Have you ever experienced an injury or ailment that left you feeling completely powerless?
I’ve been teaching yoga now for over a decade, driven by a passion to help others access the joy, empowerment, and connection I felt through my practice. About two years ago, my relationship to my practice completely changed. I still teach, and I still love to teach, but my approach has totally changed. Why? Persistent pain.
From what seemed like a “fender bender,” I’ve experienced a complete change in sensation, mobility, and function in my neck, torso, and left shoulder. I know I’m incredibly lucky, and this is minor compared to what a lot of people go through, but it’s been deeply humbling and has changed my life in a lot of ways.
I experienced firsthand the all-encompassing feeling of physical discomfort that seemed impossible to resolve. I went through the moods, thoughts, emotions, shifts in identity, and life changes that accompany this experience.
I discovered that there is a whole field of pain science! Brilliant and innovative physiotherapists, yoga therapists, and researchers have been exploring for years how we can understand persistent pain from holistic and integrated perspectives. At the forefront of this movement is Neil Pearson, physical therapist, clinical assistant professor, certified yoga therapist, author, and founder of Pain Care U.
Contributing to many written publications, clinical education, and yoga therapy programs, Neil has been helping individuals and health professionals integrate and evolve their understanding of pain for over 30 years. He is a lead researcher in pain neurophysiology and pain management education.
Most recently, Neil has collaborated with Shelly Prosko, Marlysa Sullivan, and nine other leading-edge doctors, psychologists, physiotherapists, and yoga therapists to create the book, “Yoga and Science in Pain Care: Treating the Person in Pain.”
One of the most exciting things for human evolution is when scientific study and ancient yoga philosophies coincide. The teachings passed down through the ages, when practiced with faith and devotion, allow us to understand and manage our “human-ness” and navigate our way through life’s challenges with grace. But (especially here in the West), we often want a tangible explanation for our experiences. The path to growth and change is intricate, complex, and varies for every individual.
This book takes all of this into account. To understand the science, the lived experience of pain, and the essence of non-pharmacological pain care, this book is a must-read. It demonstrates the potential within the philosophy and practices of yoga to empower, educate, and assist people in pain. Whether the pain is attributed to an event, a disease, or a specific condition, the practices, techniques, rituals, and paths of yoga can provide benefits. Yoga therapy, integrated with pain science and a holistic approach to recovery, helps to decrease the pain itself, enhance ease of movement, and improve quality of life. It supports a heightened sense of well-being for people living in pain and allows individuals to reconnect with their dharma and to peace.
It was an honor to interview Neil. We talked about the inspiration for the book and his experiences as a compassionate clinician over the years working with people in pain.
Read on to learn more!
1. What originally drew you to study pain science and ultimately inspired you to write this book?
Early in my career as a physical therapist, I met many people whose experiences made no sense based on what I learned in school about pain, injury, and healing. It made me curious—especially whether what I learned in school was wrong. Unfortunately, in the 1980s, there were no courses on pain and few books. So I started to pay attention to what people said about it in different aspects of health care, what science was reporting about it, and, most importantly, what my patients told me about it. The latter continues to be my primary teachers about pain.
Writing this book was a way for my colleagues and I (three physical therapists, certified in yoga therapy with special interests in research and pain care) to combine what we have learned from people living in pain and from our professional colleagues, from our personal experiences with yoga as a pain care modality, and from current scientific evidence and theory. We all felt there was enough evidence and enough interest to advance the field of yoga therapy as integrated with current health care, and as a parallel path of pain care for some people.
2. I loved this quote from the first chapter by Joletta Belton, sharing the perspective of how it feels to live with persistent pain: “We need to feel safe—physically, emotionally, cognitively. You can provide safety. We need to know we are adaptable, resilient, and capable.” (P. 36) Given this understanding of the needs of a person in pain, do you think a radical change in perspective on behalf of the health care practitioner is necessary?
Given everything we know about this topic, the answer is a resounding YES.
In some areas, it is not so radical, yet in most areas of health care and yoga training, an integrated view of pain care is missing. Joletta is pointing out not only the importance of safety, but that safety is not just a physical thing or a cognitive factor. In addition, there is a huge gap between beliefs and language. Practitioners may understand that humans are adaptable, resilient, and capable, yet the language we use with patients and our behaviours can convince patients that they are broken. When we tell people all the things they should avoid doing “to protect the body,” and provide no instruction on how to improve health and function, we inadvertently increase fear and limit potential.
3. In your discussion of challenges that we face today, there is a lot of mention about shifting away from the ‘bad parts/fix it’ model. What do you think is the most effective way to create a paradigm shift in this approach? Do you think each person has to ‘get it’ on their own, or can the entire system shift?
We joke that ‘all we need to do’ is simply change pre-licensure education, update the knowledge and practice of all current professionals, provide a new paradigm to the public, align health insurance procedures, shift research funding, and modify government health policies.
I don’t know how to shift the entire system. It would help if we taught all health professionals—including yoga therapy students and yoga teachers—about pain neurophysiology differently. We need to allow them to reconceptualize pain as more than a tissue health meter, and then to apply this knowledge to their work.
Part of the problem—even when we do this well—is that many health practitioners and yoga teachers follow up on their education by completing internships with mentors who hold outdated views of pain and recovery. These people have extraordinary influence, can pass/fail the student, and their knowledge and behaviours might negate the student’s more up-to-date view of pain and pain care. This is just one example of the difficulties and complexities. Similarly, some professionals have shifted their paradigm but don’t know how to communicate this to the patient, or how to morph their care.
Pain is complex, and it is multifaceted, yet when there is pain, we tend to attribute it to the body as if we view the body as a machine, or we might ignore the body and talk about psychology. Occasionally, social influences are discussed but rarely do we hear more integrated discussions. Our pain is a human experience, influenced by every aspect of our existence.
One of the great things about yoga is that we experience it. These experiences are educational moments or opportunities that are, at times, more powerful than learning from a book or listening to a teacher. And many times our experiences in yoga are inconsistent with our beliefs about pain. This can open the door to curiosity, cognitive dissonance, and thinking new thoughts about what we think about pain.
For example, repeatedly experiencing that a breathing practice results in being able to move one’s neck with more ease is evidence that pain can be changed and movement improved without ‘fixing’ the body. Beliefs can be powerful, and we should not expect them to change quickly. Even when new experiences are inconsistent with beliefs, many new experiences may be required.
4. In your discussion of Jnana yoga and developing knowledge and wisdom, it’s mentioned that for effective treatment in pain care: “Facts are not disregarded, but belief is questioned. Certainty is not as important as curiosity and inquiry.” (P. 72) In the current paradigm, health care workers are expected to know the answers in terms of diagnostics and treatment, with certainty. Can you share some examples of how you’ve been successful working with clients and helping them open their minds to uncertain outcomes, while still maintaining the integrity of your profession?
This is another example of the barriers to changing paradigms: Who wants or will accept a paradigm in which “I don’t know” is okay, especially after years of being told that the best clinicians are the ones who know? The concept of, “The only way to provide effective treatment is to know what is wrong” is flawed logic that we are taught over and over throughout our lives.
It is not the integrity of our profession that needs to be maintained—what we need are processes and values that promote evolution.
Pain is far too complex to know with precision what makes it occur or what makes it persist. This doesn’t mean we are blind, it just means that humility would help the practitioner be able to help the person in pain more, as well as an understanding that the best care is a combination of clinician expertise, ability to engage the ‘expertise’ of the patient, and re-assessing the effects of any new plans/interventions.
How to help patients be okay with uncertain outcomes? In my practice I rarely see people who have not already experienced exactly this—they have been told something will work and it has not.
Patients often explain to me how they have found some things that help through trial and error. According to one patient, “When my pain is really bad, the best thing I can do is get in the bath with the water at just the right temperature, pour in epsom salts, use aromatherapy, gaze at a candle, and calm my mind with extended exhale breath.” This solution was not based on certainty, but it shows our ability to find solutions amidst uncertainty.
Other times I will tell patients of the many different ways health professionals assess for low back pain, and the many different treatment plans. One person seeing 10 experts could get 10 different diagnoses, and 10 different treatment plans. And the person might get better from all or many of them.
The point is to try to find examples that make sense to an individual in order to explain that a perfect diagnosis is not required to help most people get better.
We can learn a lot from practitioners who use story and metaphor in their clinical practice, what is often called narrative medicine. In the book, the Jnana chapter explores the idea that the experience of yoga can provide a new narrative or story for the person living in pain.
5. One of the concepts in yoga philosophy that comes up often in this book is the idea of letting go—surrendering. There’s a recommendation for both the person in pain and the health care practitioner to trust the process and hold unwavering faith in the body’s inherent wisdom. For someone new to yoga—and experiencing a wide spectrum of emotion in relation to their pain—how do you begin to cultivate this sense of faith and surrender?
This is a great question. First though, I think it’s important to point out to readers that ‘the body’s inherent wisdom’ is not talking about magic, and it is not suggesting that the human physical body can do this all on its own. There are mechanisms of healing and recovery and resilience and plasticity.
Much of this takes place below our usual awareness, otherwise known as the autonomic processes, i.e. our breathing, muscle tension, sweating, and heart rate (which is usually below consciousness). But there are times when these processes need our conscious involvement to succeed. Our conscious actions and inactions—whether these are classified as physical, cognitive, emotional, social, or spiritual—influence resilience, recovery, and healing. One of our problems is that protective mechanisms ‘tell us’ to change our behaviour, but they do not necessarily tell us what is wrong, or precisely what behaviour to change.
I also want to state that we need to be careful with ideas such as “practice and all is coming.” This has led many to continue with practising when it was not serving them, not helping them recover, and at times worsening issues related to the body, mind, and heart.
How to cultivate surrender and faith? I don’t think there is one way. I think this cultivation is one process amongst many that can assist in a person’s path to less suffering.
6. The science on pain biology and sensation is fascinating. It was pivotal to my experience with persistent pain when I began to understand the definition of pain: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” (P. 83) In your experience, is it difficult for people to really understand and assimilate this concept?
This concept may be easier to understand: “The first increase in pain is never tissue damage.”
The harder part is when movement increases pain—or, as you state, the assimilation is more difficult. In my experience, I need to show an individual or guide them in an experience of movement that temporarily increases pain, but does not leave it provoked. Yet it is not simple or quick to change for most. We often need to convince ourselves over and over again through repeated experiences that it’s okay and safe to challenge the edge of the increased pain to understand and truly know that this increase in pain is not a signal that the body is being damaged.
7. You mention: “Pain is produced not only by sensory inputs, but also by activity related to cognitions, emotions, voluntary and involuntary movement, and stress.” (P. 102) Based on this understanding, it seems the process of working with pain is an ongoing commitment from both the practitioner and the person in pain. Each individual needs to show up with a willingness and open mind to participate deeply in the process of their own healing. How do you help people really ‘get’ this? (The difference between making sense of it cognitively and really feeling it on a cellular, somatic level?)
Some refer to this as deep understanding. Knowing is one thing, but having an ‘embodied’ experience is much more.
It isn’t that the person in pain is obliged to show up in a certain way. It is the health care professional’s responsibility to guide the individual, usually at the beginning to curiosity, to trying new things, and to exploring in more depth.
Historically speaking, people in pain have believed, and many health professionals have confirmed for them, that: “If there is pain in the body, something needs fixing, or we need to cover it up.”
It is far more complex than that.
One way to think about helping people “get it” is to consider that our work is to provide individuals with experiences that are different from their previous beliefs about pain and recovery, or their previous experiences that something is dangerous. Story and metaphor can be used for this, as can yoga and contemplative practices such as meditation.
8. When pain persists, does this mean that somewhere, on a subconscious level, our body feels unsafe? In your experience, has cultivating a sense of safety and participating in practices that regulate the nervous system been helpful for people with persistent pain?
I am not certain that the feeling of ‘unsafe’ is coming from the body—or if that is what you asked.
I would feel more certain to state that when pain persists, human mechanisms are acting to get us to stop or change our behaviour. It is tempting to jump into why this is occurring, but I don’t know if it is as simple as the body not feeling safe.
In my experience, helping individuals regulate breath, body (awareness, tension, movement), thoughts, emotions, and relationships is helpful.
For some people, the concept of increasing evidence of safety really makes sense—but not for everyone. For some, actively working on increasing a sense of safety, whether it is influencing fight and flight, enhancing social engagement, or reconnecting to peace, love, and joy can be quite powerful.
9. It’s mentioned that “Offering an experience of equanimity, tranquility, peace, ease, or connection alongside the experience of pain has the potential to shift and broaden the individual’s perspective and to create a different relationship to sensation.” (P. 116) I wholeheartedly agree with this! How do you begin if someone’s pain is really intense and stillness or deep breathing are not available to them?
I would start by listening and love through holding space—I think most call this compassion. These are often considered as ingredients that make other techniques successful, but when pain is intense, they are what is needed.
An important question is: What does it take for an individual practitioner to know what to do in situations like this? How much experience, training, and knowledge…?
Had I not worked in hospitals and watched nurses and palliative care professionals in the neonatal ICU (NICU), adult ICU, and cardiac care, would I know?
10. It seems a large part of working with pain is becoming educated on the processes in the body that stimulate the pain response. These processes are often autonomic and below our conscious awareness. If we slow down enough, are we able to make some of these autonomic processes conscious and facilitate lasting change? Can you share an example of how you have facilitated this process?
This is an area in which language is difficult—pain requires consciousness I think.
It seems that we can learn to become aware of more subtle sensations and perceptions, that we can learn to be more discerning about what’s happening, and learn that we have some influence over pain and pain-related responses.
As an example, the practices of being present, in this moment, can help us slow down and learn how to focus on what we want and on more subtle experiences and sensations.
11. One of the things I love about the approach in this book is the acknowledgement of the whole person and the lived experience of pain, relating it to the Kosha model in yoga philosophy. (P.80) This invokes the understanding that each person is made up of the physical body, the energy body, the mental and emotional body, as well as a higher mind and inner connectedness. How does this affect the way you work with your clients?
The simplest view is that this perspective includes that we are integrated. Any change in one aspect of us potentially changes all, or one aspect cannot be changed without changing all. We can change any aspect of existence by working with any other aspect.
With clients, the first thing is to hold this perspective as an important consideration.
The second is to help move away from providing therapy for the body via the body and for the prana through prana, etc.
We can use the physical body to influence all other aspects, the mental and emotional body to influence all others. We can use a yoga posture as much more than a ’physical’ intervention, and a prana or breathing practice to impact more than prana.
12. A cornerstone of Yoga Philosophy that comes up often in this book is the idea of connecting to an ever-present source of wisdom at our core—where we can observe the changing fluctuations in the body, mind, and environment. Would you say that the process of healing is not always about changing the sensation or experience, but about becoming empowered to choose how we focus our energy and attention, and therefore changing our relationship and understanding of what is being felt?
I think that pain care includes becoming more aware and discerning, increasing our ability to influence sensation and experience, as well as becoming more able to identify what is important and how to focus on it. All these things could be categorized as ‘changing our relationship.’
13. Thich Nhat Hanh said, “Breath is the bridge which connects life to consciousness, which unites your body to your thoughts.” It makes sense that breathing practices would be an important part of bringing more awareness and understanding to the pain cycle. Can you share how you’ve been able to effectively use breathing techniques in your practice?
I don’t know enough about consciousness to address this part.
I use breathing techniques to help people be more present, improve their ability to focus and concentrate, influence their energy, change their thoughts and emotions, feel stronger, lighter, calmer… And most of all to help people move with more ease.
14. Given the complexity of pain and the uniqueness of each individual experience, do you think it’s effective for therapeutic yoga practices to occur in a group setting, or do they need to be individualized treatment plans?
There are benefits to both. Classes potentially provide more support, social engagement, and greater accessibility.
I prefer to see people 1-1 before they come to my therapeutic classes. It’s for their sense of safety and ease, as well as my own. It helps to build an alliance and it helps me to know how to guide people.
15. If you could share one key message with someone who is living in persistent pain, what would it be?
The first thing that always comes to mind is ‘there is hope’. This of course can sound ridiculous and arrogant.
So I will suggest that curiosity might be one of the most important messages: Be curious about new ways to understand pain and to approach pain care, and curious about the paths which have helped others.
After 35 years as a PT, I still learn new things and new approaches from people living in pain and other health professionals committed to sharing their experiences.
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Whether you are experiencing persistent pain yourself, are a health professional or bodyworker, or have loved ones who are dealing with pain, there are incredible resources available to understand pain and shift the inner experience for yourself and those you work with.
In my personal journey with persistent pain over the past two years, I’ve used many of the principles and practices from Neil’s work. Understanding that pain is not always indicative of tissue damage has been pivotal in my experience. Becoming educated about how the body and brain work to label an experience or sensation as dangerous has allowed me to work with the level of reactivity in my body and mind.
In one of Neil’s free “Gentle Movement at Home” videos, he teaches simple and slow movement exercises, pausing right at the edge of reactivity and finding an inner knowing at that place: “If I stay right here, I’m going to be alright.” This is subtle yet powerful. I’ve also used mirror work and visualization and have been able to successfully change my experience. Our bodies and brains are incredible, and understanding how they work is an invaluable resource!
Learn more about Neil Pearson’s work and Pain Care U here.
You can access one of Neil’s free online resources to help you move with more ease at www.lifeisnow.ca. Click on ‘First 5 Steps free’ to learn more about pain, receive instructions in awareness and regulation, and then integrate this into a new approach to recovering ease of movement.
Pain Care U has generously created some free and discounted resources if you are working with pain during COVID-19 and are unable to access regular treatment. Find those resources here.
Get the book here. If you’re outside of Canada or looking for the kindle version, the book is available here.
Edited by Jordan Reed