Chronic pain has become my mission…well certainly searching for solutions to help my students, many who have been locked in a endless circle of pain and tension for years.
Chronic pain is too often either untreated, under-treated or masked by drugs leaving 42% of sufferes with symptoms so severe they are unable to work and up to 63% unable to engage in activities those who are pain-free take for granted. Chronic pain is pain that has lasted for more than 6 weeks. It means that you have quite simply been moved from acute pain where you receive immediate treatment, to the secondary pain citizens who join a waiting list, that may or may not result in solutions or possible hope of a solution.
It was my own long journey with chronic pain that brought me to the practice of yoga. I was very familiar with the consequences of chronic pain: low self-esteem, appetite and sleep disturbances, a sense of powerlessness, hopelessness and depression. As my yoga practice and teaching developed I began noticing more and more of my students whose pain has become like a brick wall separating them from health and wellness.
It was through my training and practice of Yin Yoga that I realised that the body literally locks in the pain and this led me to study at a deeper level the role of our connective tissue and chronic pain.
Yin Yoga and Chronic Pain
We know that physical injuries heal, generally within 6 weeks (of course this depends on severity). If the pain continues we then become the part of ‘chronic pain’ queue, that results in endless, often unsuccessful appointments with physios, chiropractor, osteopaths, orthopedic surgeons etc.
But what we don’t get told it that our ‘injuries’ are often the results of the body begin put under months or years of stress, due to repetitive actions or poor posture, and it finally literally breaks under the strain. You don’t just turn awkwardly and herniate a disk, you don’t just wake up with sciatica, it has been a progressive process that has led you to that point. But how we got to that point is not my concern, my concern is how we can get back to pain free and start to respect and listen to our bodies. This is where the role of Yin Yoga plays a huge part!
Yin Yoga applies stress to the connective tissue: fascia, tendon, ligament and even bone. Intellectually this might feel counterintuitive, and indeed we can all agree that over-stretching any tissue whether it’s muscle tissue or connective tissue will be injurious. But a mindful Yin practice does not overstretch – it gently stresses and unwinds. It doesn’t require tremendous strength or flexibility and yet it delivers profound physical and mental release. A Yin practice asks the body to open to the discomfort of the pose and to accept the stillness required to maintain the pose without grasping or grabbing either physically or mentally. Working to an appropriate depth for the appropriate amount of time gives the connective tissue, the heart and the spirit space to open and, in a sense, breathe.
So what is Connective Tissue?
All the connective tissues found in the body, including fascia, tendons, and ligaments, are comprised of cells, fibres (collagen and elastin), and a gel-like fluid called ground substance. The ratio of these elements varies depending on the type of tissue and its location in the body. For instance, your Achilles tendons are thicker and more fibrous than your earlobes. But they are, more or less, the same thing.
The differences in the fibre/fluid make-up of these tissues match their functions. An Achilles tendon is thick and elastic so that it can absorb impact and produce power for running and jumping. But the fascia that wraps around the individual muscles fibres in our thighs is less thick and contains a lot of ground substance to reduce friction.
Researchers have also discovered that the separate connective tissue types respond differently to different loads. What a ligament needs to maintain its optimal function is not the same as a joint capsule. The overall takeaway from the research is that to sustain the robustness of all of our tissues we need to engage in a variety of activities. Healthy loads include the kind of passive, static stretches and compressions of Yin Yoga.
In particular, we know that static stretching stimulates the deep layers of fascia that wrap around the bundles of muscle fibres. Also, the fascia that connects muscles to one another is affected by passive stretches. But, passive loads don’t affect tendons and ligaments. Due to their arrangement, the relaxed muscle fibers absorb most of the tissue lengthening (Schleip, Muller 2012).
But, what do we mean by “stimulates” and “affected by?” What’s really going on here?
The primary cells found in fascia are called fibroblasts, and their main job, among a couple of other things, is to create more fascia (Schleip et al. 2012). The brain doesn’t control the fibroblasts. Instead, fibroblast behavior is determined mainly by the mechanical loads (or lack of loads) placed on them.
In Yin Yoga, we are mainly interested in the effects of compressive and tensile (stretch) loads on our tissues. The sensation you feel in the low back during sphinx or seal pose is a result of compressive forces on the soft tissues and vertebrae. When you fold forward in butterfly pose, you are stretching the back.
The fibroblast cells will adjust the production of collagen, elastin, and ground substance to create an architecture best suited for the demands placed on them (Benjamin et al., 2005). These loads need to be progressive (appropriately increased) and occur over an extended period of time. When it comes to remodeling connective tissue, lengths of time are measured in months and years (Schleip 2012).
Researchers have found that the fibroblasts in tendons and ligaments adapt to compressive forces by producing strong, fibrous collagen that can withstand additional forces (Benjamin et al., 1998). Without specific research, we can reasonably conclude that compressive Yin Yoga poses contribute positively to fascia health.
How long does this lengthening last?
Can we retain new length permanently? Is there an end point to how much we can stretch before it becomes harmful?
Connective tissues do have some plasticity, the ability to undergo change under a load. We know that slow, sustained tensile loads as we follow in Yin Yoga change tissue length more effectively than a quick stretch (Myers 2012).
But we also need to consider involuntary tissue contraction.We humans unconsciously contract our tissues in response to stress (physical, psychological, emotional, etc.). If we are under stress for an extended period of time, we can “forget” how to relax, meaning that our tissues may remain in a constant contractive state even when the stressor has been removed (Myers 2012). I see this all the time in my classes or in massage, where people have permantly stressed neck, shoulder and upper back muscles , contracted and tight. This is evident in people who spend their working life sat at a desk with a computer.
Further, we find that this constant state of contraction leads to a thickening of the fascia (Langevin et al. 2009). The research suggests that many people aren’t feeling an increase in range of motion after stretching, but rather they experience a return to a normal resting state. This is extremely significant for people trying to correct this problem with massage, yang styles of yoga or weekly appointments with physiotherapist.
On the cellular level, however prolonged static stretching does produce changes, which over time, can create adaptations and remodeling of the tissues. Just like compression, tensile loads on connective tissues stimulate the fibroblasts to produce more collagen fibres, which increases fascial thickness and strength (Myers 2012).
Other Interesting Benefits of Yin Yoga
Approximately 70% of the volume of fascia is made up of water found in the non-fibrous ground substance. Both stretching and compression play a significant role in tissue hydration. When you load tissue, fluid is squeezed out and into the lymphatic system, including fluids present as a result of swelling (Myers 2012). When the loads are released, and the tissues are left to rest, new fluid is pulled back in like a sponge (Klingler et all 2004). Loading our tissues, especially neglected ones, refreshes them.
Well-hydrated tissues have a springy quality that helps them to return to their original shapes after being loaded. Hydrated tissues also respond better and more efficiently to stress. And, well-hydrated tissues can more easily transfer nutrients to the cells and rid the body of toxins (Clark 2012). Our bodies don’t ask much from us….hydration, movement, nutrients and sleep! Also this is where I tell you to drink more water!!! It is vital for all aspects of health.
Perhaps one of the most intriguing discoveries about fascia is that it is our greatest sensory organ, and it plays a major role in our proprioception (van der Waal 2012) and interoception (Schleip, R., Jager, H. 2012). Movement modalities that emphasize physical awareness and internal listening can help refine the sensory nature of our tissues. Preliminary studies have shown an inverse relationship between pain and proprioception, making this a worthwhile pursuit.
This is particularly exciting for those of us who practice Yin Yoga. When we hold non-neutral shapes for between 5 and 15 minutes, we have a lot of opportunity to practice listening to our outer and inner states. Taking our time between poses in the rebound part of our practice, to notice the before and after effects can also enhance our sensing abilities.
In my own purely subjective experience as a woman in her 40s, I have noticed that I need to target the same area for at least a week before I experience what feels like lasting increases in range of motion. I find this particularly true of side bends. We don’t do a lot of side bends in our daily life, and often the only time I do them is in my yoga practice. If I stop doing them for even just a few days and I return to them later, I find that I lose those flexibility gains.
This is due to a process called contracture, which is a loss of mobility in a joint. Contracture can be a result of an injury or illness, but immobility also causes it. So has a huge impact on sufferers of arthritis. Fellow yogi Paul Grilley points out that you rarely, if ever, see very elderly people walking around loose and fancy-free. Instead, as we age the body tends to retract. Our gait becomes shorter because of loss of range of motion, and we shuffle along hunched over. But it is not old age that causes this….it is lack of mobility. It is a vicious cycle of reduced activity then reduced flexibility. As the body ages we tend to reduce activity, but in fact we need the opposite., we need to move more. Our tissues need both compression and tensile loads to keep us feeling vibrant and youthful.
Yogi Pain or Real Pain
When one suffers from chronic pain, we start to become super sensitive to any sort of pain in our body. A slight use of a muscle in the area of an injury or source of pain becomes amplified a hundred times in our mind. I know this from experience. The minute I started a physical path to recovery I stopped the minute I felt discomfort in the area where I received the original injury. I associated all pain as a bad thing and never really understood that recuperating was a tough journey. This is such a destructive cycle, we ovoid any sort of discomfort and therefore ovoid movement. Our concept of ‘pain’ becomes distorted, and we think that if we feel discomfort in the area of injury we are going to ‘flare’ the injury up again. But the body does not work like that. I remember the words of a physiotherapist in the Fire Service Rehabilitation Hospital where I spent time recuperating from my accident stating ‘you have a choice, stay in your guarded body, or take courage and step into you recover’. These words stayed with me when I moved into positions that challenged my comfort zone, or brought discomfort in the areas that had previously caused me searing pain.
In Yoga and in recuperation from injury of diseases that have restricted movement, there are two broad categories of sensation that will arise in physical postural practice: sensations of tension and sensations of compression. These fall along a wide spectrum, and there are clues that can help you differentiate between them.
Tension is a feeling of resistance inside the tissues, a resistance to being stretched. These sensations can arise in many areas and in many ways. It is a very good idea to pay attention to where you are feeling sensations and to what you are feeling. By paying attention, we begin to understand what the posture is actually doing to our tissues. We can then decide whether this is the place we want to be or not.
Compression occurs when one area of the body comes into contact with another area of the body: this is where no further progress is possible, for that posture, in that direction. There are three main kinds of compression: “soft” compression is where flesh is being squished into flesh; “medium” is where flesh is being pinched by bone; “hard” is when bone is pressing into bone. When compression has been reached, there will still be some sensation of tension. To remove all the sensations of tension, we would have to stretch out the area where the tension arises, but by definition, once you have reached compression you cannot go any further, so whatever tension is still there will remain. This means that while you may be stopped due to compression, there will still be some feelings of tension as well. However, when you are stopped solely due to tension, there generally is little or no sensation of compression yet.
Part of our yoga practice is building our ability to attend, to be present, to notice what is happening. It can be helpful to have an idea of what to look for, to help us sharpen our perception. We think in many ways that we are all individuals, but in reality we all hold tension in roughly the same areas. This is not because we are all the same, but modern life has created this restriction for us. But this fact also holds us back. We get stuck in the concept that ‘my parents had a back problem’, my mother suffered fron arthritis’, my father needed a knee replacement’. But these factors are not genetic…..but our environmental habits are passed from generation to generation. The research in Epigentics has shown us that between 85 to 95 % of diseases are not genetic, but lifestyle. This has a huge impact on chronic pain, because we can no longer hide behind….’my parents suffered from….’ We must start taking responsibility for our diseases and restrictions. If we want relief, we have the power to change our lifestyle….literally change our disease outcome…including chronic pain.
”Pain is subjective: is it ever good? Everyone knows what pain is, but we don’t all agree upon what is painful. Paul Grilley often points out that there are many Black Knights found in yoga classes: these are the Monty Pythonesque warriors who truly believe “I am invincible” and that “Black Knights always triumph!” When they are about to break their arms off in a deep, binding twist, they exclaim through gritted teeth, “I’ve had worse.” When the inevitable injury does occur, it is just a flesh wound: “T’is but a scratch!” For these hardy yogis, any sensation that normal people would call painful, the Black Knights believe it is a sign that their practice is about to bear fruit. At the other end of spectrum are the timid souls for whom any sensation, no matter how slight, is a cause for pause, reflection and concern”
We can consider pain as a signal from the body that damage is about to occur, is occurring or has occurred. Ignoring these warning signs is risky: akin to ignoring the engine light of your car. You can place masking tape over the blinking red light to help you ignore it, but eventually the engine will die and a bigger expense is upon you than if you had attended to the warning. But with the wide range of variation in how people interpret sensations, as painful or not, how can we really know if the sensations we are experiencing in a yoga posture are really dangerous or necessary? Again, we have to pay attention.
Pain, like all sensation, has qualities to it. I have noticed in my work as a yoga teacher, physical therapist and pain researcher that some people have two scales: a pain scale and a discomfort scale. For these people, many sensations are not considered painful at all, but rather uncomfortable. In yoga, we do take people outside their comfort zone: we need to challenge them; they need to feel something. Only when the postures become really uncomfortable do they become painful. But, even for these people, they need to practice with both an intention and attention. If they are experiencing discomfort that interferes with their ability to relax in a posture, to breathe freely or to soften their face, they are probably too deep.
It is valuable to pay attention to pain not only while you are in the pose, but also as you come out of the pose. Delayed onset of pain may be due to some things that you were doing in your practice that were not healthy. Whenever you feel pain, it is worthwhile to investigate the cause. If you can correlate it to what you were doing in your yoga practice, you have the option to skillful modify your practice. Take guidance form yourself and the deeper facets of the practice of yoga….remember it is not just a physical practice.
Pain changes breath; breath changes pain
Just as sensations can be indicators that we are too deep in our posture, breath is another barometer for our practice. Pain changes our breath: when we have no pain at all, our breath can be free, easy, and quiet, but when pain arises the breath changes. There are degrees of breathing patterns that are indicative of levels of pain. As pain increases the breath becomes noisier, labored, sometimes faster, sometimes shallower and sometime deeper. In some cases the breath may vary dramatically and even stop. This is not the kumbaka or breath retention sought in deep yoga practice, but a lack of awareness of the power and importance of the breathe, a lack of experience of pushing past our comfort zone, or a laboured breath that indicates that we have pushed to strongly.
Chronic pain and sensitization
Our adage of “no pain, no pain” is unfortunately, for some people, just living is painful. Sufferers of chronic pain can do yoga, but for these folks everything involves pain at some level. For some, a temporary injury may have sensitized them so much that, after they have fully healed, normal, benign stresses are perceived as painful. In these situations, we need to approach the situation from a different angle and look at the pain / brain connection. (see more in my book Breaking the Attention of Pain )
Students in chronic pain are already aware of their bodies, but they may have learned to run away from the pain rather than investigating it. As a yoga therapist, experienced with working with students suffering chronic pain, I have noticed that it may help the student to pay closer attention to the sensations of the postures, to investigate what is actually happening, rather that what the student is afraid is happening. With a regular yin yoga practice, sensations may begin to ebb away and the chronic pain diminishes. Both the quality and the quantity of the pain may change for the better: we want the student to be aware of these changes, and she can only do that by paying attention. By noticing what works, and what doesn’t, a path forward becomes clearer. By paying attention to the raw experience of each moment, she may be able to differentiate between sensation and pain.
Yoga involves sensations, but not all sensations are created equal. The quality, quantity and location of the sensations help to determine whether they are healing or harming. A sharp, burning sensation deep in the knee joint is never good, while a long, stretchy tugging along the thigh can be delicious.
Electrical zingers and tingling: not good. A dull, deep, compressive stress may be quite healthy. Many styles of yoga take us outside our comfort zone, but this doesn’t mean we have to be so uncomfortable that we cannot stay in the posture, that we can’t breathe freely or that we can’t release tensions in the areas of the body not involved in the posture. Discomfort does not automatically mean we are in pain, but generally pain is a sign that we are about to damage our bodies. Listen to the body’s signals: pay attention. Have an intention for your practice, such as—to regain or maintain optimal health. By combining attention with intention, it is possible to decide whether the sensations arising in your yoga practice are healthy or not. And if not, why not change what you are doing?
Blog partly based on research from www.eurekalert.org and www.yinyoga.com