Pain is also an experience

Cognition

Context

Mood

Individual factors

Centres for
sensation, memory,

association, emotion
and behaviours

Pain impulses

Chronic Pain is when a person experiences pain on most days of the week, for > 3 months

 Sensitisation Wind-up phenomenon

Modulation mechanisms get Overwhelmed and exhausted

 Pain pathway does not adapt over time

There is sensitisation, recruitment and spread of disturbing signals through the nervous system

The modulation that generally reduces the pain felt, becomes

less and less effective

Result:
Worsening pain in intensity, severity and extent.

Acute Pain
Short duration Nervous system is normal

Chronic Pain
> 3 months to years Neuro - plastic changes in the CNS Vegetative changes Unremitting, progressive Intensity does not reduce, reminder of advancing disease Chronic pain takes on characteristics of a disease

Autonomic responses
Self limiting with healing Intensity subsides over time with

healing
Acute pain is a symptom ; it is protective

 If clear, correctible, familiar interpretation

largely a physical experience

If there is lack of clarity and meaning, non curability, unfamiliar, sense of hopelessness, helplessness
spreads to the other dimensions energy, emotional, intellectual and

behavioural spheres

Sensory discrimina tive

Cognitive evaluative

Motivational affective

... Pain guides behaviour

She has Cancer of ovary with spread to other parts

She has been in and out of hospitals for past 2 years for therapy. She is mother of a 6 year old, who is at Mysore with grandparents Her husband who is a bank manager exhausted his leave and has had to give up his job as a bank manager.

She has no appetite, vomits and food consumed does not get digested Her recent scan shows increase of her disease She has persistent severe pain in the abdomen spreading in currents to back Her daily activities are affected; she does not sleep well This is Shikha during her 1st visit to my consulting room in Bangalore

Physical
Persistent pain Unreliable pain relief Deep ms. tension, other symptoms

Social Loss of role family /society Loss of income Helplessness/abandonment Relationships - sense of isolation Body image related

Side effects of treatment

Sleeplessness, fatigue Psychological Regret at delays in diagnosis frustration at treatment failure Incomplete communications Fear of further suffering Thoughts about death

Spiritual
Why has this happened to me? What is lifes purpose? Is this a punishment?

Guilt / anger
What is the point of this all?

 Is it distressing day after day?

Does it limit regular activities?

Does the person usually feel supported? Is there clarity on what, how, how long,

why?
Can it impinge on self efficacy / self esteem? Can it lead to questioning on belief systems?

Chronic Pain is different from Acute Pain

Physical Sheath

Energy Sheath

Emotion Sheath

Wisdom Sheath

Bliss Sheath

Wind Up of NS Vital rhythms Gland secretions Metabolic activity Endocrine flow Immune activity ANS function

Shallow breathing Loss of appetite Sustained deep muscle tension Disturbed sleep Impotence Fatigue

Anderson R U J Urol. 2008 Mar;179(3):956-60. Epub 2008 Jan 22 Spring J -Plucne Bolesti. 1991 Jan-Jun;43(1-2):5-12 Jensen Headache 2003;38[1] 10-17 Michael J -Headache: volume 18, issue 4: 189 - 196

Jnana Yoga

Bhakthi Yoga

Karma Yoga

Raja Yoga

Sahaja Yoga

Kriya Yoga

Power Yoga

 Self awareness .. Be informed illness, person, environment and ongoing inputs Acquire communication skills
Active listening, understand concerns, personality, expectations

Positive regard, compassion, non judgmental attitude

 Not acceptable to all Poor intrinsic motivation for yoga as an input

Males, younger patients

Smokers, anxious patients

Those with low internal health locus of control May need additional information
Cramer et al. BMC Complementary and Alternative Medicine 2013, 13:172

 Shared goals of care Respect for body & emphasise awareness of body and breath Facilitate efficient body mechanics, optimal energy expense Gradual pace, individualised process Profound interaction body breath mind

Posture correction Reconditioning Opens channels for energy microcirculation

 Submissive, suppressed

Aggressive / assertive / dominant

 Whole body awareness Right - left, back-front Head - foot equilibrium

Tone and Posture

Essential muscles only

 Release of deep muscle tension Reduction in sensory influx

 Impact of Iyengar Yoga on Quality of Life in Young Women with Rheumatoid Arthritis 6-week twice/week Iyengar yoga program

HRQoL, pain disability, general health, mood, fatigue, acceptance of

chronic pain, and self-efficacy regarding pain
Clin J Pain. 2013 Jan 30

 A Systematic Review and Meta-analysis of Yoga for Low Back Pain

Evidence for short-term and long-term effectiveness of yoga for chronic
low back pain in parameters - pain, disability, health-related quality of life, and global improvement

Clin J Pain. 2013 May;29(5):450-60

Holger Cramer, Romy Lauche, Heidemarie Haller, Gustav Dobos

 Phylogenetic tendency for protection reflected in breath Restricted, Shallow, chest breathing - inefficient Mind interprets Ongoing stress

Plucne Bolesti. 1991 Jan-Jun;43(1-2):5-12

 Encourages the person towards the Present

Mental focusing on something under the persons control Avoids projection of past / future thoughts to present

Physiological stabilization
Physiology is unable to differentiate hypothetical / retrospective thought

inappropriate emotion and a semiconscious preparation for action

State of mind

Breath
It is both ways + positive or negative

 Start speaking before the other person has finished?

Take next gulp of food before the previous has been chewed and
swallowed?

At traffic signals, start honking when the light turns from red to yellow?
When walking with another with slower pace, ending up waiting for the other to catch up?

 Darting glances, jerky movements Irregular breath, broken flow of speech Difficulty in counting slowly till 5 during exhalation Hypertonic shoulder and neck muscles incomplete exhalation Irregular breath during asanas need help / slowing / pause

 Allow the body to breathe on its own OR watch inhalation happen spontaneously
The slowing of the flow of thoughts and allowing a thought to finish before rushing to the next one is a natural consequence of breathing in this manner.

 Filter, humidification Efficient absorption of O2 from lung through vacuum created Absorption of prana Allows cyclic alterations of predominance between nostrils Mouth breathing urgency / perception of threat

 Lowering of systolic BP, Heart Rate

J Hypertens. 2001 May;19(5):947-58. Biomed Pharmacother. 2003 Oct;57 Suppl 1:87s-91s

Heart functions more efficiently; Immunity improved

J Clin Psychol. 1993 Nov;49(6):777-89

Endocrine Diurnal rhythm return

Eur Respir J. 2004 Dec;24(6):1033-43

EEG Increase in waves

 breathing techniques do offer rapid relief from excess emotionality, poor concentration, a scattered mind, and other disturbances they can be taught to be used on demand Cramer, General Med 2013, 1:2

 Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors
Pranayama (breathing exercises), 16 Gentle Hatha and Restorative

yoga asanas (postures), and meditation

J Clin Oncol. 2013 Sep 10;31(26):3233-41

 Addresses Life STANCE - Yama, niyama Preferable after establishing a therapeutic relationship Give scientific perspectives to emphasise thoughts body
lie detector

Walk the talk

 Mana [mind]

Budhi [intellect]
Ahamkara [individualised self]

Chitha [substratum vasanas, samskaras]

 Recommended for all. .even more relevant in

Physically unfit, bedridden Emotional component as predominant factor Fatigue, insomnia

 Yoga nidra applicable at all stages

Healing visuals - Warm envelop of gentle light; series of lit lamps signifying continuity of life, hope etc.

Ajapajapa agitated, anxious

Chidakasha dharana, antar mouna - a level of calmness is

required

Relaxation Response

 Subtle notional corrections Change in the context of the disease, pain and meaning of life

Subject Pain

Experience Sensation of pain

Evoked feeling, thoughts Manas, Budhi, Ahamkara

Unpleasantness, denotes damage, disease, revulsion, dont want, distress

Associations with experience and memory victim, no hope, fear of dependence, chitha helplessness, death Response / reaction Anthahkarana Oh . this is unbearable, why me? this is unfair, I am doomed, am I being punished?

Subject
Pain

Experience
Sensation of pain

Inputs that may help

Treatment of underlying issue, pain medicines

Evoked feeling, thoughts Manas, Budhi, Ahamkara

Unpleasantness, denotes damage, disease, revulsion, dont want, distress

Awareness, perceived support, pratyahara Cognitive Behavioural modifications [CBT]

Associations with experience and memory chitha Response / reaction Anthahkarana

victim, no hope, fear of dependence, helplessness, death Oh . this is unbearable, why me? this is unfair, I am doomed, am I being punished?

Communications, contemplation, awareness

Awareness, pratyahara, sakshi bhava, venting fears, misconceptions, caring team, CBT, sense of control

Factors that lower pain threshold Anxiety Depression, Grief Insomnia Isolation Lack of control on pain Doubts, unresolved conflict

Factors that raise pain threshold Calm outlook Optimism, Joy Adequate sleep Support family, community Perceived control over pain Clarity, communication

 Incorrect training of the trainer Premature introduction of mobilisation before adequate relaxation and stretch

Competitiveness in asanas
Aggressive Pranayama

Exclusive attitude can be harmful

Relaxation asanas Breath awareness and DPH breathing Deep relaxation techniques in range of movement Individualised asanas and Pranayama practices according to capacity and need Focus on awareness and Pre meditation practices if patient chooses

 Chronic Pain is a multidimensional disease Shared decision- as active participation is expected Incorporating Yogic discipline influences the different realms positively Specific individualised approach enhance results

 Awareness of body, breath and thoughts Aim for gradual improvement Emphasise relaxation and optimal energy expense Practices based on knowledge, tailored to suit the person Therapist open to learning

Yoga is annulling of ripples of the mind

Rishi Patanjali 400AD

aanandini@hotmail.com