Solutions for Pain with BREATHING, VISUALIZATION, AND POSTURE THAT BRING AN AWARENESS OF SELF.

Includes a commentary on repetitive stress injury/ chronic pain


     Our bodies have natural internal mechanisms to help us regulate pain.  Pain regulation is influenced by numerous factors including gender, hormones, genetics, stress and the brain’s neurochemistry as well as the severity of injury.  We also have the innate ability to influence pain levels through techniques and self-education to stimulate the body’s release of our own natural and effective pain killers. However, training and practice are essential for successful self management.


Pain is a difficult phenomena to deal with, especially if it is something that is ongoing in our lives.  Pain is both physically and emotionally stressful, and this physical and mental tension can, in turn, make the pain worse as anxiety amplifies the perception of pain.  Pain can consume us as we start to identify with its presence as who we are as well as becoming wrapped up in the stress and worry about the length of its stay and the limitations it presents.


Western medicine offers solutions such as medication, biofeedback, and therapies to alter the physiological mechanism of pain and our interpretation of it.  However, in the battlegrounds for pain, one of the fundamental techniques or solutions beyond modern day medicine is to reach inside of ourselves in order to disassociate from the pain and recognize it for what it is; a separate communication signal from our bodies to alert us from harm.  Sometimes in the face of adversity, there is nowhere to go but in.


Alternative and supplemental self-management solutions also exist that help to relax the body including breathing, meditation/visualization and postural relaxation that are at the heart of yoga techniques.  These methods require practice and effort, however they can have a more long-term benefit by serving as tools that are available to you whenever life’s challenges arise.  They help to induce the body’s natural pain defense system and offer a planned, purposeful relaxation that can help break the pain-stress cycle by lowering heart rate and blood pressure, relaxing tense muscles, reducing anxiety, and giving you a sense of control and well-being. 


What is pain and what are its effects on the body?


    Pain is part of the body’s defense system; a mental and physical reaction of the body to a stimulus in order to avoid further damage.  It also trains the brain to avoid similar noxious stimuli for future situations.  Pain receptors are found in a multitude of places: ligaments, tendons, bones, blood vessels, fasciae and muscles. Pain may also promote the healing process, since most organisms will protect an injured region in order to avoid further pain.


  Pain can be either short term, acute, or longterm, chronic.  When a pain stimulus is ongoing, ranging greater than 3-6 months, it affects brain biochemistry and negatively affects neural network patterning. The presence of pain inhibits 40-60% of motor function as in the contraction of a muscle to support a joint or an optimal postural position. So when we don’t listen to our pain, ignore its presence and continue doing the things that irritate it, we are inviting a change in our system that has more long-term derogatory effects.


Endorphins: the body’s natural defense mechanism against pain


When pain or other sources of stress become significant and threatening, groups of cells in the brain release chemicals called endogenous opioid chemicals, commonly known as endorphins or enkephalins. They are also shown to be released with the practice of exercise, deep breathing and meditation as well as listening to music or eating certain foods like chocolate and spice.

Endorphins work by binding to receptors on nearby brain cells and influence how the brain interprets and regulates the pain-related signals those cells are sending to one another. The effect is called antinociception, because the neurotransmitters typically suppress the pain response, as opposed to nociception, which is the actual perception of pain.



Repetitive strain injury and pain.

        Repetitve strain injury (RSI) is a condition resulting from the overuse of a structure of the body where tissue damage occurs that leads to pain. Its common symptoms are pain, tingling, numbnes and weakness. RSI is most commonly found in the upper extremities: fingers, wrists, elbows and shoulders. The pain may be felt from the fingers to shoulder.  The numbness and tingling may be felt at night and disturb sleep. Deficits in sensation may develop as well as decreased strength and endurance for activities.  Its onset can be gradual or acute and when symptoms are treated in the acute phase, complete recovery is possible.  If symptoms and aggravating behaviors become chronic and treatment is ignored, permanent nerve and muscle damage may occur.


The US National Institute of Occupational Safety and Health concluded that repetitive motions, particularly in combination with high force or awkward postures, increase the risk of developing work-related musculoskeletal disorders. Musculoskeletal injuries associated with repetitive motions include many of the itis’: tendonitis, tenosynovitis, ganglionic cysts, focal dystonia, fibromyalgia, myositis, bursitis, osteoarthritis and synovitis.  Repetitive strain injury can also develop with repetitive yoga postures and sequences performed incorrectly, or when a joint is excessively flexible and not supported by stabilizing structures like ligaments or strong enough muscles. A study done on women that measured the maximum acceptable power grip force across the wrist joint found that more than 15 movements per minute at 2.5-5% the force of body weight resulted in RSI symptoms.  This finding was adversely affected by an increased exposure to the activity in the day and repeated days in the week. 


What happens? Pathophysiological Tissue Changes Associated with Repetitive movement.


Various tissue structures like muscles, tendons and nerves can be physiologically damaged after repetitive strain is placed on them.  There is a chain reaction of responses.   First, overusing a body part when it is tired overrides the body’s natural reparative process. An inadequate repair of tissues can occlude the oxygen supply to the area and lead to the breakdown of protective inner linings.  This breakdown makes the linings more susceptible to leaking and taking in extra fluid known as inflammation.  With increased inflammation, cells are summoned to the area to repair the linings and if this process becomes repetitive, the extra linings can thicken and bear down scar tissue, limiting optimal physiological movement as well as causing pressure on surrounding structures.  When the body assumes compensatory patterns additional mechanical strain can be added to the system and further the pain process. What is the lesson here? Go with your gut and stick with the good feeling.


What to do about it? The immediate combat.

To combat the effects of pain, muscle cramping and inflammation, one must first adopt a healthier posture and pattern of movement.  First, seek the counsel of a health professional and get an ergonomic assessment of your workstation or work environment, a movement analysis and body mechanic education to ensure correct positioning to avoid unnecessary strain. Secondly, as humans, we are not meant to routinely be in one type of position all day as with sitting at a computer or lifting in a repetitive way.  A change of position or 30 second stretch every 15-30 minutes can often give significant relief.  Lastly, the application of ice for 10-15 minutes once an hour can help with inflammation and sensations of increased warmth or burning on the skin.  Other suggestions include splinting, anti-inflammatory drugs, conservative use of cortisone injections and in some cases surgery which may or may not be successful. These tips will help reduce the acute pain process, however in the prevention of further injury and maintaining what gains you have seen, it is beneficial to adopt a self managing awareness as a defense.


Retraining the mind to evade pain patterns and sensations. Breathing, Visualization and Postural relaxation and strengthening


Optimal breathing mechanics affect cell function


Our first breath marks our entry into life, as our last breath marks our exit. No doubt it has vital importance.  The breath can offer us relief with a sigh of exhale as it releases tension in the body and mind. The benefits of correct breathing mechanics have been prominently apparent over the ages and in health education. Deep breathing brings in oxygen to the body, which works on the sympathetic nervous system and the stimulation of the release of endorphins.  Eastern medicine has attributed the breath as a vital part of our life energy called chi or prana.  When its optimal natural and rhythmic pattern is integrated into our lives, we are said to be born and dying every breath cycle. Too theoretical for you?  What it states is that each breath offers us an opportunity to start fresh and then to exhale/release the unwanted.  And why not, air is free! Breathe!


     The lungs function to provide an uninterrupted flow of oxygen to the blood when a person inhales, and to eliminate carbon dioxide upon exhaling.  This process is unconsciously regulated by nerve cells in the reticular formation of the brain. When the lungs cannot exhale enough carbon dioxide, a toxic buildup occurs, compromising cell function in the entire body. Any factor that causes the airways to constrict or narrow, as in poor posture, stress and shallow breathing, or disease can cause the lungs to become less effective and will increase the work of breathing. How much air we take in is primarily in the relationship of posture, lung volume, breathing rate, and a balanced inspiratory and expiratory rate. How much we get into our cells is another matter as chemistry affects that.

     Optimal natural breathing includes balanced, slow and relaxed diaphragmatic breathing that fills the deeper lungs and encourages rib expansion in the fashion of an inflating balloon with synchronous motion from all planes: front to back, side to side and up and down. If the breath is filled at the top of the chest as with shallow breaths, it is inefficient as we are using accessory muscles that are used for coughing and sneezing and are not designed for prolonged use of rhythmic breathing.  This can cause muscle strain as well as not reaching the full potential of our oxygen capacity intake. The diaphragmatic breath stimulates the parasympathetic nervous system.  It reverses the cycle of stress and rapid shallow breathing that is characteristic of the stress response.


We also need to adopt a steady breathing pattern to meet the demands of a wide variety of emotional states and activities, not just while relaxing. The awareness of our breaths in different situations plays a key role in how we sense how stressed we are. It is recommended that we take 4-7 breaths/ minute for optimal oxygen intake to the cells.  It is measured that most people take about 12 breaths/ minute which is unhealthy as it overtaxes the breathing system and increases the energy cost of breathing. Increased breathing rates will also excessively stimulate the fight or flight aspect of the autonomic nervous system affecting hormone and thus stress levels.

A slower breath rate ensures more oxygen to cells as the inhalation may reach the lower lobes of the lungs that have a greater perfusion of alveoli and potential for oxygen uptake, regulate heart rate and/or blood pressure. It also increases the release of endorphins which are natural chemicals released from our nervous system and bodies that are able to bind to the neuro-receptors in the brain to give relief from pain.  Endorphins come in several forms and can be anywhere from eighteen to five hundred times as powerful as any man made analgesic.

In yoga, when asanas are linked to the breath, they affect not only the physical body but also the mind. Remember the last time your yoga instructor reminded you to regulate your breathing during a challenging posture and the effect resulted in a steadier, calmer attitude toward the posture?  Establishing steady breathing patterns reinforces a homeostatic functioning body system, especially with challenging situations like pain and stress.


Breathing techniques:  deep breathing, Ujjayi breath, Alternate Nostril breathing for brain hemishphere balancing

In order to deep breathe pull in the air into the lungs while expanding the stomach instead of the chest. Sit or lay still someplace that is quiet and be in a comfortable position. In order to feel the difference between normal breathing and deep breathing place one palm on the stomach and the other palm on the chest. You will be able to feel the difference in breathing. It is important to breathe long and slow. This form of deep breathing gives the body the ability to draw in a larger amount or degree of the inhaled oxygen. It is important to make deep breathing a daily habit to reap full benefits for long term. By helping you deal with stress, deep breathing will help you to cope through all walks of life.

VISUALIZATION REINFORCES OPTIMAL BEHAVIOR AND OUTCOMES


   Lost in dreams? Isn’t it quite easy to daydream about the things that we love and desire?  Your gift of picturing the ideal may finally come in handy.  One key premise of visualization that even scientists support is that it helps to re-establish an optimal patterning of movement and release pain from the body. 

    Visualization plays a part in managing our mind’s connection with the body.  When we are able to picture and feel a desired response, we are that much closer to achieving a goal. Research shows that “practicing in your mind” is almost as effective as practicing physically, and that doing both is more effective than either one alone. So write down the action steps and visualize them - the entire process, not just the end result. See yourself accomplishing them and feel the process as if it was real.  Dr. Richard Restak, a neuroscientist and author of 12 books about the human brain states:

“The process of imagining yourself going through the motions of a complex musical or athletic performance activates brain areas that improve your performance. Brain scans have placed such intuitions on a firm neurological basis. Positron emission tomography (PET) scans reveal that the mental rehearsal of an action activates the prefontal areas of the brain responsible for the formulation of the appropriate motor programs. In practical terms, this means you can benefit from the use of mental imagery.”


Another example of this is that neurologists have studied a technique used by physiotherapists called graded motor imagery that supports the theory of the cerebral origin of pain.  This type of visualization was used with a specific group of people with reflex sympathetic dystrophy (RSD) and is aimed at retraining the brain and not the body as a tool to improve chronic pain and restore function.

  There are some simple steps to complete this technique; 1) visualizing an ideal posture, 2) integrating the posture into a movement with the unaffected body part, 3) using a mirror image to visualize the mirrored affected body part completing the movement in a pain-free and smooth manner, and finally 4) mimicking this movement with the affected body part. Results were reported to be effective, practicing the technique regularly for three months showed results better than could be expected with conventional or invasive methods.


    Visualization also encourages transference of information between the two sides of the brain.  This is especially beneficial when one side of the body is compromised in function and can progress with an internal guide to strengthen the motor programs on its own side.  One thing to keep in mind with these techniques is that practice is vital for its success. Just as any habit takes continual reinforcement to change a behavior, the neural networks that are in our bodies need a persistent stimulus to strengthen their connections.  So, try, try and try again until it is second nature!


POSTURAL AWARENESS, STRENGTH AND BODY MECHANICS ENSURE AN EFFICIENT FUNCTIONAL STATE


In my years of training and experience as a physiotherapist I have crossed paths with thousands of people and seen the key elements of preventing bodily injury; the awareness of oneself in your own body, the strength to maintain it, and knowledge of how to use the body correctly.  Essentially, your body is a living and breathing machine that needs to be treated as sacred and used effectively.


The importance of maintaining optimal posture is directly related to the design of your anatomical structure and thus the way that your musculosketal, neurological, and organ systems are structurally positioned when engaging in certain activities.  After one is alert and holds the body correctly, then strength must be developed to maintain it in this position as well as to withstand external forces that act upon it.  This means core and extremity strength must be linked functionally so that all muscle groups act as a functional unit, not one area of the body is used as separate from the rest and thus overtaxed. Therefore, we function as an efficient and effective whole system.  Lastly, understanding physics and forces and how they relate to the body are vital strategies to prevent damage to its structures. By moving consciously and with awareness to our bodies biomechanical needs, we prevent strain to the body and increase the longevity of our movement system and ensure a pain-free life.


Yoga asanas or postures when correctly applied, can combat pain by retraining the ability to direct the mind and body. The essential qualities of asanas are from the Sanskrit words sthira, steady alertness; and sukha, light and comfortable.  When Yoga is applied therapeutically, the poses are adapted to the individuals as directed by their therapist/ teacher.  The first yoga-based therapy for carpal tunnel syndrome, a related RSI injury was published in the Journal of the American Medical Association (JAMA) in November, 1998.  The subjects in the study were divided into two groups.  One group received two yoga classes a week for eight weeks that focused on upper body postures: improving flexibility, correcting alignment of hands; wrists, arms and shoulders; stretching; and increasing awareness of optimal joint position during use.  Every session ended with relaxation in savasana (corpse pose).  The second group was offered a standard wrist splint with a metal insert and told to continue whatever treatment they were already receiving. The results of the study were positive, the yoga group had significant improvement in grip strength and improvement in a nerve test as compared to the control group showing that yoga can be a useful method for effective treatment.


Incorrect use of asanas to create excessive spinal flexibility or muscle length can cause injury and prematurely age our movement system.  Excessive muscle length or flexibility alters the control a muscle has over the segments that it influences, leading to repetitive stress and eventual pain.  Furthermore, practicing yoga asanas beyond the strength capacity will result in your body to develop compensatory patterns to achieve the desired movement.  Many times this causes injury to surrounding structures and joints that are not supported with the attempted movement.  Some problematic poses when done incorrectly include poses like mukha svanasana (downward facing dog), which takes weight on the wrist and can compress the rotator cuff of the shoulder.  Other poses that put weight and pressure on the wrists include urdvha mukha svanasana (upward facing dog) adho mukha vrksasana (upward facing tree or full arm balance), bakasana (crane) and should be avoided for people with RSI until optimal strength and support of trunk in relation to the upper extremity and wrists is restored for a pain-free practice. 


Modifications of poses can help reduce strain on the upper-extremities, like rolling up a sticky mat and putting it underneath the heel of the palm in down dog to create a less acute angle for the wrist.  A strap may also be tied across the elbow joints and pulled apart to take weight out of the hands.  In addition, passive backbending over bolsters or using props like blankets or chairs also can take weight out of the hands.  However, if pain persists with these modifications it is best to avoid wrist weightbearing until symptoms are alleviated.


Self-awareness and consistent practice to develop appropriate whole body flexibility, strength and alignment will inherently reinforce the preservation of the body. When the body becomes accustomed to recognizing how to engage proper muscle groups for movement and moving in supported ways, this internal awareness supports the mind and body to achieve independence in establishing self-referring limits with movements or activities that may cause injury and prevent harm.  This is especially important when we find ourselves amidst the fast paced working world and we want to preserve ourselves within it.


The slow repetitive nature of a movement performed with full attention and paced by the breath has numerous benefits. The process of motor learning occurs more easily.  Neuromuscular relaxation is enhanced.  Sympathetic dominance is decreased with correct breathing.  This increases blood flow to the muscle, normalizes muscle tone and optimizes cell repair.  Mental focus is improved. There is improved ability to re-educate muscles and stabilize segments through increased kinesthetic and sensory awareness. New patterns of movement and posture are more readily integrated into daily activities.


Many elements compromise the totem pole of our being: diet, exercise, emotional balance, self-fulfillment are only a few. By treating yourself with respect, striving towards your goals but owning up to your limitations you will apply a healthy function to fulfill your own desires in this physical world. It is valuable to take a few moments at the beginning of our workday to dedicate the merits of our actions in keeping with our spiritual beliefs or our purposes in life. Through the ages and in many cultures, it has been said that true healing begins within.  It begins when we realign our activities, speech and thoughts with our highest values and when we re-establish our priorities.


So, during your next yoga class or self-practice, remind yourself of the internal potential of yourself to guide your body towards a pain-free existence.  With each breath, set an intention of the awareness of yourself, allow the internal guide within to lead your body to move consciously and respect your limitations yet strive patiently towards your goal. Listen to the imagery of your instructor or visualize yourself in the most optimal and supported postural position, and see the freedom of your movements becoming possible and without pain. Over time with practice and effort you will see the change that you have set out for yourself and be happy that you were so dedicated in achieving it.


Recommended Poses: Savasana , progress to Savasana lying on a foam roller with arms out at sides, Balasana/ Child’s Pose with arms outstretched and using cushions and bolsters for ultimate relaxation, Tadasana Standing with arms up against the wall, Viparati Karani – legs up on the wall pose, Plank pose, Setu Bandha Sarvangasana/ Bridge Pose, Matsyasana/ Fish Pose progressed to Purvottansana/ Upward Plank Pose, All poses held for 30 sec, 60 sec, 5 min increments at least 1x if not 2x/day.


References


Barr, Ann E, Mary F Barbe. Pathophysiological Tissue Changes Associated with Reepetitive Movement: A Review of the Evidence.  Physical Therapy. Vol 82, No 2. February 2002.

Moises C. Lima, MD, Felipe Fregni, MD, PhD. Motor Cortex stimulation for chronic pain.  Systematic review and meta-analysis of the literature. Neurology® 2008; 70: 2329-2337.

Siddall, Philip J.  Magnetic Resonance Spectroscopy Detects Biochemical Changes in the Brain Associated with Chronic Low Back Pain: A Preliminary Report.  Anesth Analg 2006; 102: 1164-8

Birklein, Frank MD, PhD.  Use Your Imagination.  Training the Brain and not the body to improve chronic pain and restore function.  Neurology 2006; 67:2115-2116

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