Senior Yoga Medicine® teacher Rachel Land shares tips and best practices for teaching safe, effective, and compassionate private classes that serve students with chronic illnesses or injuries.
Editor's note: This article contains general recommendations for yoga practitioners and teachers. It is not a replacement for the personal advice of a health professional. Yoga teachers should remain within their scope of practice: This means not attempting to diagnose, treat, or offer medical advice to students.
For students with persistent illness or injury, yoga as a complementary therapy to traditional medical treatment can potentially offer numerous benefits for both body and mind. These can include reduced inflammation, fatigue, and perceived pain and improved mood and immune function.
However, group classes can be challenging, because their sequence, pace, and intensity are geared toward a group average and the teacher’s attention is shared among students. One-on-one yoga instruction can be a much better fit for students with specific needs. But if you’re a teacher working with these students for the first time, the process can be intimidating.
When it comes to long-standing conditions, symptoms can be clouded over time by ongoing inflammation, lack of circulation, or other neuromuscular patterns that have developed around the original issue. Chronic pain is particularly daunting to work with.
We used to believe that pain is a straightforward signal of damage from the body to the brain. But recent research has revealed that pain is mediated by the brain rather than the body, and is a warning sign related to perception and experience as much as it is to physical damage.
Our aim as teachers is to reduce our students’ pain and suffering, but that can be a challenge if the student has an ongoing injury or illness. The perfect approach for one condition could exacerbate another, and yoga teacher trainings are not designed to equip us to address every injury or medical condition.
The good news is that our students should already have expert medical support, and what they need from us is something different. Our expertise does not lie in treating chronic conditions, but we are perfectly positioned to provide tools for down-regulating the nervous system, and this can have surprisingly global effects.
Many of us have an overactive sympathetic nervous system, which is responsible for the “fight or flight” response and has wide-reaching effects on chronic conditions: It increases heart rate and blood pressure, suppresses digestion and immunity, and promotes anxiety and feelings of vigilance, potentially exacerbating perceived symptoms and pain.
And while you would expect this heightened state to make students more aware of their internal sensations, the opposite tends to be true. Because the sympathetic nervous system evolved to be on the lookout for outside threats, students with an overactive one may in fact have become desensitized to the subtle internal signals that often precede pain. The ability to ignore bodily sensations may have even been an important coping mechanism for those with chronic pain, allowing them to continue to work and function despite their discomfort, but it doesn’t help them make skillful decisions regarding what will improve or exacerbate their symptoms.
The balancing influence of the parasympathetic nervous system, which is responsible for the “relaxation response,” is therefore crucial. It reduces heart rate and blood pressure, supports healthy digestion and immunity, promotes feelings of calm and relaxation, and can reduce perceived pain. It’s only in the comparative safety of the parasympathetic nervous system that we are able to be introspective and aware of nuance in body sensations. Fortunately, yoga teachers are well equipped to address this division of the nervous system.
While the needs of yoga students with chronic conditions are varied, there is a general approach we can follow in order to work with these students safely and maximize the soothing influence of the parasympathetic nervous system.
The first and most important place to start is with professional medical advice. Some students will have a concrete diagnosis, a history of treatment, and a clear indication of which poses and practices could be helpful and which to avoid. For example, one of my first one-on-one yoga students had debilitating neck and arm pain, to the extent that she couldn’t drive, clean her home, or cook. Her diagnosis was cervical stenosis, and we were advised to avoid neck extension and any weight-bearing with her arms above shoulder height.
Other students will have chronic symptoms without a clear diagnosis. They may have ruled out several potential issues, and not be any closer to clarity. For example, I worked with a student whose hip pain was so intense that she was often unable to walk. MRI and blood analyses had ruled out fractures, labral tears, arthritis, and malignancy, and while there were white flecks of unknown origin showing in scans of both hip joints, one hip was pain-free. Even in situations like these, which are surprisingly common, it’s helpful to know which conditions have been eliminated, what diagnostic tools have been used, and what the remaining possibilities are.
Obviously, yoga is not a replacement for traditional medical care in cases like these, but it can help get to the root by reducing anxiety and unrelated sources of muscle tension.
Whether the potential student has a medical diagnosis or not, it’s important that they are cleared for yoga by their healthcare provider and that they have medical advice that both of you can refer back to should questions arise.
Determine the positions that are most soothing for your student. As well as being a helpful starting place, one of these positions could be a home base to return to throughout practice to check-in. It’s tempting to rush into the practices you hope will improve the student’s symptoms, but it pays to prioritize the process of calming the nervous system. After all, if your student is in a heightened or anxious state, they may not be able to notice the more subtle influences of their practice.
Some students will feel most comfortable supine, some seated, and some will prefer gentle movement over complete stillness. Some will like the support of props, or the weight of a blanket over their hips or hands, and others not. So rather than either assuming your student is comfortable, or rushing in to make a suggestion, be willing to invest time in finding the best options for each student.
You may be surprised by the impact of true relaxation, especially on chronic pain. The student I mentioned earlier with cervical stenosis arrived for our first session in such intense discomfort that she was in tears. We were able to identify a supine position she found completely comfortable, with a small rolled towel supporting the curve of her neck, a bolster under her knees, and a soft, warm blanket over her hips. We spent our entire first session observing her breath, with each exhalation aiming to relax her face, head, neck, and shoulders. By the end of our time together, without our “doing” anything, my student estimated that her pain had reduced by more than half.
Some students understand their chronic condition very well; they know what will make their symptoms worse and what will alleviate them. But the opposite is true for many others, and that lack of knowledge can generate uncertainty, even anxiety. Now that we understand how the parasympathetic nervous system impacts secondary symptoms, it’s obvious that reducing anxiety enough to allow the student to notice their body’s early warning signs is important.
A history of having to ignore pain signals or symptoms in order to carry on in life can interfere with some students’ ability to recognize the initial signs of fatigue or discomfort. After a decade of Lyme disease, one of my students experienced several periods of apparent improvement, followed by overexertion and burnout. She no longer trusted her own ability to make decisions to facilitate recovery. Sequencing a restorative pose after each active pose gave her time and space to gauge how it affected her energy. Over time, this pattern helped her relearn how to truly listen to her body and trust her own decisions again.
Research suggests that paying detailed attention to tactile sensory inputs, or improved proprioception (your sense of where and how your body is positioned in space), can reduce perceived pain. At least in your initial sessions with a student, it helps to build in mindful pauses between more active practices to encourage this attention to develop. So start in a comfortable position, introduce some gentle movement or activity, and then return to that safe “home base” position to guide the student through the process of checking in. Prompt the student to pay attention to sensations in their body, the depth of their breath, their heart rate, and their energy level before you move on.
Each student will have different needs: core and joint stability, improved circulation, building range of motion, addressing postural imbalances, supporting better breathing or sleep. Regardless of the program you have in mind, once you have a plan, it’s tempting to want to move through it and see the student benefit as quickly as possible. But with a chronic condition, rushing into a new practice may create a negative reaction.
I worked with a student who had degenerating lumbar intervertebral discs, resulting in nerve compression that influenced leg function and gait. His intention was to use yoga to build core stability and standing balance, but the potential for nerve pain from unfamiliar positions or movements was high. After a little trial and error, the fastest path to progress turned out to be starting with isolated supine movements and combining them on all fours before moving into more highly loaded standing work.
So with the same intention of soothing the nervous system, start gently, allow plenty of pauses for checking in, and build a simple program of poses and practices that provide a sense of enjoyment and safety for the student. Repetition is key: one or two tried and tested poses repeated daily will be more helpful than a longer program performed once a week.
Stick with a practice that is largely familiar, adding just one area of variety or challenge per session, so that you know what to leave out or modify if the student experiences an adverse reaction after your session. When adding a pose or practice, break it down into component parts or actions that you can introduce separately, allowing each to become familiar before you combine them. You can regress any given component, make it easier, by adding support from props or the floor, or by reducing the body weight involved. Conversely, you can progress it by removing supports, adding body weight, combining actions, or introducing a balance element.
It can be challenging for both teacher and student to accept this slower pace, but the key to accelerating positive outcomes is to maximize the benefits of practices you know to be safe, rather than pushing ahead to harder positions or movements. This means more regular sessions, or having the student repeat key poses between sessions as homework. Given the impact of the nervous system on inflammation, perceived pain, healing, and sleep, don’t underestimate the power of simple practices like breath awareness and gentle rhythmic movement.
The overarching aim of yoga is to better equip our students for life. As your student hones the ability to pay attention to more subtle signals from their body, the next principle is to empower them to make skillful decisions in their practice as preparation for making them outside of it.
Start each session by checking in with their mood and energy level, and ask them what they need that day—such as more movement, more quiet, more activity, or more rest. Rather than setting a time duration or count for a given pose, have the student move with the pace of their breath and rest when they choose. Bring their attention to unconscious signals of strain like held breath, a clenched jaw, or frown. Ask them what they noticed during the practice, and how they feel afterward. Help them compare present sensations with how they felt at the beginning of practice. Have them decide when they are ready to move on, and what they would like to work on in future sessions.
Skills like these were key for my student who was recovering from Lyme disease. Her ongoing ability to notice how she felt between practices, and to make decisions accordingly, empowered her to trust herself enough to return to physical activity off the mat.
It’s human nature to focus on the next step, rather than celebrating how far we have already come. It is not surprising in the context of a chronic complaint that your student may feel frustrated by the challenges that remain, rather than acknowledging the progress so far. So as your student takes control of their practice, the emphasis of your role may shift from teacher to witness. Some days will represent sideways or even backward steps, but you’ll be there to remind them of the progress they’ve made—not necessarily advancement in poses but in measures more relevant to healing, such as freer breathing, improved sleep, decreased compensatory patterns in the neck or jaw, speed of recovery, examples of fine-tuned body awareness, or decisions to stop or rest when required.
One of my students had two total hip replacements two months apart. After years of movement patterns that had evolved to compensate for lack of hip mobility, she had limited awareness of the muscles surrounding her hips and abdomen and subtle movements like adjusting pelvic tilt were impossible. After years of working with me, she became stronger and more stable, but also much more capable of nuanced actions—like engaging her lower abdominals to tilt her pelvis posteriorly, or using her lateral hip stabilizers to level off her frontal hip points, or relaxing her neck and breathing during strength work. Some days her standing balance was better and some days worse; it would be easy for wobbly days to feel like a backward step if not for me reminding her of the progress she had made in more subtle aspects of her practice that might otherwise have escaped her notice.
There is no doubt that one-on-one yoga offers potential benefits for students with chronic illness or injury, especially through the wide-reaching influence of the parasympathetic nervous system on healing and pain perception. Every student has different characteristics and different needs, and while that can be intimidating for yoga teachers, the good news is that the same basic framework can apply for any long-term condition: Start gently, progress slowly, and empower the student to take charge.
References and Further Reading:
Effectiveness of body awareness interventions in fibromyalgia and chronic fatigue syndrome: a systematic review and meta-analysis. Imke Courtois MSc PT, Filip Cools PhD MD and Joeri Calsius PhD DO PT. Journal of Bodywork and Movement Therapies, January 2015.
Effects of yoga on chronic neck pain: a systematic review and meta-analysis. Holger Cramer, Petra Klose, Benno Brinkhaus, Andreas Michalsen and Gustav Dobos. Clinical Rehabilitation, November 2017.
Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review. Jost Langhorst, Petra Klose, Gustav J Dobos, Kathrin Bernardy and Winfried Häuser. Rheumatology International, 2013.
Low Back Pain: The Potential Contribution of Supraspinal Motor Control and Proprioception. Michael Lukas Meier, Andrea Vrana and Petra Schweinhardt. The Neuroscientist, November 2, 2018.
Motor control exercises reduce pain and disability in chronic and recurrent low back pain: a meta-analysis. MG Byström, E Rasmussen-Barr and WJ Grooten. Spine, March 15, 2013.
Pain Control by Proprioceptive and Exteroceptive Stimulation at the Trigeminal Level. Claudio Zampino, Roberta Ficacci, Miriam Checcacci, Fabio Franciolini and Luigi Catacuzzeno. Frontiers in Psychology, August 7, 2018.
Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. G. Lorimer Moseley, Nadia M. Zalucki and Katja Wiech. Pain: July 31, 2008.
Yoga as a Holistic Treatment for Chronic Illnesses: Minimizing Adverse Events and Safety Concerns. Shirley Telles, Sachin Kumar Sharma, Niranjan Kala and Acharya Balkrishna, Frontiers in Psychology, April 2, 2019.
Yoga for chronic low back pain: a meta-analysis of randomised controlled trials. Susan Holtzman and R Thomas Beggs. Pain Research and Management, Sep-Oct 2013.
Yoga for osteoarthritis: a systematic review and meta-analysis. Romy Lauche, David J Hunter, Jon Adams and Holger Cramer. Current Rheumatology Reports, July 23, 2019.
Yoga Has Beneficial Effects on Patients with Chronic Diseases and Improves Immune Functions. Nobuhiko Eda, Journal of Clinical Research & Bioethics, Jul 22, 2014.