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 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, 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 that such fear is a common reason that mented reductions in pain, more energy and a 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 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 (), 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, moun- tain, 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 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). 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 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). : 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). : 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