April 2012

San Francisco Medicine April 2012, Volume 87 Number 3

18 San FranciSco Medicine aPril 2012 www.sfms.org Pain Management 19 San FranciSco Medicine aPril 2012 www.sfms.org Yoga for Chronic Pain Timothy McCall, MD Understanding the Yogic tools Used to Aid Chronic Pain Yoga is probably not the first option you think of in pain management for those patients who ei- ther want to add alternative approaches or who cannot tolerate the side effects of conventional drug therapy. With the growth in popularity of this an- cient Indian tradition, you’ve undoubtedly seen the ads and magazine covers featuring yoga poses, probably have patients taking yoga classes (and maybe had a few injured in them), and perhaps you’ve even tried a class at your gym. Ironically, those experiences might give you a misleading impression that could make you even less likely to recommend yoga to patients with chronic illness, including those in pain—and that would be a shame. Unless you get around in the yoga world, you may not realize that yoga has tremendous potential as therapy, even for people who wouldn’t—and shouldn’t—attend the typi- cal yoga class. Modified practices can be taught to people who are bedridden, the morbidly obese, those with spinal cord injuries, cancer patients undergoing chemotherapy, and women in their third trimester. The type of yoga popular in health clubs and many yoga studios is demanding—even ac- robatic—requiring fitness, flexibility, and balance. The best of these classes, those that stress safety and teach poses in an anatomically precise way to avoid injury, can be wonderful as stress reduction and preventive medicine for those young and healthy enough to survive them. But these classes could be torturous and counterproductive to those in chronic pain from arthritis, disc disease, fibromyalgia, repetitive strain in- juries, neurological conditions, and so on. This is where yoga therapy comes in. Yoga therapy is the use of various yogic tools to improve health and well-being, and it can be targeted to help specific health conditions. These tools include yoga poses, breathing techniques, visualization, meditation (the Buddha was a yogi before he became the Buddha), and many others. Therapeutic yoga is typically taught one-on-one or in small groups and is personalized to the individual. Indeed, a good yoga therapist will repeatedly adapt the prescription to meet the client’s ever-changing needs. The goal is to teach the student a routine that they will take home and practice. One of the central tenets of yoga is that change usually happens slowly and incrementally over a long period of time. This is the key to both its effectiveness and its safety. It is fre- quently said that practicing ten minutes a day is much more valuable than ninety minutes once a week. It’s all about tak- ing advantage of neuroplasticity to carve out new behavioral (and thought) patterns. Regular repetition over a long period of time, precisely what Patanjali recommended almost 2,000 years ago in the classical yogic text the Yoga Sutra, is the best way to do that. In yoga, we believe the best way to change a bad habit is to replace it with a new one. When I use yoga as medicine, I work with students to ascertain how much they can realistically practice every day. For most people, twenty to thirty minutes is manageable, but if five minutes is all they can spare, we’ll start there. I know from experience that if I can just get someone going with the practice, their improved well- being will often be all the motivation they’ll need to keep it up. Although some pain relief can come quickly in those who take up the practice, it is over the long term that dramatic im- provements become possible. One reason is that yoga is so ef- fective at dealing with stress. Enduring chronic pain can keep stress hormone levels elevated and the sympathetic nervous system repeatedly or chronically activated. Fight or flight may prepare you well for an imminent threat to life or limb, but it’s counterproductive when it comes to chronic pain. When you’re stressed, you tend to breathe more quickly and errati- cally, which, from a yogic perspective, keeps the mind on edge. Stress contributes to muscle tension, increases anxiety, and depresses mood—all of which can make pain worse. Other mechanisms for reducing pain with yoga include increasing GABA (gamma-aminobutyric acid) levels, improving posture (particularly helpful for back and neck pain and carpal tunnel syndrome), and facilitating longer and more restful sleep. Yoga includes an array of tools to calm the nervous sys- tem (as well as others to activate it, when that’s called for). Simply learning to breathe slowly and deeply through your nose can make a surprisingly large difference. Learning to subtly increase the length of the exhalation relative to the inhalation tends to further increase parasympathetic domi- nance. Beyond its acute effects on shifting the autonomic ner- vous system from sympathetic to parasympathetic control, yoga over the long haul increases stress hardiness. Seasoned yogis undergo stressful experiences just like everyone else, of course, but things are much less likely to get to them. The ongoing practice of yoga appears to repattern the stress response itself, which is now understood to be plas- tic. Many people who are chronically in pain live in a state of abnormally heightened reactivity. Their pain is real, but their response to even minor insult can be inappropriately strong, only fueling the fire. Yoga can also help those whose nervous systems don’t mount an adequate response to pain and other stressors to balance stimulation and relaxation. The longer and more steadily you practice yoga, the more profound the changes to the wiring of your brain and nervous system. Crucial to the yogic perspective on pain relief is under- standing the difference between pain and suffering. Pain is the