Team Up to Fight Pain
Penny Rickhoff lives with pain that never ends. It began in 1985 when she ruptured a disk in her lower back, and it worsened several years later when a file cabinet fell on her. "Basically, on a scale of one to 10, my pain averages about a five, which is moderate," says Rickhoff, a substitute teacher in her early 50s who lives in Scottsdale, Arizona. "In the evening, it goes to a six. And periodically, I have flare-ups that send it up to an eight or nine."
The intense flare-ups in her lower back, which occur a few times a year when she lifts something heavy or suddenly moves the wrong way, are excruciating. "My muscles contract, and they become hard and immobile. Sometimes I can hardly even turn in bed. It's like a constant, heated, deep pain—and if I move, it becomes a stabbing pain," she says. "Then I feel faint, and if I try to get up and move too much, my blood pressure goes up and sometimes I feel nauseous." Even after the flare-up subsides, she still hurts nonstop. "It's a constant aching feeling that is always there and never goes away."
Rickhoff's suffering has made a huge impact on her life. After the file-cabinet injury, she was forced to give up her job as a corporate pilot. Her condition contributed to marital problems. (She and her husband eventually got divorced.) Even going out with friends has become difficult, because her back often hurts more late in the day.
Rickhoff is one of 50 million Americans who suffer from chronic pain, including pain from lower back problems, arthritis, cancer, repetitive stress injuries, headaches, fibromyalgia, and other ailments, as well as from botched surgeries and industrial accidents. "The individual with chronic pain is not comfortable while awake, and usually doesn't sleep well at night," says Steven D. Feinberg, M.D., clinical adjunct professor of anesthesiology at the Stanford University School of Medicine and director of the Bay Area Pain Program in Los Gatos, California. "Weight gain and sexual difficulties occur," he continues. "Anger, depression, despair, and irritability are common. Chronic pain is often accompanied by loss of hope and self-esteem. It saps the individual's energy and the ability to think straight."
Chronic pain, defined as continuous pain for more than six months, can trigger a cycle of disability. Those who suffer from it often retreat into themselves, becoming inactive and minimizing contact with other people; lack of social interaction contributes to feelings of depression and isolation. They may rely on medications to get through the day, and then to sleep, and those medications may cause side effects—dizziness, nausea, and drowsiness—that immobilize them further. Inactivity causes their muscles to weaken; deconditioned muscles make them feel even more infirm. Over time, despair may set in, and the pain may seem even worse; studies show that depressed people feel pain more acutely than nondepressed people. Feeling worse, they may ask their doctor for more medication, and when they take it, they may feel even groggier, debilitated, and depressed. And the cycle progresses downward.
Because chronic pain is such a complicated problem, managing it requires a multidimensional approach. Although chronic pain is the most common reason people seek medical attention in the United States, physicians admit they often feel powerless when it comes to easing it. The typical Western approach—bed rest and trial-and-error treatment—is far too narrow to help many people.
Some patients look for alternative solutions, such as traditional Chinese medicine or acupuncture. These treatments sometimes help lessen pain, but they offer little in the way of easing psychological, social, or occupational burdens; they're only part of the solution. That's why physicians and complementary-care providers alike are heralding a new option: the pain-team approach.
Developing a Game Plan
A pain team works like this: Instead of an individual practitioner using a single Eastern remedy or Western therapy, a multidisciplinary squad of physicians, physical therapists, psychologists, occupational therapists, family therapists, and other conventional-care providers joins forces with acupuncturists, yoga and qi gong instructors, massage therapists, biofeedback practitioners, nutritionists, relaxation therapists, or other complementary-care givers. All of them work together to create a whole-body, East-meets-West approach.
"Treatment of pain by one therapy or a single approach is just not appropriate," says James N. Dillard, M.D., assistant clinical professor of rehabilitation medicine at the Columbia University College of Physicians and Surgeons and author of The Chronic Pain Solution: Your Personal Path to Pain Relief. "We get better results in people from combining the best of conventional medicine with the best of complementary and alternative therapies."
Enthusiasm for the pain-team approach is growing among both complementary-care providers and conventional physicians. "There is increasing interest in this approach because people are not doing well just taking tons of medications," says Dillard, who directs a course on integrative pain medicine at Columbia each year that is attended by hundreds of physicians and complementary-care providers.
The multidisciplinary pain-team philosophy is the guiding force at the Bay Area Pain Program, where chronic-pain sufferers take part in an eight-week program led by a pain team. Participants, many of whom have industrial injuries and have undergone repeated surgeries, get various treatments. Along with being immersed in physical therapy; wellness, yoga, tai chi, and qi gong classes; psychological and job counseling; art therapy; and peer support, they also learn anger management, assertiveness training, coping strategies, and relaxation techniques.
Yoga is a crucial part of the program, says coordinator Bridget Flynn. "A lot of these people have been completely sedentary for years," she explains. "They're petrified to move. They're afraid to even bend over." Stiff muscles and impaired range of motion amplify their pain; yoga helps them relax and begin to embrace the notion of moving again after so much physical stagnancy. As they become more active physically, they begin to break the cycle of pain, muscle weakness, and isolation. Many find that when they begin to move again, they require less medication and are able to do other activities, such as biking and swimming. Their pain may not completely disappear, but they feel more optimistic and proactive, and they find ways to manage their pain and improve their quality of life.
Flynn describes a patient with a degenerative disk disease that left her so bent that her ear touched her shoulder: "For her, the big thing was to stand straight. She would become nauseous trying to hold her head up." With the support of her yoga teacher and her fellow classmates, the woman challenged herself week after week. "She got to the point where she stood in Mountain Pose, and the whole group was cheering," Flynn recalls. "It was such a huge deal for her just to stand straight—it was a perfect Mountain Pose. What a great metaphor for her life. If she can conquer that mountain, she can do other things too."
Working With the Pain
Similar successes are found at the UCLA Pediatric Pain Program. It combines acupuncture, biofeedback, massage, yoga, psychology, and other therapies with cutting-edge Western medical treatments to help children and teens with arthritis, headaches, irritable bowel syndrome, and other chronic-pain conditions.
Iyengar Yoga is an essential part of the UCLA program, according to director Lonnie Zeltzer, M.D., who is also a professor of pediatrics, anesthesiology, psychiatry, and biobehavioral sciences at the UCLA School of Medicine. "For people with chronic pain, Iyengar is particularly good," Zeltzer says, "because B.K.S. Iyengar has researched and understood the therapeutic benefits of the poses." Iyengar Yoga's use of bolsters, blocks, straps, blankets, and other supportive props also lets them modify the postures for optimal effectiveness. "Using props allows students to work with their pain instead of avoiding it," Zeltzer says. Props also allow people to do poses that would otherwise aggravate rather than help their condition.
"For kids with headaches, just sitting cross-legged and resting their foreheads on a bolster is so calming," says Beth Sternlieb, a certified Iyengar teacher and the staff yoga instructor for the UCLA program. "And for those who are depressed—a common side effect of chronic pain—we do a lot of backbends and chest openers. These poses make them feel alive and confident and optimistic." Other postures give them a sense of satisfaction: With props, for example, children with arthritis in their hands and shoulders can learn to do Handstand, which many of their friends can't do.
Sternlieb's duties extend beyond the yoga studio. Each week, she meets with all the other care providers of the UCLA pain team to share information about each patient's progress, sleep patterns, medication changes, eating habits, and pain levels. Sternlieb says this information-sharing process is crucial in treating each patient as a whole, individual person, and it is one of the most important components of the pain-team approach. "People are complex, especially the kinds of kids who come to the pain clinic," she says. "They come to us after long periods of searching. Because of that complexity, it takes a variety of approaches to help them. As a team, we gather a lot more information than we would individually. Each practice opens up a different window of observation."
Eddie Cohn, a 29-year-old songwriter and recruiter for a market research firm in Santa Monica, California, is one of Sternlieb's students outside the program. At the age of 12, he was diagnosed with rheumatoid arthritis, a persistent and painful inflammation of the joints. It went into remission when he was 18 but then returned five years later. He relied mainly on medications during his first bout with the disease, but the second time around, he was determined to expand his treatment options. "I wanted to be more proactive as to what I could do rather than just going to a doctor and getting medication," Cohn says.
He faced considerable challenges. In addition to joint pain and swelling, he suffered from pericarditis, a painful inflammation around the heart. With Sternlieb as his teacher, he practiced mainly restorative poses and inversions for about a year. "It gave me a lot of strength, both physically and mentally," he says.
He gradually worked up to four or five Iyengar classes a week, and over time, he reduced and then eliminated his many medications. He then added active poses—standing poses and backbends—to his practice. Now he is in remission again, and he credits his good health to continued yoga practice and an overall commitment to maintaining balance in his life. "I am careful—no alcohol, no smoking; I eat fish three times a week and lots of fruits and vegetables," Cohn says. "I believe you need to nurture your immune system as if it's a precious thing. For me, it's all about not being overextended."
Why Yoga Helps
Experts believe there are many reasons yoga helps people with chronic pain. First and foremost are the physical ones: Yoga loosens muscles that have been tightened by inactivity, stress, and tension. It helps release muscle spasms, corrects postural problems, increases range of motion, and enhances flexibility.
Yoga also delivers psychological benefits. Many people in continual pain shut themselves down emotionally as a way of coping. They take sleeping pills, always keep the television on, or do other things that help block out their own consciousness. Many feel angry and bitter. "Patients come in with so much psychological baggage," Flynn says. "Reflection is hard, because they are so uncomfortable with their own thoughts. Yoga gives them a safe, positive way to become more conscious. It's a personal, private journey, and they can take it as slowly as they want."
Engaging in physical activity can also empower a person who has felt mistreated by the health care system. "It makes the person feel less like a victim, because they're taking control," Dillard says. "It gives the person something to do besides pop pills and go to the doctor."
And there's more. Zeltzer believes—and she is busy working on research to support her case—that yoga can bring about physiological changes in the central nervous system that relieve pain. Here's her theory: Intense pain causes pain-processing pathways in the brain to function abnormally, allowing pain to persist even after the disease or injury heals. How does this happen? Zeltzer believes that severe pain throws the nervous system off-kilter, and as a result, the body's pain-control system "gets out of whack" and doesn't turn itself off. "Yoga helps get the central nervous system back in service," she says. "And I think there are changes in the body's inflammatory process with yoga. It's more than just increasing flexibility and strength."
Perhaps the most important advice for those with chronic pain is not to give up. It may take time to find caregivers who can truly help, but those who continuously search, learn, and take a proactive approach will find them. "It's really important that people know there is help for their chronic-pain problems," says Sternlieb, "that their suffering can be transformed into insight and a sense of mastery."
Can't find a pain team in your area? Create your own.
Despite the raves given to the pain-team approach by physicians, complementary-care providers, and patients, it's not the norm in our health care system. Why not? You guessed it: money. "Insurance companies don't see the multidisciplinary approach as a viable, cost-effective way to treat pain," says Penney Cowan, executive director of the American Chronic Pain Association, which is working to convince insurers that a multidisciplinary approach makes financial sense in the long run. Meanwhile, patients may be losing out.
As a result of dwindling reimbursements by health insurance companies, multidisciplinary pain clinics across the United States are in jeopardy. "Unfortunately, in this country, what gets done is just what gets paid for by the insurance companies," says James N. Dillard, M.D. "It's sad." Dillard advises patients who can't find a pain team at a major hospital or university clinic in their city or town to put their own together. "To a large degree, people need to take control of their treatment," he says. "They have to become a member of their own pain team—they can't be passive."
Here's how to do it:
Learn as much as possible about your condition: Read books, consult websites, and obtain copies of your medical records.
Develop your resources: Find out what treatment options exist in your area. Support groups, national organizations, and local hospitals can be starting points.
Learn about the mind-body connection in chronic pain: "Take your own temperature, stresswise," Dillard says. "Pain, stress, depression, and anxiety go hand in hand." If you feel you would benefit from psychological help, get it.
Search for a pain-care provider who will work with you: Get a referral from a hospital that uses the pain-team approach, and interview doctors in your area. "There are a lot of physicians who do understand pain and pain management," says Cowan. Ask around and you're likely to find one.
Seek out a yoga teacher who is trained specifically in chronic-pain problems: Begin with private sessions, if possible, so you can work at your own speed. If you doubt your teacher's ability to work within your limitations and comfort level, find a new teacher. "I've seen a number of people with chronic pain get injured in an inappropriate yoga class," says Lonnie Zeltzer, M.D. "You must be an advocate for your own health and safety."
As much as possible, have your health care providers work together as a team: Encourage them to communicate with one another, to share lab results, to discuss therapies with you and with one another. The more they know about you and the treatment you're receiving from other practitioners, the better they can calibrate your care.
Stick to It
Many physicians recommend acupuncture for chronic pain. Once dismissed by conventional Western health practitioners, acupuncture is winning approval from physicians, researchers, and patients for its effectiveness in treating a variety of health conditions, especially chronic pain. In fact, chronic-pain relief is one of the main reasons Americans seek acupuncture treatment, according to the National Institutes of Health (NIH).
Acupuncture has shown so much promise in combating chronic pain that it has become the subject of numerous scientific studies. During the past five years, the NIH's National Center for Complementary and Alternative Medicine (NCCAM) has made acupuncture research a top priority. The NCCAM is currently funding more studies on the benefits of acupuncture for chronic-pain ailments, such as osteoarthritis, carpal tunnel syndrome, temporomandibular disorder, and postoperative dental pain.
While scientific and anecdotal evidence suggests that acupuncture is a viable treatment strategy, some types of pain appear to respond to it better than others, according to James N. Dillard, M.D. For example, he says, the evidence is "very strong" that acupuncture helps nausea and facial pain, "moderate" for neck pain and headaches, "mediocre to good" for arthritis pain, and "pretty positive" for fibromyalgia. There is less evidence that it helps lower back pain. "The jury is still out on that," says Dillard.
Eastern and Western explanations as to why acupuncture might work are different. In the Eastern view, a practitioner can, by inserting needles into the proper points, restore the proper flow of chi, the life force that flows throughout the body.
From the Western standpoint, acupuncture stimulates the body to release painkilling biochemicals, such as endorphins, opioids, and certain neurohormones and neurotransmitters.
In any case, Dillard and other physicians often advise their chronic-pain patients to give acupuncture a try. "Some people respond to it and some people don't, but that's also true of a lot of conventional and unconventional therapies," Dillard says. However, he quickly cautions that acupuncture should be used in addition to—not in place of—yoga and other exercise, psychotherapy, physical therapy, or other more active approaches to pain management.
Alice Lesch Kelly is a regular contributor to Yoga Journal.