V. H., tionary process found in any emerging Wiffen, P. J., Akafomo, C., & Schoelles, K. M. (2010). Long- sis of the practice of yoga therapy in the term opioid management for chronic noncancer pain. United States. Upon reflection, however, profession. Cochrane Database of Systematic Reviews, 20(1):CD006605. it makes sense for the YA to distinguish • For those of you who are interested in 15. Ballantyne, J. C., & Shin, N. S. (2008). Efficacy of opioids for chronic pain: A review of the evidence. The Clinical Jour- what they do from what IAYT does, since an extensive review of the YA-financed nal of Pain, 24(6), 469–78. neither YA's standards nor their mission legal analysis and a different perspec- 16. Eriksen, J., Sjogren, P., Bruera, E., Ekholm, O., & Ras- are designed to support yoga therapy as tive on the unregulated practice of yoga mussen, N. K. (2006). Critical issues on opioids in chronic non-cancer pain: An epidemiological study. Pain, 125(1), an emerging field distinct from yoga therapy, see the following document on 172–179. teaching. Yoga therapy is here to stay, the IAYT website: “Comments regarding 17. Noble, M., Treadwell, J. R., Tregear, S. J., Coates, V. H., with widespread and growing acceptance the Legal Risk of Unregulated Yoga Wiffen, P. J., Akafomo, C., & Schoelles, K. M. (2010). Long- term opioid management for chronic noncancer pain. as an adjunctive therapy in an integrative Therapy,” by Daniel Seitz, JD, EdD. Cochrane Database of Systematic Reviews, 20(1):CD006605. approach to health, so it is timely to more • The language requirements of the new 18. Kalso, E., Edwards, J. E., Moore, R. A., & McQuay, H. J. carefully identify the distinguishing charac- (2004). Opioids in chronic non-cancer pain: Systematic teristics and develop distinct credentials. YA policies initially appeared confusing review of efficacy and safety. Pain, 112(3), 372–380. and disruptive to those who provide 19. Ballantyne, J. C., & Shin, N. S. (2008). Efficacy of opioids both yoga therapy and yoga teaching. for chronic pain: A review of the evidence. The Clinical Jour- After discussion with our members, nal of Pain, 24(6), 469–478. our committees, and at IAYT's recent We are now observing new language 20. Nicholas, M. K., Linton, S. J., Watson, P. J., & Main, C. J. annual board meeting and a community emerging, however, which seems to (2011). Early identification and management of psychological comply with both the letter of the YA risk factors (''yellow flags'') in patients with low back pain: A meeting at the Beloved Yoga studio in reappraisal. Physical Therapy, 91(5), 737–753. Reston, VA, we would like offer a few requirements and the spirit and sub- 21. Kreek, M. J., & Koob, G.F. (1998). Drug dependence: stance of their yoga therapy teachings. Stress and dysregulation of brain reward pathways. Drug additional comments on the YA position on and Alcohol Dependence, 51(1-2), 23–47. yoga therapy. 22. Preter, M., & Klein, D. F. (2008). Panic, suffocation false IAYT is concerned that the YA posi- alarms, separation anxiety and endogenous opioids. • From IAYT's perspective, yoga therapy tion could create a divide in the yoga Progress in Neuro-Psychopharmacology and Biological Psy- world and a communications gap between chiatry, 32(3), 603–612. is not “diagnosing and treating” health two organizations that ideally would have 23. Gonzalez-Liencres, C., Shamay-Tsoory, S.G., & Brüne M. conditions. While it's not easy to sum- (2013). Towards a neuroscience of empathy: Ontogeny, phy- marize a wide range of healing prac- good lines of communication and offer logeny, brain mechanisms, context and psychopathology. each other mutual support. Indeed, good Neuroscience and Biobehavioral Reviews, 37, 1537–1548 tices in just a few words, we might say yoga therapists “assess and educate” in communication and mutual support with order to “empower individuals to the YA and our other sister association in improve their health and wellbeing the U.S., the National Ayurvedic Medical through the application of the teachings Association, has been IAYT's long estab- and practices of yoga.” lished policy. We are heartened, then, by the fact that Yoga Alliance recently • IAYT's complete definition is, of course, reached out to us to communicate about much more comprehensive than the the issues above, and we look forward to summary sentence above. Our defini- continuing such communication in order to tion was first published in 2012 in con- Frederick R. Taylor, MD, FAAN, FAHS, is better serve the broad yoga tradition, our a clinical professor of neurology at the junction with our educational standards; overlapping membership and especially University of Minnesota Medical School. for more information, refer to the article the millions of individuals practicing yoga He is a UCNS certified headache medi- “What is Yoga Therapy, an IAYT Defini- for health, healing, and spiritual support. cine specialist and board-certified neurol- tion” in the Resources section of the YTT ogist with special interests in patient-cen- IAYT website. tered care, integrative medicine, role of o The YA-financed legal analysis of * Read the full commentary on IAYT's the empowered patient as self-care heal- website http://www.iayt.org/news/277490/ er, and inter-professional practice. yoga therapy practice in the United States cited as IAYT's def- IAYT-on-Yoga-Alliance-Stance-on-Yoga- Matt Erb is an integrative physical thera- inition of yoga therapy a single Therapy.htm pist with specialization in chronic pain and sentence we published back in headache. He is on faculty with the Cen- 2007. See also “YTh Leading Voices Comment ter for Mind-Body Medicine and owner of on YA Policy” Embody Your Mind, LLC. He integrates o Similarly, that analysis quotes www.iayt.org/page/YThLeadersComment therapeutic yoga in his clinical practice. and criticizes a very old article w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 5 3 Case Report Yoga Therapy in Yoga Therapy in continued from page 38 P r a c t i c e P r a c t i c e continued from page 44 continued from page 50

References Yoga therapy has much to offer those When to Refer Clients 1. Garner, G. (Last sourced 2016). Professional Yoga in chronic pain. Almost 50 percent of Amer- Therapy Institute. Retrieved from icans report having some type of chronic If the pain worsens or if clients have not http://proyogatherapy.org/about-pyts/ pain10—that's almost 160 million people experienced any relief in a couple of 2. Rollnick, S., & Miller, W. R. (1995). What is motivational whose lives could potentially be improved weeks, then I would recommend that interviewing? Behavioural and Cognitive Psychotherapy, with your help! YTT 23(4), 325–334. they see a healthcare provider. There are 3. Zimmerman, G. L., Olsen, C. G., & Bosworth, M. F. (2000). some injuries to the knee that yoga can- A 'stages of change' approach to helping patients change References not fix. For example, there are some behavior. American Family Physician, 61(5), 1409–1416. 1. IASP Task Force on Taxonomy. (1994). Part III: Pain terms, meniscus tears that may be in the area 4. Ware, J. E., Snow, K. K., Kosinkski, M., & Grandek, B. A current list with definitions and notes on usage. In H. where there is blood supply and healing (1993). SF-36 Health Survey. Manual and Interpretation Merskey & N. Bogduk (Eds.) Classification of Chronic Pain can occur, but other meniscus tears may (2nd Edition, 209–214). Seattle: IASP Press. Guide. Boston, MA: The Health Institute, New England Med- be more severe and/or not in the area ical Center. 2. Finan, P. H., et al. (Feb. 2013). Discordance between pain that receives blood supply and may 5. Garner, G. (2016). Medical Therapeutic Yoga: Biopsy- and radiographic severity in knee osteoarthritis: Findings from chosocial Rehabilitation and Wellness Care. East Lothian, quantitative sensory testing of central sensitization. Arthritis require surgical intervention. Scotland: Handspring Publishing Ltd. and Rheumatism, 65(2), 363–372. 6. Garner, G. (2005). Professional Yoga Therapy Institute 3. Dunn, W. R., et al. (May 21, 2014). Symptoms of pain do When I worked for Dr. James Gar- Course Manual: Professional Yoga Therapy Volumes I-II. not correlate with rotator cuff tear severity: A cross-sectional rick at the Center for Sports Medicine, he 7. Pearson, N. (2016). Reconciling movement and exercise study of 393 patients with a symptomatic atraumatic full-thick- would put all of his patients on a rehabili- with pain neuroscience education: A case for consistent edu- ness rotator cuff tear. The Journal of Bone and Joint Surgery, American Volume, 96(10), 793–800. tation program to strengthen the VM at cation. Journal of Physiotherapy: Theory and Practice, In the very least, whether the patient was a Press. 4. Barkhuizen, A., et al. (May, 1999). Musculoskeletal pain and candidate for surgery or not. Sometimes 8. Butler, D., & Moseley, G. L. (2003). Explain Pain. Adelaide, fatigue are associated with chronic hepatitis C: a report of 239 Australia: NOI Group Publishing. hepatology clinic patients. American Journal of Gastroenterol- the rehabilitation would work well enough ogy, 94(5), 1355–1360. 9. Pearson, N. (Last sourced 2016). Life is Now Pain Care. that no surgery was required. If the Retrieved from www.lifeisnow.ca 5. Carragee, E. J., Alamin, T. F., & Miller, J. L. & Carragee, J. patient still needed surgery, they would M. (2005). Discographic, MRI and psychosocial determinants recover faster because the extensor 10. Louw, A., Diener, I., Butler, D. S., Puentedura, E. J. of low back pain disability and remission: A prospective study (2011). The effect of neuroscience education on pain, dis- in subjects with benign persistent back pain. Spine, 5(1), mechanism, in particular the VM, was ability, anxiety, and stress in chronic musculoskeletal pain. 24–35. already strong before surgery. With this Archives of Physical Medicine and Rehabilitation, 92(12), 2041–2056. 6. Westman, A. E., Boersma, K., Leppert, J. & Linton, S. J. in mind, yoga therapists can still play an (Sep. 2011). Fear-avoidance beliefs, catastrophizing, and dis- important role when they work in tandem 11. Moseley, G. L., Nicholas, M. K., & Hodges, P. W. (2004). tress: A longitudinal subgroup analysis on patients with mus- with other healthcare providers in helping A randomized controlled trial of intensive neurophysiology culoskeletal pain. Clinical Journal of Pain, 27(7), 567–577. education in chronic low back pain. Clinical Journal of Pain, to optimize their clients' health and out- 20(5), 324–330. 7. Feitosa, A. S., Lopes, J. B., Bonfa, E., & Halpern, A. S. (March 22, 2016). A prospective study predicting the outcome comes even when surgery is necessary. 12. Pearson, N., & Prosko, S. (2014). Overcome Pain with of chronic low back pain and physical therapy: The role of YTT Gentle Yoga Levels 2 & 3 DVDs. Life is Now Pain Care, Inc. fear-avoidance beliefs and extraspinal pain. Revista Brasiliera de Reumatologia (English Edition). doi: References 10.1016/j.rbr.2016.03.002. 1.DeAvilla Whiting, N. (2006). The role of yoga therapy in 8. Pedler, A., Kamper, S. J., & Sterling, M. (2016). Addition of knee rehabilitation. International Journal of Yoga Therapy, Shelly Prosko, PT, posttraumatic stress and sensory hypersensitivity more accu- 16, 79–94 PYT, CPI, physical rately estimates disability and pain than fear avoidance meas- 2. Garrick, J. G., & Radetsky, P. (1989). Peak condition: therapist and yoga ures alone following whiplash injury. Pain. doi: Winning strategies to prevent, treat, and rehabilitate sports therapist, is dedicated 10.1097/j.pain.0000000000000564. injuries. Random House Value Publishing to promoting the 9. Vallath, N. (2010). Perspectives on yoga inputs in the man- integration of yoga agement of chronic pain. Indian Journal of Palliative Care, Nicole DeAvilla, therapy into our 16(1), 1–7. E-RYT500, RPYT, current healthcare system. She is a 10. Gallup. (2011). Gallup-Healthways Well-Being Index. Retrieved from http://www.gallup.com/poll/154169/Chronic- RCYT, bestselling graduate of University of Saskatchewan, Pain-Rates-Shoot-Until-Americans-Reach-Late- author, researcher, Professional Yoga Therapy Institute, and 50s.aspx?ref=image Two-Minute Yoga host, Life is Now Pain Care. She teaches at pioneer in prenatal medical colleges, yoga therapy trainings, Lori Rubenstein Fazzio, yoga and yoga and conferences, and she offers work- DPT, PT, MAppSc, therapy, has appeared shops globally. www.physioyoga.ca YTRX, is on faculty in on radio and TV. An Ananda-trained Loyola Marymount (1984) disciple of Paramhansa University's Master of Yogananda, she serves through ministry, Arts in Yoga Studies yoga therapist training, and yoga online. and Yoga Therapy Rx where she is director of the Level IV Yoga Therapy Internship at the Venice Family Clinic in Los Angeles. She is the founder of Mosaic Physical Therapy in Los Angeles, www.mosaicpt.com. She can be contacted at [email protected].

5 4 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g w w w. i a y t . o r g Yo g a T h e r a p y Today | Spring 2016 5 5 R e v i e w tings on Salt Spring Island, Canada, nervous system, therefore increasing the where the videos were filmed. chances of changing the pain experience.

The movement sequences, each The sequences were developed by Neil approximately 45 minutes long, also inte- Pearson, PT, MSc, BA-BPHE, CYT, grate breath, mantra, and mudra congru- ERYT-500, and Shelly Prosko, PT, PYT, ent with the theme. The movement prac- CPI, and they also narrate and perform tice for confidence includes the same the sequences on the videos. Pearson mudra and breathing as the meditation and Prosko are well known and respected sequence for confidence, but the mantra within the yoga therapy and physical ther- has been changed to “Unleash my apy professions. They both lecture at uni- strength. Ready to carry it.” The asanas versities in North America and in yoga chosen for confidence include warrior, therapy programs and teach workshops goddess, and other standing poses that on pain nationally and internationally. focus on grounding and strength, as well Pearson was the founding chair of the as stability poses such as boat and a vari- Canadian Physiotherapy Pain Science Overcome Pain with ety of planks. The movement sequence for Division, and Prosko has taught work- the courage theme uses many of the shops on pelvic pain and other topics for Gentle Yoga: same movements that are being used in many years. Not many people have the Levels 2 and 3 confidence, but the movements for extensive knowledge of yoga therapy, courage has more of an emphasis on flow rehabilitation, and pain education that By Neil Pearson and Shelly Prosko from one asana to the next, implying that these two possess. The videos represent Review by Staffan Elgelid courage is about daring to move on and their combined knowledge of the three not be stationary. In the balance move- fields as well as what their patients have oday a growing number of people ment sequence many of the movements told them was beneficial to support them are being affected by chronic pain. are unilateral or bilateral and combined as they practiced each theme/intention. TThe problem of chronic pain is fur- with either unilateral or alternate-nostril The result is that Overcome Pain with ther complicated by an increasing number breathing. Gentle Yoga: Levels 2 and 3 are stunning of opioid overdoses. The Centers for Dis- videos that will immensely benefit not only ease Control and Prevention (CDC) The videos illustrate the deep under- people with chronic pain whether they released their new guidelines for prescrib- standing the authors have of yoga and have a background in yoga or not, but ing opioids for chronic pain in March, pain education. Mudras, mantras, breath- also practicing yoga therapists, physical 2016. The CDC now suggests nonphar- ing, and movements are combined into therapists, and anyone else who is inter- maceutical or non-opioid therapies. With coordinated practices with each sequence ested in pain education and movement. this in mind, the release of the DVDs demonstrated by Pearson and Prosko side Overcome Pain with Gentle Yoga: Levels by side in sitting and standing postures. In light of the new CDC guidelines, if 2 and 3 comes at an opportune time. This is very important, since it gives the Western society is ever to escape the viewer the impression that it is okay to do dominance of opioids as a main treatment Level 2 contains three themes: the practices either way, depending on for pain, videos like Overcome Pain with balance, courage, and letting go. Level 3 their present level of pain/function. Gentle Yoga will have a big role to play in contains four themes: confidence, persist- pain relief. It is my sincere hope that these ence, purpose, and patience. Each theme The DVD subtitles "Level 2" and wonderful videos will find the audience starts with 10 minutes of meditation. Each "Level 3" do not represent a progression they so richly deserve. YTT meditation is filmed in a different setting, or a difference in intensity. Each of the focuses on a different mudra (gesture), practices included in each level can be and includes a different breathing tech- performed if the participant is at any level Staffan Elgelid PT, PhD, GCFP, RYT-500, nique, mantra, and other practices that of function and in any order. Participants is an associate professor of physical ther- are congruent with the theme. For exam- can choose any one of the seven themes apy at Nazareth College, where among ple, the meditation on confidence includes that suits their needs for that day. What is other subjects he is teaching how to utilize the vajrapradama (unshakable confi- great is the flexibility of options that these yoga in physical therapy. Staffan lectures dence) mudra, the ujjayi (victorious) videos offer for any given day. For exam- on a wide variety of topics both nationally breath, and the mantra, “Strength inside ple, if the individual is experiencing a flare- and internationally. me. Live my life.” The meditation on per- up, he or she may choose to only partici- sistence includes the Ganesha mudra, pate in the 10-minute meditation practice instructions for a longer, smoother breath, that includes awareness, breathing, and the mantra is “surrender, commit- mantra, and visualization techniques. ment” and “commitment, surrender.” This However, if the person is experiencing a kind of congruence runs through all the relatively good day with more energy, sessions, and is complemented by the strength, and less pain, he or she may tone of voice of the narrator, the music, choose to continue on with the 30-minute and the beautiful cinematography and set- movement practice that challenges the

5 6 Yo g a T h e r a p y Today | Spring 2016 w w w. i a y t . o r g

INTERNATIONAL ASSOCIATION NONPROFIT ORG. OF YOGA THERAPISTS U.S. POSTAGE P.O. Box 251563 PAID Little Rock, AR 72225 MANSFIELD, OH PERMIT #158 CHANGE SERVICE REQUESTED

MOVING? Update your address online at www.iayt.org or email [email protected]

NOT GETTING EMAIL FROM US? Please add [email protected] to your address list or safe senders list.