Good Pain, Bad Pain? Some Pain, No Pain?
How to know what I should be feeling?
Table 1) There is a wide range of qualities of sensations that we can attend to. [Entries in red
may indicate compression is occuring.]
Yoga involves sensations; lots of physical sensations—we seek them out deliberately, we marinate in the juiciness of the postures, we play the edges of our poses where sensations ebb and flow, swell and retreat. But, what happens if the sensations become sensational? Is that a good thing? When do I back off? When do I go deeper? Is pain a reliable signal; is it always bad; and what is pain anyway? Is it discomfort or something more?
|Qualities of Sensation
- Deep or superficial
- Spread out
- Moving up or down
- Dotted line
- Dashed line
- Interrupted line/jumping
|Other qualities (may indicate pain):
- Activity related
If our intention in our yoga practice is to regain or maintain optimal health, we need to exercise our tissues to an appropriate degree. Exercise requires both stress and rest—but stress sounds negative: it sounds dangerous, degenerative and depleting. Unfortunately, this is a bum rap: stress is necessary for health. All tissues need stress to regain and remain healthy: our muscles, our fascia, our immune system, our nervous system ..., but it is very true that we can do too much. Too much stress leads to degeneration (think of osteoarthritis—this is an overuse problem), but too little stress leads to atrophy (think of osteoporosis—this is an underuse problem.)
"If you are feeling it, you are doing it"
Stress is necessary, and in our yoga postures we can feel it: when we are aware of sensations physically, we can be sure that we are stressing our tissues. Another way of saying this is, "if you are feeling it, you are doing it." But how can we tell if the sensations are sufficient, appropriate or too much? We pay attention. We notice the quality and quantity of the sensation. This is not easy for beginners, but with training we become more alert and aware of what we are doing to our bodies, and where the appropriate edge is in each pose, in each day that we practice. (Edges do vary from day to day: see the article Playing your edge.)
The sensations of tension and compression
There are two broad categories of sensation that will arise in physical postural practice: sensations of tension and sensations of compression. These fall along a wide spectrum, and there are clues that can help you differentiate between them.
Tension is a feeling of resistance inside the tissues, a resistance to being stretched. These sensations can arise in many areas and in many ways. Table 2 shows how the sensations of tension may manifest in the skin, our fascia, the muscles, and even in the joint capsules and ligaments. [Tables 1 and 2 are from my book Your Body, Your Yoga.] It is a very good idea to pay attention to where you are feeling sensations and to what you are feeling. By paying attention, we begin to understand what the posture is actually doing to our tissues. We can then decide whether this is the place we want to be or not.
Compression occurs when one area of the body comes into contact with another area of the body: this is where no further progress is possible, for that posture, in that direction. There are three main kinds of compression: "soft" compression is where flesh is being squished into flesh; "medium" is where flesh is being pinched by bone; "hard" is when bone is pressing into bone. When compression has been reached, there will still be some sensation of tension. To remove all the sensations of tension, we would have to stretch out the area where the tension arises, but by definition, once you have reached compression you cannot go any further, so whatever tension is still there will remain. This means that while you may be stopped due to compression, there will still be some feelings of tension as well. However, when you are stopped solely due to tension, there generally is little or no sensation of compression yet.
The qualities of sensations created by compression are listed in red in Table 1. This is not a definitive list, everyone is different; use it as a guideline that you can adopt and adapt to determine what sensations arise when you reach your edge in a posture.
|Table 2) Noticing where and what sensations are arising can give us a clue as to the cause of resistance to further movement.
- Spread out
- Stretchy or tugging
- Like a mild burn
- Spread out—multiple areas sensed at once
- Linear or rope-like
- Tugging or pulling
- Follows the shape of the muscle
- Muscle: sensation found in the belly of the muscle
- Tendon: sensation found in the attachments closer to the bone
- Mysterious (vague)
- Electrical zingers
- Spread out over a large area
- Stuck or blocked
- Very localized
Part of our yoga practice is building our ability to attend, to be present, to notice what is happening. It can be helpful to have an idea of what to look for, to help us sharpen our perception. Table 1 offers several adjectives that we can use to look at our sensations. It may be helpful as well to trace your sensation: use your fingertips to outline where you feel the sensation and lightly draw on top of it. This will guide your awareness and help you to deepen your attention. While everyone's experience is unique, you may find that the sensations shown in colour in the table are more typical of compression than tension.
Pain is subjective: is it ever good?
Everyone knows what pain is, but we don't all agree upon what is painful. Paul Grilley often points out that there are many Black Knights found in yoga classes: these are the Monty Pythonesque warriors who truly believe "I am invincible" and that "Black Knights always triumph!" When they are about to break their arms off in a deep, binding twist, they exclaim through gritted teeth, "I've had worse." When the inevitable injury does occur, it is just a flesh wound: "T'is but a scratch!" For these hardy yogis, any sensation that normal people would call painful, the Black Knights believe it is a sign that their practice is about to bear fruit. At the other end of spectrum are the timid souls for whom any sensation, no matter how slight, is a cause for pause, reflection and concern.
We can consider pain as a signal from the body that damage is about to occur, is occurring or has occurred. Ignoring these warning signs is risky: akin to ignoring the engine light of your car. You can place masking tape over the blinking red light to help you ignore it, but eventually the engine will die and a bigger expense is upon you than if you had attended to the warning. But with the wide range of variation in how people interpret sensations, as painful or not, how can we really know if the sensations we are experiencing in a yoga posture are really dangerous or necessary? Again, we have to pay attention.
Pain, like all sensation, has qualities to it. Included in Table 2 is a column listing symptoms of pain that could arise in our practice, and where certain kinds of pain are likely to occur. These qualities include burning, stabbing, tingly, sharp or boring sensations. Pain can also be quantified, as shown in the Mankoski pain scale of Table 3. Any ranking above 3 is not healthy: we are not trying to damage our tissues; we only want to stress them. Going above level 3 is probably not necessary, unless you are in the hands of a therapist.
|Table 3: The Mankoski pain scale
- Pain free
- Very minor annoyance—occasional minor twinges
- Minor annoyance—occasional
- Annoying enough to be distracting
- Can be ignored if you are really involved in your work, but still distracting,
- Can't be ignored for more than 30 minutes.
- Can't be ignored for any length of time, but you can still go to work and participate in social activities.
- Make it difficult to concentrate, interferes with sleep, you can still function with effort
- Physical activity severely limited. You can read and converse with effort. Nausea and dizziness may occur.
- Unable to speak, crying out or moaning uncontrollable—pain makes you pass out
- Unconscious. Pain makes you pass out.
A list of attributes of pain is not always helpful; some people need another way to quantify their pain, so cartoon figures are used, as shown in figure 2 (these are used for very young children who can not describe their sensations but can recognize pain in others.) If you see someone in a yoga class with a fascial expression beyond the second drawing in figure 2, you may have to question their intentions in doing yoga. Why are they staying in a posture that is creating such bad sensations? Part of the reason is the Western adage of "no pain, no gain." Many people really believe this, and it may be true in a therapeutic setting. But in a yoga class, a more practical adage to adopt is the Eastern saying of "no pain, no pain." If you experience the sensations listed in the pain column of Table 1, if it is above level 3 on the pain chart of Table 3, or if you look like guy #4 or worse in the faces scale, it is a good idea to back away from that edge.
FIGURE 2—The faces pain scale
Neil Pearson has noticed in his work as a yoga teacher, physical therapist and pain researcher that some people have two scales: a pain scale and a discomfort scale. For these people, many sensations are not considered painful at all, but rather uncomfortable. In yoga, we do take people outside their comfort zone: we need to challenge them; they need to feel something. Only when the postures become really uncomfortable do they become painful. But, even for these people, they need to practice with both an intention (optimal health?) and attention (what sensations are too much?) The faces scale can be used for these people as well: if they are experiencing discomfort that interferes with their ability to relax in a posture, to breathe freely or to soften their face, they are probably too deep.
It is valuable to pay attention to pain not only while you are in the pose, but also as you come out of the pose, and even over the next day or two. Delayed onset of pain may be due to some things that you were doing in your practice that were not healthy. Whenever you feel pain, it is worthwhile to investigate the cause. If you can correlate it to what you were doing in your yoga practice, you have the option to skillful modify your practice.
Pain changes breath; breath changes pain
Just as sensations can be indicators that we are too deep in our posture, breath is another barometer for our practice. Pain changes our breath: when we have no pain at all, our breath can be free, easy, and quiet, but when pain arises the breath changes. There are degrees of breathing patterns that are indicative of levels of pain, as described in table 4. As pain increases the breath becomes noisier, labored, sometimes faster, sometimes shallower and sometime deeper. In some cases the breath may vary dramatically and even stop (the condition known as apnea). This is not the kumbaka or breath retention sought in deep yoga practice, but an apnea that could potentially cause harm to the lungs and even heart failure.
|Table 4: Pain assessment through the breath: the higher the number, the greater the pain being felt.
- Pain free—Normal breathing is characterized by effortless, quiet, rhythmic (smooth) respirations.
- Occasional labored breathing is characterized by episodic bursts of harsh, difficult, or wearing respirations.
- Short period of hyperventilation is characterized by intervals of rapid, deep breaths lasting a short period of time
- Noisy labored breathing is characterized by negative-sounding respirations on inspiration or expiration. They may be loud, gurgling, wheezing. They appear strenuous or wearing.
- Long period of hyperventilation is characterized by an excessive rate and depth of respirations lasting a considerable time.
- Cheyne-Stokes respirations are characterized by rhythmic waxing and waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing). This is due to an inability to regulate CO2 levels causing these wild swings in breathing.
In the other direction, people suffering pain have found some relief in changing their breathing pattern to one of slow, easy rhythms. Deep, slow breathing, for example—inhaling for 3 seconds, exhaling for 6 seconds and pausing for 1 second before beginning the next breath—has been shown to positively affect both the threshold at which people perceive pain and their tolerance of pain.
Chronic pain and sensitization
Our adage of "no pain, no pain" is lovely as far as it goes, but unfortunately, for some people, just living is painful. Sufferers of chronic pain can do yoga, but for these folks everything involves pain at some level. For some, a temporary injury may have sensitized them so much that, after they have fully healed, normal, benign stresses are perceived as painful. In these situations, our normal rules of thumb fly out the window. How do these students determine what is too much?
Usually, people suffering chronic pain have seen several therapists, doctors or other health care professionals. They will have been given guidance and advice on what to do or not do, and yoga teachers should not be recommending that any student ignore these directions. In cases where chronic pain occurs that is not caused by tissue damage, a therapist may be able to help desensitize the area experiencing pain. The therapist will explain how movement is necessary in these sitations even when pain is present. Whlie doing yoga, these students can benefit from paying attention and practicing with intention. Remember one of our primary understandings: to create health we need to stress our tissues. If everything hurts, obviously adding even a little stress will increase pain, but in these situations this added pain may be necessary.
Students in chronic pain are already aware of their bodies, but they may have learned to run away from the pain rather than investigating it. A yoga therapist, experienced with working with students suffering chronic pain, may help the student pay closer attention to the sensations of the postures, to investigate what is actually happening, rather that what the student is afraid is happening. With a regular yoga practice, sensations may begin to ebb away and the chronic pain diminishes. Both the quality and the quantity of the pain may change for the better: we want the student to be aware of these changes, and she can only do that by paying attention. By noticing what works, and what doesn't, a path forward becomes clearer. By paying attention to the raw experience of each moment, she may be able to differentiate between sensation and pain. The pain may never go away completely, but the student through her yoga practice may become better able to cope with the pain and become more functional in her daily life.
Yoga involves sensations, but not all sensations are created equal. The quality, quantity and location of the sensations help to determine whether they are healing or harming. A sharp, burning sensation deep in the knee joint is never good, while a long, stretchy tugging along the thigh can be delicious. Electrical zingers and tingling: not good. A dull, deep, compressive stress may be quite healthy; but a deep, boring pain in the bones is never good. Many styles of yoga take us outside our comfort zone, but this doesn't mean we have to be so uncomfortable that we cannot stay in the posture, that we can't breathe freely or that we can't release tensions in the areas of the body not involved in the posture. Discomfort does not automatically mean we are in pain, but generally pain is a sign that we are about to damage our bodies. Listen to the body's signals: pay attention. Have an intention for your practice, such as—to regain or maintain optimal health. By combining attention with intention, it is possible to decide whether the sensations arising in your yoga practice are healthy or not. And if not, why not change what you are doing?
This material is adapted and expanded from the second chapter of Your Body, Your Yoga written by Bernie Clark, with guidance by Paul Grilley and many other yoga teachers, therapists and biomechanical researchers. The book is now available for ordering via www.YourBodyYourYoga.com and other book vendors.
1) Sometimes it may be possible to go around a point of compression, by slightly modifying the posture, by using a prop, or by using a different posture, until eventually we come up against a new point of compression that ultimately stops us. In this final place, we have taken the body as far as it can go in this lifetime. No point now in trying to go further; instead we accept our limitation and enjoy what we have achieved.
2) In a Yin Yoga practice, dull and achy sensations often arise that are not indication of trauma to the tissues. They are often to be expected when a long-held traction is applied. However, if these sensations arise in short held Hatha postures, that may not be a good sign.
3) Pain does have a place in physiotherapy, and in the enlightened hands of a qualified therapist pain can be a useful tool, to dissolve scar tissue for example, or to recover lost range of motion. But, most yoga teachers are not trained physiotherapists, and a yoga class with 20 other students or more is not the venue for seeking personalized therapy.
4) Mankoski Pain Scale ©Copyright 1995, 1996, 1997, 2000 by Andrea Mankoski. There are a variety of pain scales available, and not all agree in their specifications. For a different version, check out the Michigan Pain Measurement Scale.
5) Faces Pain Scale—Revised, ©2001, International Association for the Study of Pain. Based on original work by Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB, "The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties", in Pain, 1990 May;41(2):139-50.
6) See J Brown's interview with Neil Pearson at Neil Pearson—"Pain Science".
7) Adapted from Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9-15.
8) See Volker Busch et al., The Effect of Deep and Slow Breathing on Pain Perception, Autonomic Activity, and Mood Processing--An Experimental Study in Pain Medicine 2012; 13: 215-228.