What Yoga Teachers Need to Know About Pain in Asana

Pain is complex. Myths and misconceptions about pain can inadvertently lead yoga teachers to create fear of movement within students, and limit their potential for recovery and growth. Thus, understanding more about pain is vital as we endeavour to inspire resilience in our students and keep them safe on the mat. 

Below are some common myths about pain in yoga. Are you aware whether some of these may inform your teaching?

• Pain is an accurate indicator of tissue damage and tissue healing.

• Increased pain always means there is increased tissue damage.

• Persistent pain means the body has not healed.

• Sharp pain means stop. Pain that isn’t sharp means caution.

• Pain is something to transcend, so don’t stop.

• If you keep doing it, you will adapt and the pain will stop.

• People know the difference between good pain and bad pain.

• The solutions to pain in asana practice lie in correcting alignment, maintaining proper posture, and/or detaching from pain (because pain stems from disconnection from your true nature).

People in pain will likely be in your yoga classes.

An estimated 20–25% of North Americans and 1.5 billion people worldwide live with chronic (or persistent) pain.(1),(2) That means, as yoga teachers, there is a good chance there will be people in your classes who experience pain during asana, or who have chronic pain. National surveys also report that a growing number of people are seeking yoga to address their health concerns, with one of the reasons being back pain.

Additionally, healthcare professionals usually advise people in pain to stay active. They are also recommending yoga, since we now have scientific evidence supporting yoga as a potentially safe and effective approach to reducing pain and improving functional outcomes and quality of life for people with persistent pain and pain-associated disorders.(3) 

But there is a problem. Currently, most curricula in both yoga trainings and healthcare programs do not include enough pain education, if any at all. What is offered is scarce and often includes outdated theories on pain. However, research shows that learning about pain through postgraduate continuing education courses is vital for healthcare professionals in gaining the knowledge and making the changes in their practice that will ultimately improve prevention and recovery from injury and pain.(4)

For yoga teachers specifically, misunderstanding pain can lead us to avoid yoga practices that ultimately could increase tissue health, decrease inflammation, improve self-efficacy, and help recover more ease in movement and in life. 

Restorative poses or relaxation practices are possible places to start when there is pain in asana, especially when minimizing struggle and achieving a greater sense of peace are the keys to moving forward. Yet at some point, every part of our existence can benefit from knowing it’s okay to challenge the edge of our pain and to explore new yogic ways of doing so.

Understanding Pain and Pain in Yoga

Let’s start with a common teaching point that is not always helpful: “Listen to your body and stop if it hurts.”

Pain is not an accurate indication of tissue health(5) and therefore cannot be used as an accurate indicator of how much to move. Stopping when it hurts is akin to the flight mechanism of the fight or flight response. It can promote fear-avoidance behavior.

For many students, “Listen to your body” can be interpreted as “Listen to the pain—it is telling you that you are damaging your body.” But this is not necessarily true. Contemporary understanding of pain tells us that the purpose of pain is to protect, and not to give us specific information about tissue damage. 

When pain persists, the “danger detection” or pain system typically becomes overprotective or hypervigilant and better at producing pain and other protective responses. When yoga teachers are trying to guide movement for people with persistent pain, saying “Stop moving when it hurts” will not help decrease the vigilance or sensitivity of the danger detection system. In fact, this overly cautious language may actually perpetuate threat and pain if it leads people to believe that more damage is being caused every time they move and experience pain.

On the other hand, if we cue students with persistent pain to ignore and push through their pain, this often leads these protective mechanisms to respond more loudly in order to motivate behavioral change. This can result in increased pain and a flare-up. 

Knowing that detection and protection systems become wound up when pain persists guides us to consider how we can provide yoga techniques and classes that not only help students recover movement and health of their tissues, but also calm these systems.

Pain as Cautionary

The first increase in pain we experience with movement is most likely a caution. The student’s job, then, can be to foster curiosity: “Is this really dangerous?” 

Perhaps if we start by considering pain as a caution, or as something to explore, we can then see pain not only as an experience that can help keep us safe, but also as an experience that’s impacted by far more than what is happening in our tissues. 

Pain is affected by everything, and one of the gifts of a mindful practice such as yoga is that it can provide us with the opportunity to explore our experiences, including our pain.

So if pain alone does not give us an accurate indication of how much to move, what other guidelines should yoga teachers use in order to help people with pain to move well?

Understanding pain allows us to approach it in new ways, such as monitoring it as a guide to movement recovery. But it’s not the only guide, nor an all-knowing one. On that note, we also do not believe that there is only one way to guide students who are experiencing pain. But we would like to offer these Recovery of Movement Guidelines(6) from Pain Care U as an option for yoga teachers to consider.

These guidelines are based on contemporary pain science, the lived experience of pain, and yoga practices and principles.(7)

In your classes, consider including the following:

• More guidance on awareness of subtle body sensations and breath: An example would be to simply guide students to notice and observe aspects or qualities of their experience, without instructing them to change anything. Differentiate this from guidance and techniques intended to “regulate” body and breath, such as specific pranayama, guided visualizations, or body tension reduction techniques. 

• Questions that guide students to be aware of multiple alarms rather than using only one as a definitive indicator of when to modify asana: “Does this feel safe for my body?” “Is it easy to smile now?” “Is it easy to breathe?” “Can I find the ‘just right’ effort: not too much or too little?” “Is there anything I can let go of that’s not serving me?” and “Do I feel I will be okay if I stay in this posture?”

• Guidance to divide attention between body, breath, thoughts, emotions, energy, discomfort, tension, and pain. No single aspect of our existence provides an accurate indicator of safe movement. The student is guided to listen to multiple alarms for the best guidance.

Our approach in Pain Care Yoga(8) includes asking people to practice awareness, discernment, and regulation—all of which are skills we cultivate in yoga.

As one example, a student may go to the edge of their increased pain (which takes awareness), then ask whether it feels safe for their body to be there and whether they’ll be okay later (discernment). Then they might explore how calming their breath and body tension (regulation) could change the pain and the experience.

Explorative language such as: "Play with your edge," "Be curious,” “What happens if you change your breath, your body tension, your thoughts, your emotions, etc.?" are all helpful cues that offer space for people to cultivate their ability to do all of the above.

A Practical Example

How to guide yoga students to move with pain associated with knee osteoarthritis

Recent research and clinical practice guidelines related to pain and the treatment of pain associated with knee osteoarthritis confirm what we’ve discussed thus far.(9)

FThese new guidelines are based on considerable evidence that moving the knee and applying physical force through movement will not only decrease future changes in the joint but also decrease joint inflammatory chemical processes and improve the health of the remaining joint tissue. Yet for your student with pain related to knee OA, the experience will still be that bending it or putting more weight through the joint causes pain. So how can you advise the student?

As we’ve discussed, the first step is for you to know more about pain. We hope this will help you dispel any myths and misunderstandings and prevent your own beliefs about pain from limiting your students.

The second step is to communicate with the student in a way that fosters curiosity, and also to use something like the Goldilocks “just right” principle. Being tough and gritting their teeth is not the answer, nor is completely avoiding knee movement. 

Then try using the Recovery of Movement Guidelines we explored above coupled with this idea of identifying the “just right” spot. This spot will likely be the place where one feels their movement is not dangerous and will not cause regret later. It will be where one is able to feel calmness and ease in breath and body while still dividing their attention so as not to ignore their pain.

Other factors to consider:

Avoid telling people how they “should” be aligned, such as “Put your foot here,” “Align your knee directly over your ankle,” or “Keep your knee in line with your second toe.” Remember, more explorative language that fosters curiosity is recommended. Instead, try saying: “What happens if you try bringing your knee into this different position—if you bend it a bit more? A bit less? How does your breath change? Your body tension?”

Cue regulation that cultivates resilience and a sense of safety.

We often have more influence over pain than we think. When we have more regulation options, we are more resilient and we feel safer. As we now understand, if people do not feel safe, this can contribute to overprotection of the danger detection systems, which results in increased pain. Whether someone feels safe, and to what degree, depends on numerous and complex physiological and contextual factors, and our language and cueing can play a big part. 

Not only do we want to avoidlanguage that instills fear of pain or movement, we also want to avoid promoting the idea that the body is vulnerable and fragile by saying things like, “To protect your knee, don’t let it fall past midline,” or “Careful, don’t put too much weight on your knee if it hurts, or over time it might eventually erode your joint,” or “Protect your knee from wear and tear or ‘bone on bone’ shearing forces by stopping when it hurts and not bending it too much.” Instead, use language that cultivates safety without promoting fragility or fear—language that is more in line with yogic views that compassionately and humbly reflect the body’s incredible capacity, resilience, and wisdom. Language like this: “Try mindfully and patiently shifting over to standing onto your right leg, using as much support as you need. Notice any sensations, the effort it takes...finding some support and trust in your leg.”

Allow and suggest options. 

Give genuine permission and opportunities to pause, stop the movement, modify, or continue. Start with an asana with the least amount of force on the joint. Give permission to explore, to pause, to adjust. Then offer opportunities for moving further into the asana while being aware of breath, body, thoughts, emotions, and pain. 

Once again guide students to explore, pause, and adjust. Then once again, guide them to try more if it feels safe, and if they won’t regret it later.

In Summary

Yoga teachers, like many health professionals, have been taught to view pain as a direct indicator of tissue damage, poor posture or alignment, poor body mechanics, or poorly healed tissues. But when we understand pain based on current science, we get past these pain myths, especially a tissue-centric view of pain. 

Pain is a complex experience potentially impacted by all aspects of our existence, including environment and relationships. When we improve our understanding of pain, we can keep our students safer and guide them to develop the skills to become more aware, discerning, resilient, and resourceful when pain arises in practice.

These same skills will help those students with persistent pain to become more curious, confident, and empowered, and less likely to either fight too much or flee from perceived limitations.

Our communities desperately need safe and accessible group movement options led by people who understand pain. 

Yoga teachers can be part of the solution for helping people move with more ease and keep their body safe and healthy. Due to availability and cost, yoga classes are far more accessible for many people than are movement classes led by health professionals. Yet it is important for yoga teachers to guide their students to approach pain during movement in a way consistent with both yogic views and contemporary science.

Our hope is that more yoga teachers will be motivated to increase their understanding about pain, people in pain, and movement guidelines like those of Pain Care U and the Pain Care Aware yoga teacher training modules. With greater capacity, more yoga classes can be made available to help people in pain move and live with more ease, joy, peace, and purpose.

To learn more about yoga and pain science, check out Shelly's presentation in Yoga International's : Understanding and Addressing Chronic Pain Through Yoga.

References:

1. Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults—United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006.

2. Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health. 2011;11:770. Published 2011 Oct 6. doi:10.1186/1471-2458-11-770.

3. Moonaz S. Current Research in Yoga and Pain. In: Pearson N, Prosko S, Sullivan M. (Eds) Yoga and Science in Pain Care: Treating the Person in Pain. (2019). London, UK: Singing Dragon Publishers; pp. 37-51.

4. Louw A, Diener I, Butler DS, Puentedura EJ 2011. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation 92: 2041–2056.

5. Butler DS and Moseley GL. Explain Pain. (2003). Adelaide: Noigroup Publications.

6. Pearson N. Yoga Therapy. In: Thompson and Brooks (Eds) Integrative Pain Management. (2016). Scotland, UK: Handspring Publishing.

7. Blickenstaff C, Pearson N. Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiotherapy Theory and Practice. 2016; 32(5). doi:10.1080/09593985.2016.1194653.

8. See www.paincareu.com for more on Pain Care Yoga training.

9. Bricca A, Juhl CB, Steultjens M, et al. Impact of exercise on articular cartilage in people at risk of, or with established, knee osteoarthritis: a systematic review of randomised controlled trials. British Journal of Sports Medicine. 2019; 53:940-947.