Role of Yoga in PainDisorders

Chairperson : Prof. Geetha Desai Dept. of Psychiatry, NIMHANS

Presenter : Shreelakshmi. A. P.

Pain

Latin word “ Poena ” means Penalty orpunishment. Definition:

“An unpleasant sensory & emotional experienceassociated with actual or potential tissuedamage or described in terms of such damage.”(The International association for the study ofpain-IASP)

Pain is a complex integrated response.

Chronic Pain

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Multi dimensional;Described in terms of total pain with physical,emotional, social, and spiritual components;Lasts beyond natural healing periods, out ofproportion to the causative factor, accompanied bysensitized nervous system disallowing natural checks;Several chemical, anatomical, patho-physiological andgenetic alterations in the neural pathways lead topersisting patterns of pain;Takes characteristics of a disease that needs specificmanagement.

Multidimensionality of Chronic pain

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Described in terms of total pain, with thefollowing components:Physical;Emotional;Social;Spiritual;

Physical and non-physical aspects perpetuatechronic pain.

A) Physical

Not just a symptom, takes form of disease through activeprocesses;Multiple plastic changes determine duration and intensity ofpain;Central and peripheral sensitization in the nervous systemwith neuro-chemical and neuro-anatomical components,results in hyper excitability, recruitment and disinhibition ofthe pathways;Besides the actual nociceptive initiators there are neuro-endocrine-immunologic components to chronic painperceptions;Breathing becomes mainly thoracic with lesser excursion ofthe diaphragm;Sustained deep muscle tension characterized by repetitivestatic loads to the muscles and psychological stress,especially postural groups of muscles.

B) Emotional

Decreases function and causes anxietyand depression;Physiology in a state of persistent stress;Hypothalamic – pituitary- adrenal axis andthe sympathetic system, in a state of hyperarousal;Affects sleep, energy reserve and appetite;During acute episode, high scores onpsycho-social screening and emotionaldistress (Hopkin’s symptom check list),significantly associated with non-recoveryand persistence of pain.

C) Social

Interpersonal relations, adversely influenced;Sufferer feels loss of control over the situation loosesself-confidence and withdraws;Becomes irritable, hostile and aggressive;People close to the ill person could react with over-protectivity, avoidance, guilt or resentment;Loss of role, fear of dependency and future sufferingsperturb the patient;Sense of isolation and loneliness;Evidence suggests inadequate social problem solving,an important factor in the pathogenesis of chronicpain.

D) Intellectual and Spiritual

Uncertainty of progress leads to distressand interpretations create a sense ofhopelessness, helplessness, lack ofmeaning for what is happening, guilt ordisturbed belief systems.

These five dimensions together evolveinto a state of total pain with persistent,disturbing ripples in the mind, whichmaintains the neural wind up and lowersthe threshold of pain perception further.

Classification of Pain

Purpose of Assessments

Accurate evaluation of the myriad ofpsychosocial, behavioral & psychophysiological factors that contribute to thesubjective experience & report of pain;Patient assessment implies the measurementof pain & pain related variables on 3 levels ofbehavior:Subjective : Measurement of paincharacteristicsMotor behaviors : Assessment of painbehaviorsOrganic : Measures of medical status as well aspsycho physiological or neuro- physiologicalparameters

Problems during assessment ofChronic Pain

Communication : Common Language Acceptance : Patients face difficulty accepting assessmentthat focuses on their bodies & physical symptoms and mainlyassessing psycho-social factors are much less likelyacceptable by patients because they believe that pain isexclusively result of the injury, disease or physical pathology. Reference to Mental health professionals : Patient maybelieve that he is hopeless case & implies that they can nolonger be helped by traditional health care system. They willreject any implication that psychological factors may becausing the symptoms. Hence it is important to prepare thepatient for a referral to mental health professional forassessment when appropriate.

PSYCHOLOGICAL INTERVIEW1.

Pain & related symptoms:OnsetLocationProgressionDuration & chronologySetting (under what circumstances does painoccurs)Perception of causeAggravating & alleviating factorsPattern of symptomsAssociated features ( thoughts, feelings &behavior that precede, accompany & followfluctuation of symptoms.Impact of sleep cycle

2. TreatmentsTreatment history Medications ( previous, prescribed, current ) Pattern of medication use (time) Physical modalities Exercise Complimentary & alternative approaches Helpfulness of each type of treatment Compliance with recommendations of health

care providers Attitude towards previous health care providers

3. Compensation :

Current disability status ( absent to work ,amount, % of former income, duration)

Reduced efficiency of work

4. Responses by patient and others :

Changes in patients activities & responsibilities Changes in other’s activities & responsibilities due to symptoms Patient’s behavior when pain is intense & flares up Other’s responses to behavioral expressions of pain What does patient do when pain is not bothering him/her? Others responses when patient is active Impact of Symptoms on inter personal, family, marital & sexual relation

ship Activities avoided by the patient because of the pain Pattern & pacing of the activities Activities continued despite of the pain

5. Coping :

Current life stresses How does the patient try to cope up with the pain Success or adequacy of coping efforts Pleasant activities

6. Educational & vocational history : Education Work history Current work status ( homemaking activities ) Vocational plans 7. Social history : Relationships with family of origin History of pain, disability, pain in family members History of substance abuse in family members History or current physical, emotional or sexual abuse Marital history Quality of current marital & family relations 8. Alcohol and substance use : History & current use of alcohol (Quantity & frequency) History & current use of illicit Psychoactive drugs History & current use of prescribed psychoactive drugs

9. Psychological dysfunction : Current Psychological symptomatology & diagnosis

History of psychiatric disorders History of Psychiatric treatment, including family counseling Family history of mental disorder Current & history of family psychiatric disorders treatment. 10. Concerns and expectations : Patients concerns/fears Explanatory models Expectations regarding future Expectations regarding treatment Treatment goals Plans if symptoms are not eliminated Plans if symptoms are eliminated

YOGICUNDERSTANDING OF

PAIN DISORDERS

Majority of chronic pain cases are due tonon specific causes related to adhijavyadhisTo understand this, we need to know theconcept of 5 aspects of our body (5 layeredexistence of human body)This concept of pancha kosa is describedin “Taittireya Upanishad”

This concept of pancha kosa is described in “Taittireya Upanishad”

FLOW CHART SHOWING RELATION BETWEEN EMOTION,STRESS & PAIN:

STRESS(emotionalburden or

physical injury)

EMOTION(negative

thinking, anger,fear, irritability,

anxiety)PAIN

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PAIN AND ITS MANAGEMENT ACCORDING TO YOGICUNDERSTANDING

Pain is a sensation produced by locking up of the consciousness,subtle energy and atoms into a limited space due to imbalances ateither all or anyone of first three layers: emotion, life energy ormaterial body. Depending on the depth of origin corrections are required at

Body level: Asanas and loosening practices to enhance micro-circulation and promote equal body surface awarenessPranic level: Pranayama to correct flow pattern of subtle energyand open up pranic blocksEmotion level: Meditation and mindfulness to calm down andregulate emotions; channelize emotions from asuri sampath(anger, rage, fear, frustration, jealousy) to positive emotions(compassion, sense of connectivity, satisfaction and let go)

According to yoga:Pain disorders

Adhija (functional)Begins at mind level

Anadhija (organic)toxins/infections/

trauma

Majority of chronic pain cases are due to non specific causes related to adhijavyadhis

To understand this, we need to know the concept of 5 aspects of our body (5layered existence of human body)

This concept of pancha kosa is described in “Taittireya Upanishad”

Yogic definition of Stress

The seed of stress is in the Manomaya kosha; The excessive speed of rate of flow of thoughts in the mind is called

stress i.e. speeded up state of the mind; If you learn to slow down the rate of flow of thoughts in the mind &

become master of this speed, you have learnt to manage stress in the mostefficient way.

Mechanism of Adhija Vyadhi Long standing stresses begins in the Manomaya Kosha & manifests

initially only as psychological problems over years, it starts disturbingPranamaya Kosha;

This prana imbalances go on fluctuating depending on the degree ofstress & shows up in Annamaya kosha first as imbalance of the digestive fireand then the undigested food (ama ) gets absorbed into the blood and settlesdown as imbalance (inflammation) in the form of pain and stiffness;

Combination of some of these imbalances settle down in one particularpart of the body (depending on genetic make up of the individual) showing upas recurrent episodes of acute or chronic musculo skeletal pains with noorganically detectable causes.

How Does Yoga Help In PainManagement

Asana or posturePranayama or breathing exerciseDhyana or meditation

Asanas and Pain

Asanas brings steadiness, health andlightness of the body;Optimises tissue functioning;Opens up the vital flow of energythroughout the body;Strengthens muscles, improves bloodcirculation; stabilise autonomic nervoussystem Decrease in cortisol and cholinesteraselevels, which reflect quietening of thestress response.

Pranayama and Pain

Pranayama is the controlled expansion of the vitalenergy;Influences the para sympathetic activity of vagus nervewhich produces the body’s relaxation responseReduces anxiety and negative thoughtsImproves flow of oxygen to musclesSlow breathing helps to change in heart rate variability

Meditation And Pain

Reduced EMG(electromyographic)activity in quadriceps;Increased finger temperature, pulsevolume and circulation, reduced oxygenlevel consumption;Deep meditation increases hypo-metabolic arousal state;The cortisol levels came down andwhile Prolactine and Ach levelsincreased.

ConclusionPain is multi factorial & complex in

origin & yoga adopts multi dimensionalholistic approach to address this.

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References:

Medically unexplained somaticsymptoms and chronic pain

assessment & management - Dr.Geetha Desai & Santosh K Chaturvedi

Chronic pain : An integrated Behavioralapproach – Herta Flor and Dennis C.Turk.Yoga VashisthaInteroception and stress Andre schulz &claus vogele ..https://www.frontiersin.org/articles/10.3389/fpsyg.2015.00993/full

Acknowledgement

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Dr. Geetha Desai , Professor,Department of Psychiatry, NIMHANS.Dr. Sowjanya, SRF, NICY,NIMHANS.Ms. Kankan Gulati, SRF, NICY,NIMHANS

THANK YOU