Friday Q&A: Neck Pain and Fear

Q: I read of yoga for back pain, but little about neck pain. I've been in PT for months, with good ideas about posture/extension/alignment, etc. And now I'm in a series of skillful massage targeted to the neck muscles...but such stiffness in spite of it all! Did yoga for years, but not lately (still active!) I'm wary of yoga that my pain might be exacerbated. I'm 52. My work is varied, with some hours at a desk but broken up with people interaction. Thanks for your counsel!

 A: I understand why you might be afraid of doing yoga again but I want to reassure you that starting to practice again will be beneficial for you in so many ways. I currently have a student with a lot of physical challenges and chronic pain from prior surgeries. She has told me so many times that even though her body may not be able to move the way she wants it to, when she wants it to do something, she finds that “yoga is good for my mind. It makes me tune in and just listen to myself.” This individual needs a lot of modifications when she practices, but because she trusts both me and my co-teacher Bonnie, she is willing to try new things, "even when they are scary,” specifically because she knows she can stop WHENEVER she needs or wants to and we respect her decisions. We have a “circle of trust” in our class that is very valuable to both the teachers, the students and our assistants.

The great thing about yoga in my mind is the ability to stop whenever necessary. The practice is an internal dialogue not an external show. Sometimes we need to be reassured we can still do an activity but are afraid because it might hurt. Well, if something or an activity causes an increase in pain, then we have the ability to stop the action. Sometimes although our minds fear something when there really isn't a physical correlation between the fear and the action, we have to teach our mind not to fear the action. It is kind of like relearning to ride a bike when we have fallen off in the past and done some serious damage but now have the desire to get back on the bike. But where to start? With all activities it is helpful to imagine the activity first before attempting it. So, if you had some yoga poses that you used to do that gave you pleasure, start with those. I would set myself up in a position of comfort where I was warm and felt safe, and then I might mentally begin the practice using only my memory. After a while of envisioning the pose, I would try it just a little bit. If I felt scared that I was going to hurt myself, then I would stop and leave it and try again tomorrow.

If this type of mental re-entry into yoga doesn't work for you, then you might re-contact your teacher (if you had one) and ask to talk about your concerns about returning to a class. If you don’t have a teacher anymore, look for someone in your local area who has experience with working with individuals with neck injuries and discuss your concerns about re-entering a class. If that isn’t possible, look for a class either for people recovering from injuries or with a gentle focus, and, again, approach the teacher with your concerns. Going back to a class has to feel safe for you, and in order to feel safe you have to be able to trust the teacher to not make you do more than you are comfortable with. Don’t be afraid to be frank about your needs and to have the ability to keep yourself safe. If you still can't find a teacher who fits this profile, contact the International Association of Yoga Therapists and ask for a teacher in your area or near to you that you can work with. They keep a registry on file for all members.

 And finally when you do begin to practice I would follow the motto of “less is better” because more than that might spiral you back into a flare-up cycle and put you off of yoga for quite a while. Poses that I particularly like when my own neck is feeling fragile are more passive poses like Viparita Karani (Legs Up the Wall pose) or a passive backbend over bolster with neck and head support. Active practice like standing poses with arm motions often make my own neck feel worse, so go easy on those. Learning to twist again without using arms for leverage also is important. I also like Chair Shoulderstand with a bolster under my upper back and no weight on my neck.

You mention only the physical aspect of asana but as you can see on many of the posts on our blog, that is only one small part of the practice of yoga. I might use this opportunity to re-visit some of the other limbs of yoga, especially some pranayama or basic breathing practices. The ability to fully breathe is a gift in learning to manage chronic pain and stiffness because it's like doing a massage from the inside out. I suffer from major neck issues myself, and I find that my neck will often let me know when I am overworked or overly stressed because the littlest things can set off my own pain cycles. There is no quick fix, but there are many pieces to the puzzle in learning how to manage ourselves in life.

—Shari

Yoga and Pain Management

by Shari

Since I have been on a “pain alert” myself for the past 10 days (a very cranky knee is having trouble settling down), I thought I would discuss the difference between acute and chronic pain, and how yoga may assist in pain management.

More than 115 million people nationwide (1 in 3 Americans) suffer from some type of long-term pain, according to the Institute of Medicine. People often try to alleviate pain with conventional therapies and medications. According to the CDC, narcotic pain medication addiction and overdosing accounted for over 16,651 deaths in 2010. When conventional treatment fails, people will often turn to complementary medicine techniques, and yoga is often tried to alleviate pain symptoms.

I thought I would first define the difference between acute and chronic pain. An acute injury will typically resolve within three months of the body’s normal healing process. Chronic or persistent pain is pain that lasts more than this time frame. Acute pain is associated with tissue damage. Pain (nerve) receptors are activated with an acute injury because the body is trying to protect the damaged area - this minimizes usage so normal healing can occur.

But with chronic pain, the brain’s perception of the cause of the pain changes. The inhibitory mechanisms of the central nervous system become faulty, and we may avoid physical activity because we have learned “If I do this, it will hurt.” We may be afraid that, because we are in pain, activity will further damage or injure the area. But generally the tissue damage is healed after three months, and avoidance of physical activity is therefore no longer beneficial in the healing process.

However, the brain may now remember stress and pain in an exaggerated way, as if it were in a continuous sympathetic feed back loop of fight or flight. So some of us can become hyper vigilant about everything that causes pain. But one of the beauties of yoga practice is how helpful it can be for people both in acute and chronic pain!

Physical asana has properties of both squeezing and soaking areas of the body. Compressive forces, with and without weight bearing, and long restorative poses move fluid, assisting the body to decrease edema in a joint after an acute injury. Decreasing the edema reduces the pressure on nerves and muscles, resulting in a reduction of pain symptoms. (However, it is key to understand how much can you can move your cranky joint and when you need to stop, so see When to Stop Practicing Yoga for information.) Along with the practice of physical asana, long relaxation poses and Savasana can help because of their restorative qualities and the way they quiet the sympathetic nervous system while stimulating the parasympathetic system (the relaxation response). And at this time, modifying the asanas that you regularly do is important. This way, you can still get the benefit of the asana with modifications, and then as the injury heals you can slowly bring the full asanas back into your regime.

For chronic pain the “prescription” is a bit different. Chronic pain is a global body phenomenon. When your body is in chronic pain you walk differently and you may even sit differently. Your attention is often directed to the painful region because keeping it still may make it worse and positional change needs to be frequent. The individual may be chronically exhausted because the ability to sleep well has been affected. There may be difficulty in completing tasks in a timely manner so things “start to slide” and don’t get done. Because energy is limited, the individual may rush through tasks to get things done and then be in more pain because they hurried. It is a terrible wheel to be on and difficult to get off onto solid ground!

In my own practice and teaching of yoga, I try to share with my students how yoga helps to focus the mind, quiet the breath and improve the mental focus. Yoga meets us where we are NOW. Yoga is nonjudgmental and everyone can do yoga. Yoga teaches us self-awareness. Yoga gives hope where there may be no hope.

Simple grounded breathing while you sit on a chair or lie in bed in your position of comfort is a great way to start. Set a timer and do simple breathing for three to five minutes. Notice how this may affect your mind and sense of self. Progressing to GENTLE range of motion of all body parts within your ability and not pushing yourself is beneficial. You can even do your range of motion activities in your position of comfort. Notice your pain levels (0-10) at start of practice and then again when you are done. If your pain levels stay the same, you are teaching your body NOT to be afraid of movement. Once your confidence has improved, then you might be ready to join a local class. Look for instructors who will be sympathetic to your pain but not overly solicitous. Make sure the teacher understands that you will stop when you need to, not necessarily when the teacher tells the class to release the position. Try to set aside five minutes a day to practice your own breathing awareness and your own Savasana. It becomes your sacred time to care for yourself.

Remember, the results may be slow in coming but persistence and gentleness are the keys to relieving and managing both acute and chronic pain.

Note: For my achy, swollen and hot knee, I am trying to work with my available range of motion, not moving too much into pain but inching into the pain and then backing up and repeating multiple times trying to make the available movement  smoother. Also, stretching related areas like my hip flexors, hamstring muscles, gastroc/soleus is really helpful for pain relief of my knee. In the standing poses, I’m working with gentle isometric contractions but not going into my full knee flexion (bending)—pumping a lot. I’m doing a lot of passive inversions like Viparita Karani (Legs Up the Wall pose) and Chair Shoulderstand, with pumping from my ankles. And, finally, modifying poses, for example, for Virasana (Hero pose), which I was previously able to do without any props, I now use two blocks stacked up high because I have just about 100 degrees of flexion (ability to bend the knee). And, lastly, cautious, aware walking. Patience is the crux though I am not a very patient individual.