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F Eatu Rea Rticle 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 pro- of 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.
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