Pain and Yoga: The Good, The Bad and The Neurological
What first brought you to yoga? For some it’s stress, for others, it’s a desire to have less pain and, for others still, it’s a desire to find a deeper meaning to life. Well, what if I told you that pain science is relevant to all of three of these factors, possibly in equal measure!
Scientific research on pain has, in recent years, focused on three ‘game-changing’ concepts that are so relevant to how we practice and teach yoga asana. They also support the relevance of pranayama, mindfulness and even yoga philosophy. This is because pain is much more complex than previously thought - and lies at the interplay between body, neurological system, brain and psychology.
These three factors are revolutionising our understanding of pain, and changing the world of physiotherapy, but they are equally applicable to us yogis:
Pain is not a signal originating from bodily tissues, instead it is an output of the brain which interprets the body’s signals.
Pain is not an accurate measure of tissue damage, as we may experience pain without any damage to muscle, ligament etc., and sometimes we may have no pain, even when tissue damage is severe.
Pain is mediated by the nervous system and interpreted by the brain, so the nervous system itself is a viable target of treatment for pain.
These three concepts together tell us that pain is complex! But also, that we can influence pain through the nervous system, which is the mediator of our experience of pain. Since yoga can be SO effective at “calming” the nervous system; with appropriate practices, language, and mindfulness, we can potentially help to ease or to create “space” around the pain so that it becomes a more manageable experience.
Pain is an opinion on the organism’s state of health rather than a mere reflexive response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain.
Phantoms in the brain by VS Ramachandran & Sandra Blakeslee
Let’s explore the three key concepts in more detail and see how they are relevant for us as yogis and teachers of yoga.
1. Pain as an output from the brain
Some of the best and definitely the funniest descriptions of this are here in Lorimer Moseley’s, TED talk. Moseley is a Professor of Clinical Neurosciences, a tireless pain researcher and a natural entertainer.
He describes the role of “nociceptors” which are the body’s pain receptors, i.e. the part of the neurological system which is primed to look out for pain, as receptors that can warn us with pain, and get us to respond appropriately, so we have a better chance of staying alive. The key thing here is that the nociceptors simply respond to stimulus, if we believe we have been bitten by a snake- the brain will interpret the sensation of being touched on the leg with a big neurological outpouring of pain. If we think it was a little stick we brushed past, the brain responds with the pain output of “little scratch”. (Mosely makes it much funnier!)
How is this relevant to yoga teachers?
If we continue to warn students that the body is in imminent danger from asana, that it might be about to “slip a disc” (they actually don't “slip” anyway, but different story), or damage the ligament with “misalignment”, then we prime students to experience pain.
The body is waiting on high alert for the crisis moment, and, when it comes, all those warnings are likely to trigger a greater pain response.
My last blog on updating alignment cues here goes into more detail on this, if you haven't read it already- do! It's important.
So instead, we can use language that is affirming. The body is not likely to be damaged by something as gentle as yogasana. In fact, we can use a scientific approach to benefit the body in so many ways.
2. Tissue damage
Pain is not an accurate measure of tissue damage. Pain is our brain’s interpretation of how “bad” the situation is- ie how much the brain needs to shout “pain”, plus how horrible - or not - the situation leading to, and surrounding the pain is.
If a pain trigger e.g. trip up a stair and bang to the knee, is a reminder of past distressing trauma, or humiliation e.g. when the same thing happened in front of the whole school, we are primed to feel more pain.
When researchers looked at knees in this BMJ study (LINK) they found that while 29% of participants experienced pain, tissue damage could be seen in 89% of cases, and those who did experience pain were not all in the “damaged tissue” camp. In fact, those with pain were almost as likely to have no visible damage.
Similarly with back pain researchers have found an absence of tissue damage where a patient suffers from pain. Whereas with others where there is significant tissue damage, such as pressure of a spinal disc onto the nerve, there is an absence of an experience of any pain at all!
While this may not be super relevant as yoga teachers, because we are not there to diagnose or suggest someone's pain is “not real”- because it is! It is relevant as far as mental health goes, since a higher experience of pain is associated with both anxiety and depression.
Students often seek out yoga to help with their mental health, understanding the role yoga can play in alleviating mental health conditions and there has been a lot of research into how best to support mental health through yoga.
As teachers we can research and practice the best evidence based approach to support mental health. For further information on practicing and teaching Yoga for Anxiety Course online, take a look at my online course.
FYI I will share more on this soon with a short course for teachers and on the forthcoming Yoga Web launching in October.
3. The Nervous system
Pain is mediated by the nervous system and interpreted by the brain, so the nervous system itself is a viable target of treatment for pain.
Since pain is so deeply affected by the nervous system, we can use methods that we know help to regulate the nervous system to improve pain outcomes.
There are many factors that can contribute to improved outcomes and these can sometimes seem contradictory. For example, both strength work, which stimulates the sympathetic nervous system, and slow holds or yoga nidra which stimulate the parasympathetic - can positively affect pain outcomes. Confusing perhaps, but we can use this to offer a variety of practices, types of classes and types of movement and stillness within a single class and/or in different classes throughout the week.
Overall, one of the most significant roles yoga can play is to help us develop a more resilient and adaptable nervous system, so that we can respond in a flexible way to stress and then relaxation. An elevated heart rate is associated with the sympathetic nervous system, and an ability to return to parasympathetic mode when appropriate, signifies good mental and physical health. This scenario of moving between these states of “stress” and “de-stress” is often repeated several times during yoga class.
We even practice keeping the breath steady and therefore managing the heart rate while in a stressful situation- say a long hold in Warrior II, mindfully watching our response and feeling calm, despite the raised heart rate to hold the body in the pose.
This sort of “nervous system training” is ideal as a way to mediate our responses to other stimuli such as stress and pain in real life situations.
Strength Practices and Pain
Strength work is associated with:
1. Improved confidence in the body, which in turn will help the brain interpret potential pain signals from the nociceptors in a more ‘muted’ way.
2. An increase in strength is associated with reduced incidence of injury
3. Increased strength is also associated with more efficient movement as the brain makes a better ‘map’ of the body, hence reducing the ‘need’ for pain.
Relaxation and Pain
Gentle postures, (which still stimulate a muscle response in the body) also influence the nervous system, sending signals through the nervous system to the brain that we are at ease, and promoting a relaxation response. A lot of this information travels from the fascia since so many of our receptors are embedded there.
Practices like shavasana or yoga nidra, when they are accessible (as if we are stressed already they may not be) also reduce the intensity of pain responses, as increased stress levels are associated with increased pain levels.
Also, if our relaxation response through yoga helps us to relax more, and therefore sleep better, this has been shown to reduce our experience of pain.
What is surprising is how malleable pain signals are, how readily the intensity of a pain signal is changed by the sensations, feelings, and thoughts that coincide with the pain stimulation.
“The brain is not a mindless pain-ometer, simply measuring units of ouchness.”
Why Zebras Don’t Get Ulcers by Robert M Sapolsky
Conclusion
Many discoveries about the physiology of pain have been painfully slow to reach the public, or even health professionals and yogis. But, this is really useful and relevant information for us and our students, so let’s get talking and share it!
The main consideration is to stop thinking of pain in simple terms. There is no single cause or cure for pain, our explanations of “it all started when” “it’s all coming from” are oversimplifications at best! Pain is not a reliable sign of what’s really going on and long term or chronic pain tends to be a concoction of different factors, complex by nature.
At the very least, at least one layer of brain generated complexity, and at the worst our pain response can be very diverse and colourful. Causing pain that is much more intense and interesting than just a symptom, so that the pain itself is the problem.
As yoga teachers we do not need to diagnose, our work can help improve pain outcomes in a general way, and more specifically, we may have a role to play for those who have been assured there is little to no tissue damage, by reassuring and encouraging students to work their way from pain to increased ease. Or perhaps, to an acceptance of long term pain as something bearable, not the main focus of attention.
Since our neurons tend to continue to fire in the same way over time, unless we create new neural pathways, pain signals from the nervous system actually become more, not less, persistent over time. Plus the signals get more vague and generalised, so we experience more pain over larger areas of the body. This obviously causes distress, and costs a fortune for individuals and to the NHS.
Yoga is ideally placed to mediate all of the factors involved in pain causation- we have discussed the role of asana and mindfulness, on the body and mind. We also can help to rewire the brain through yoga philosophy - new ideas and concepts, moving us away from such strong identification with the body. Also new movements mean an opportunity for new neural networks, so creative movement and joyful movement support health.
Armed with our new scientific knowledge, the ancient wisdom of yoga seems more relevant and prescient than ever. Armed with this knowledge we are in a great place to talk about, and promote our practice and teachings. So get out there and fall in love with yoga more than ever, and your students will too!
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059532/
https://www.csp.org.uk/frontline/article/physio-findings-exercise-pain-doesnt-equal-tissue-damage
https://www.ncbi.nlm.nih.gov/pmc/?term=pain+%26+tissue+damage
https://www.bmj.com/content/345/bmj.e5339
Why Zebras Don’t Get Ulcers by Robert M Sapolsky
