Chronic Pain and the Brain

Chronic Pain, the Brain, and the Yoga Train; Using Yoga to Retrain the Brain’s Perception of Chronic Pain

“Suffering is transformed not by avoiding it, but by changing the way we relate to it.” – Mark Epstein on Buddha’s vision of transformation

Anyone who has lived with chronic pain has, at one time or another, had a feeling that they are going crazy. The quest to find out the cause of the pain may seem endless, leaving them feeling helpless and hopeless. This scenario of suffering is what has drawn millions to the teachings and philosophy of yoga. The yoga philosophy states that dukkha, or suffering, is a human condition, which is why so many of us seek out this 5000-year-old discipline that facilitates physical movement, moral teachings, and mental training. Over the last 50 years, the Eastern philosophy of yoga, the uniting of body and mind, has been edging its way into our society. A diverse group of scientists, yoga therapists, doctors, and other clinicians have come together to discover what the Indian culture has been practicing for thousands of years. It’s not a trendy pill and there are no costly side effects. Many find that yoga brings them peace within their suffering and an understanding that they are not alone in their pain.

What You Will Learn

It has been not only my personal experience with pain but also my clients’ experiences that have led me on this journey to find the common solutions a yoga practice affords people with pain and how magnificent the relief can be. How do we transform our suffering and change the way we relate to chronic pain? The brain is a powerful piece in the puzzle of persistent pain and yoga is the guide to arranging the pieces through the process of healing. This paper will outline the definition of chronic pain, discuss pain science and how the brain sends signals to our nervous system when in persistent pain, and explore how we can begin to retrain the brain to reduce suffering from chronic pain, using the tools and philosophical practice of yoga.

Chronic Pain

Physical Therapy researcher Lorimor Moseley, Ph.D. defines pain as “a multisystem output that motivates and assists the individual to get out of a situation that the brain concludes is dangerous.” Pain exists to protect the body and drive change, and can be classified as acute or chronic (Butler & Moseley, 2016). Acute 2 Chronic Pain, the Brain, and the Yoga Train Cummins pain is often felt at the onset of injury or trauma and disappears after the body has healed itself. Chronic pain, however, persists well beyond the expected healing time (Pearson, 2012).

Peter Przekop, a researcher in the Chronic Pain Clinic at the Betty Ford Center, defines pain as “any sensation with a negative context in the mind that is holding one from being able to heal” (Przekop, 2015). Przekop’s research has shown the importance of emotional pain’s effect on the physical body. People with symptoms of depression, negative thinking, and difficulty recognizing and coping with stress were more likely to have chronic pain. In one case, a patient being seen by multiple doctors to address an on the job injury was in so much pain that she no longer wanted to live. When she started going to Przekop, he quickly discovered that no one had asked her about her past. Przekop revealed that she was abused as a teen and that she hadn’t realized she had internalized her emotions. She simply coped by holding her feelings within. She had never considered that not dealing with her past was affecting her present pain (Przekop, 2015).

Chronic pain expert Neil Pearson, yoga and physical therapist, agrees that successful treatment of chronic pain must address the internalized emotions and underlying stressors that hold us captive to the sensations of pain. In yoga, there are five koshas or sheaths: the physical body, the energy body, the mental body, the awareness body, and the bliss body. Through our life experiences, we store these impressions called samskaras within these five layers. The samskaras, the internalized emotions, perceptions, and thought patterns we hold within can keep us from living a full life (Pearson, 2012). These samskaras cannot be detected on an MRI machine and make it difficult for doctors of Western medicine to treat.

Traditional Western medicine focuses solely on isolating a body part, which may be partially effective for the management of symptoms, but the body is the sum of all the parts and by not getting to the root cause of the chronic pain, there will be no permanent healing. Many medical doctors fail to look into past experiences of a patient because of lack of time and few are trained in pain biology and the chemical changes occurring in the brain and nervous system. Since many medical professionals are poorly trained in assessing and holistically managing pain, they are inadequately equipped to design effective treatment for chronic pain outside of the usual opioid prescription (Przekop, 2015).

Leading Health Problem in our Country

Chronic pain is one of the leading health problems facing our Western world. The Journal of Pain in 2015 estimated that 25.3 million American adults suffer from chronic pain, costing our society nearly $630 billion per year. Tragically, nearly 20,500 people died from opioid overdose in 2015 (Pain Dr, 2015). Opioids are synthetic narcotic drugs derived from the poppy seed that are used to soften shortterm pain. When used long-term, the brain changes in response to the drug and the body becomes more tolerant, which requires a larger dosage, eventually leading to addiction (Przekop, 2015). Opioids work on the part of the brain that turns off the pain signal. Research shows that a reduction in pain using opioids occurs in only 2030% of chronic pain patients, with the effects lasting only three months before the body builds a tolerance. The opioids become less effective when the pain signals in the brain begin to change and the patient then perceives pain increasing (Przekop, 2015, p. 32). Perception is an important word in understanding how our brain evaluates pain. Pain is a result of a change in our nervous system and the good news is we have the power to change how our brain processes persistent pain with a little understanding of pain science.

Chronic Pain and our Brain

Throughout the rest of this paper I will be discussing the brain and the mind. Though these terms are sometimes used interchangeably, it is important to understand how the two words differ as we move on. The brain is the physical organ, the command center, that receives and transmits messages throughout our body. The mind, contained within the brain, is the vessel in which thoughts, emotions, mood, perceptions, expectations, and imagination are manifested. The brain has hundreds of parts that can be monitored throughout a pain experience, but the mind contains the perceptions and stories created that are individualized and vary in every person and in every instance of a pain experience.

If a person has problems within the body, he/she will not feel pain, unless the mind believes they are in danger (Butler & Moseley, 2016). The brain actually only pays attention to what the brain concludes is most important. Think about your pain on vacation versus your pain at work. Most of us will describe feeling much less pain when we are sipping a daiquiri on the beach. Or consider having a large bruise, but no recollection of how it got there. Pain is inconsistent and the onset of pain begins because the brain has concluded there is a threat and an alarm activates to warn us of damage or encroaching damage (Pearson, Life Is Now Pain Care, 2018).

These alarm responses in the human system are designed to protect and heal. Information coming from the senses, is evaluated by the nervous system and pain is then perceived (Butler & Moseley, 2016). Fear, anxiety, anger, muscle tension, unpleasant sensations, changes in breathing, muscle weakness, and protective postures are all, natural protection mechanisms (Pearson, Life Is Now Pain Care, 2018).

Pain is not an accurate indicator of injury, tissue damage, or what is taking place within the body and therefore not an accurate indicator of movement. The perception of pain is a process within the mind. What we perceive through our senses is not accurate. There are many factors that affect our pain; emotions, thoughts, sensations, experiences, memory, expectations, or the anxiety or attention given to pain (Pearson, Life Is Now Pain Care, 2018). These perceptions make up our belief systems and define our reality. Our mind is what we use to experience the world around us, the place where we put meaning to things and create discernments and interpretations. It is through the mind that we create our own private story. Our mind remembers and stores information that helps us to learn and recall the memory later and is capable of prioritizing or choosing aspects of our internal or external environment that draw our attention (Przekop, 2015).

Scenario

For example, if a child falls and scrapes his knee and looks to his mother for a reaction, when no reaction is present the child moves on perceiving his accident as “I am fine.” If another child falls and scrapes his knee and looks to his mother for a reaction and she runs to him with a worried expression and an abundance of attention, his perception of the incident will be much different. The child believes, “Mom seems to think this is a problem, therefore this scrape must be scary and painful, I am not fine.” In this moment, the perception causes the brain to send a message along the nerve to the spinal cord saying, “danger.” Within seconds of the incident, the brain receives and analyzes the input to create an experience that may or may not include pain. The mind begins to couple the newly arriving information with the vast amount already stored in the memory to construct a new chapter to the story. Messages that enter the brain get evaluated by the mind, which then makes a judgment and response. Thus, perception becomes reality: “I feel pain” (Przekop, 2015).

As these stories are processed, they are perceived and preserved by the mind as actually happening, and are then presented to the physical brain and anatomical body as if they were, in fact, real. Every memory, every experience, is stored in the body, even when the memory is repressed. When we are in pain over an extended period of time, the pain pathways become dedicated neural pathways of favored and frequent communication of hurt. In essence, we have trained our brain to take uncomfortable sensations, activities, or experiences down the fast lane to pain, the most frequent road of travel. The nervous system becomes sensitive to the sustained hyper-activity of the endocrine and immune system, leading to other problems including inflammation, bone or joint damage, and/or nerve issues. For example, back pain is among the most common chronic pain complaints. Yet research shows that the amount of disc and nerve damage rarely relates to the amount of pain experienced (Butler & Moseley, 2016). Inflammation, bone or joint damage, and nerve issues don’t necessarily result in pain unless the mind perceives it as such, and the brain has told the system there is pain.

In Healing Back Pain by John Sarno, he coins the term TMS (Tension Myositis Syndrome), a condition of pain that has no physical evidence for occurring. The “unexplained” pain makes one produce stress chemicals, which then activate sensors that fire danger messages to the brain. It is this increased sensitivity of the alarm system that is telling the brain there is more damage to the body than there actually is. The increased signals to the brain amp up the paranoia within the mind that something is wrong, despite all doctors saying the test results show no reason for the pain, and the person gives the pain full attention (Sarno, 1991). It is at this point the brain begins to change. This sensitized central alarm system creates a repeated cycle. Within this cycle, neurons that have learned to link together in the interpretation of a single input, called pain neurotags, are being constructed whenever you move in a way that you perceive as causing pain (Butler & Moseley, 2016). It is within this chemical process happening in the brain that the mind decides that physical pain is preferable to the emotional issues driving the perceptions. Sarno theorized that rather than expecting and fearing pain, instead look to the emotional situation that occurred at the onset of pain. The repressed emotion is actually the cause of the pain, not an injury. These samskaras or impressions within our koshas as mentioned earlier, can prevent us from living a full life. Once the samskaras or emotions are accepted as the cause of pain, the memories linked to pain lose their power and the pain should then recede (Sarno, 1991).

Real Life Example

A perfect example of this comes from my client Tamara. She came to me with excruciating hip pain, trouble getting in and out of her car, was visibly in extreme pain when getting up or down from the chair or floor, and had difficulty walking up stairs. She could hardly get on her mat anymore to do gentle stretching. When asking her to move outside of her perceived limited range of motion from the hip she only had to think of moving to feel pain. These thoughts and fears of certain movements or activities or fear of re-injury can increase pain which Butler and Moselely named “thought viruses.” These thought viruses can be enough to prevent someone from returning to normal activity. This is when the person begins to move differently, hold the body in new ways, and change normal behaviors. Once these new patterns are learned they can be difficult, but not impossible to reverse (Butler & Moseley, 2016). These thought viruses can also be thought of as kinesiophobia, an excessive fear of movement (Larsson, 2016). After a few treatments of yoga therapy, we uncovered that Tamara’s pain began around the time of severe emotional turbulence in her life. Tamara needs to change the way she relates to her suffering in order to heal.

What happened within Tamara’s brain that created thought viruses or fear avoidance? Tamara’s brain was using a term called neuroplasticity, the brain’s ability to learn new things, to change and adapt. The neuroplasticity of our brain makes it not only pliant to the damages of long-term stress and fear of the cycle of chronic pain, but thankfully also contains the ability to reprogram itself and reverse persistent pain (Przekop, 2015, p. 80).

Pain worsens because the nervous system decides to listen to the danger signals, but it is possible to change how the mind decides to perceive these brain signals. Our thoughts and habits can change our neural pathways and yoga training has been proven to help people find new ways to move that are enjoyable without making the internal alarm activate. As the brain begins to change, so does the heightened sensitivity of the nervous system. The following discussion will examine the teachings of yoga and the evidence that yoga will alter the brain and its patterns to relieve pain and change the way we relate to suffering.

The Yoga Train

In my late 20’s I was entrenched in a high-stress lifestyle with an active duty military spouse who deployed continuously for four years, leaving my son and I alone. I worried about everything. I battled sleep deprivation, stress-related illness, natural disasters, the news of the current war, and wondering when I’d get the next phone call to know he was alright; fear, fear, fear. Depression, anger and resentment became routine. As my mind created these perceptions, my brain interpreted and responded; the aches and pains became a new normal part of each and every day. I spent hours in doctors’ offices getting referrals to more doctors. I needed help, but doctors continued to tell me nothing was wrong but somehow a rainbow of pills would solve my problem. For my own sake and my son’s, I needed an answer to why I was feeling so awful and to not mask the problem with medicine. I didn’t know it at the time, but I needed to change the way I related to my suffering. My journey led me closer to yoga and its healing power and became the answer to relieving my pain.

Sri Swami Satchidananda said, “Everything begins in the mind. If you want to see clearly, you need clear vision” (Carrera, 2006). Yoga training and philosophy offer some amazing tools to treat and understand chronic pain clearly. Self-study (svadyaya), is the beginning and lifelong journey to eliminate suffering through the observing of the self without judgement. Concentration and meditation (dharana and dhyana) with a practiced awareness can bring about healing of our samskaras, those deep internal impressions we hold onto throughout life. Functional movement (asana), breathwork (prananyama), and relaxation strategies (pratayahara) are the root of the yoga teachings to retain a healthy body and to heal and deal with inner sufferings. The yoga sutras can guide you towards spiritual enlightenment (samadhi), while observing your principles and moral guidelines (yamas and niyamas), and learning to love yourself and surrender to the divine within (ishvara pranidhana). These are just some of the tools a yoga therapist can use to bring healing to our minds and bodies and change the way we think in a natural, holistic way. These foundational, core systems of belief and integrative practice had me wanting to know more, leading me down a path to yoga therapy certification.

Yoga Therapy and Pain

Yoga therapy allows the therapist to tailor the treatment to the client and not the disease, giving them the experience and allowing them to choose what works for them at any given time. As we have likely experienced in the medical model of pain treatment, what works for one, won’t necessarily work for another. Treatment must be unique and built to the client’s particular habits, thought patterns, and belief system. Yoga therapy meets the client where they are. What is the first step then at applying this yoga philosophy to treatment of chronic pain?

The first step at applying yoga philosophy to the treatment of chronic pain is to identify the threats that are causing pain. Knowledge is power. Learning how the brain, mind, and body function together to create our own unique pain experience can give the client an explanation and reassurance that their pain can change. Instead of avoiding or pushing through the pain we begin to respect it, without fear, and develop a plan for recovery. Neil Pearson, Pain Care Yoga educator for yoga therapy, devised five steps for recovering movement when in persistent pain. These five steps are: first move to the edge of increased pain, then ask if it is safe for you to continue at this edge, followed by asking yourself if you will regret this movement later. Then if you choose to stay at the edge continue to monitor your pain while keeping your breath calm and muscle tension low (Pearson, Life Is Now Pain Care, 2018). With a little yoga training, we can empower our clients to change their thought patterns and begin to adjust the level at which they feel pain.

We now know that pain doesn’t necessarily mean we are in danger. Through mantra or meditation, we can remind ourselves that pain doesn’t necessarily mean something is physically wrong. Through the practice of meditation, a person can clear the mind enough to be drawn inward to a state of oneness. It is in this unconscious level that mind and body communicate. In this state of mental clarity, we can overcome daily stress from today’s chaotic lifestyle by teaching us how to eliminate negative thought patterns, the very thought patterns that create the cycle of persistent pain (Fulford, 1996).

Mindset

Creating a mindset that can redirect your attention and retrain your brain might be done with a sankalpa. A sankalpa is a short, positive, present tense statement of intention that becomes planted in our mind like a seed of transformation and healing. The sankalpa becomes a guide to creating new, pain-free pathways in the brain. A sankalpa is often created during a session of yoga nidra, or “yogic-sleep.” Yoga nidra is a powerful relaxation technique of guided meditation through breath awareness, guided imagery, and body sensations leading the person to a state of consciousness between wakefulness and sleep (Miller, 2015). Yoga nidra is a practice of concentration, using the prefrontal cortex, the part of the brain above and behind your eyebrows, sometimes known as the third eye. This part of your brain is particularly trainable and can be taught through yoga nidra to move attention away from negative, worrisome thoughts to more positive, calming thoughts (Wilson, 2015). Based on iRest research, a personalized yoga nidra program created by Richard Miller, the US Army Surgeon General’s Pain Management Task Force uses yoga nidra as a primary approach to manage chronic pain in health care for the US military (Miller, 2015). A one-hour practice of yoga nidra is equivalent to 4 hours of sleep (Lusk, 2008). That’s a pretty impressive way to catch up on your z’s.

With body awareness and knowledge of how much power the mind has over our being, we can work mindfully in moving the body, finding a baseline for movement and working gradually from that point with patience to progression (Butler & Moseley, 2016). Sometimes this progression only has to be visualized first as an experience we can have without feeling pain. It is this awareness that is key to relieving the burden of our chronic pain. It is the skill of awareness that pulls our attention from pain to the present. The memory of a particular pain may not go away, but the conscious mind can be refocused. The emphasis should be on observing the personal story without judgmental or emotional interpretation and elimination of the perceived physical pain by making peace with it.

A yoga therapist uses the physical movements of yoga to adapt functional movements safely and gradually back to a life you deserve. For example, a forward bend doesn’t have to be done standing, bending at the waist to touch your toes. The movement can be done just by sitting and visualizing the movement while simply thinking about not feeling pain. Changing the position in which you perform the exercise, in varying locations such as in water, a bed, on a chair, or by varying the sensory aspects of the practice with eyes closed or with music playing can all change thought patterns. Simple lifestyle changes can challenge the minds perception and the movement we once feared, gaining back confidence and trust in our bodies. You are in control of your mind, and that can change your pain and the chemical processes within your brain and nervous system (Butler & Moseley, 2016).

Studies have proven loss of gray matter is directly related to pain (Villemure, 2013). Using thermal detection, pain thresholds, and cold pain tolerance in experienced yoga practitioners, the study examined the structural differences in brain gray matter and white matter between yogis and non-yoga practitioners. The results were astonishing. The study found that those who practice yoga on a regular basis could tolerate pain twice as long as the control group. The yoga practitioners also had more gray matter in multiple cortical regions related to effective pain processing, pain regulation, and attention than the non-yogis (Villemure, 2013).

What is gray matter? The American Pain Society states that “gray matter is brain tissue with numerous cell bodies located in the cerebral cortex and subcortical areas. Decreased gray matter can lead to memory impairment, emotional problems, and decreased cognitive functioning.” M. Catherine Bushnell, Ph.D., at the National Center for Complementary and Integrative Health, (NIH) found in similar imaging studies that people with multiple types of chronic pain and depression showed they had reduced gray matter. The studies found that gray matter loss is directly related to the pain when considering depression. Bushnell states the evidence is compelling, that yoga and meditation can counteract the brain anatomy in chronic pain patients. Bushnell says, “Insula gray matter size correlates with pain tolerance, and increases in insula gray matter can result from ongoing yoga practice” (Weber, 2015). The greater the masses of gray matter, the higher the level of pain tolerance. The practice of yoga as therapy increases gray matter, therefore decreases pain.

Let’s put what we now know about the brain and chronic pain into visualization and a yoga practice to which we can all relate. Most of us have experienced headache pain at some time; consider these sensations of a monstrous headache coming. Your brain tells you there is pain. You may start to feel nauseous, have sensitivity to sunlight, or start to feel tension build up in your neck and jaw. Anger and impatience build, because who has time for a headache? The more you try to control the pain and push it away, the more anxiety you create, tension increases, the pain worsens and the cycle continues. Borysenko, in the book Minding the Body, Mending the Mind, recommends yoga treatment for pain. The next time you have a headache, rather than trying to control the pain, begin by observing the tension in the jaw and the shoulders. Let the shoulders drop and the teeth separate so the jaw relaxes and the backs of the eyes grow heavy. Recognize the pain, rather than ignore it, send it loving attention. Breathe with awareness and without attachment to results. Be a loving witness to the pain. Use positive affirmations to neutralize the negative thought cycle by stating the words “I accept my headache and wrap my head in loving attention.” Become aware of repetitive negative emotions towards the headache, in this case, anger, and replace it with thoughts of love (Borysenko, 1987).

I have tried this particular practice on myself and other clients who were ready to skip their regular yoga practice due to a headache. In several cases, within 15 minutes of Borysenko’s suggested practice, several of my clients were well enough to attend their yoga class. At the end of a mindful, loving yoga practice, the headache was gone! It might sound counterintuitive to your regular habits of popping a Tylenol, but the power of the mind is incredible in treating pain.

Conclusion

“As you think, so you become.” We may have developed a pattern of thought that is unhealthy and wreaking havoc on the physical body, but luckily for us evidence proves the brain is pliable, the mind is powerful, and new thought patterns can be created through proper yoga training. This can give clients suffering from chronic pain a new hope. We can change the way we relate to our suffering through meditation, mantra, functional movement, breath control, and the yoga teachings. Yoga has proven to treat chronic pain, not just in my own personal story of healing, but also many of my clients who wished to be free of their suffering from chronic pain and go on to live our best lives. The solution may not be a simple magic pill that makes the pain go away, but instead an understanding of the underlying source of the chronic pain, pain science and the dedication to retraining the brain and its habitual thought patterns, with a little bit of guidance and support from a yoga therapist. I stand by my favorite quote I often recite at the end of a yoga class, “Practice makes permanent; what we practice is who we become.”

Read more articles I’ve published here. Or watch a video that discusses this subject of chronic pain and the science behind it here.

Chronic Pain, the Brain, and the Yoga Train Cummins Bibliography Borysenko, J. (1987).

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Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain. Bio Med Central Geriatrics. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936054/ Lusk, J. (2008).

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Conquer Chronic Pain: An Innovative Mind~Body Approach. Center City, MN, USA: Hazelden Publishing. Sarno, J. E. (1991). Healing Back Pain: The Mind Body Connection. New York, NY, USA: Warner Books. Villemure, C. (2013, May 21).

Insular Cortex Mediates Increased Pain Tolerance in Yoga Practitioners. Cerebral Cortex, 24(10), pp. 2732-2740. Retrieved from https://academic.oup.com/cercor/article/24/10/2732/307000# Weber, C. (2015, May 15).

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