Kathryn Ahuja PT, DPT RYT200 Patients with chronic pelvic pain (CPP) often ask, “Is there anything else I can do?” They have often been living with pain for a long time and are eager to feel better as quickly as possible. The truth is that there is no fast lane to healing CPP. Healing should integrate the biomechanical, psychological, and social factors, which can all play a part in your symptoms. Yoga can be a very effective way to address each of these players and move you towards increased freedom and function. Biomechanical factors: How can yoga help? Previous blog posts,Pelvic Pain Awareness Month Part 1: What is Pelvic Pain and Pelvic Pain Awareness Month: Part 2: Hope for Chronic Pelvic Pain have discussed how the muscles of your pelvic floor can lead to CPP. If you have lived with pain in the pelvis, genitals, reproductive and urinary organs, coccyx, or pubic bones for a long time, the pain can alter the way you move in everyday life. People with CPP tend to be less active than their peers, have altered postures, (usually with a more posteriorly tilted pelvis (a tucked tail bone) and an increased thoracic kyphosis (hunch in upper spine), and they tend to adopt ways of sitting or standing that is protective of their painful spots (Zhang 2015). It makes sense! Pain in this area of the body makes us just want to curl up in a ball and stay there! Being curled up like a cashew all day has a real influence on your pain. Our bodies are designed to move and when we stay in one place for a long time our joints get stiff, blood flow to and from our tissues is impaired, and the muscles that should help us stand tall become weak and tight. It can become difficult to actually differentiate the pain that is coming from your pelvic floor and the discomfort you may feel because of the adaptations you have made because of this pain. Practicing yoga poses called asanas is an effective, safe way to get you moving again. Standing poses like warrior II (Virabhadrasana II) and crescent lunge (Anjaneyasana) simultaneously lengthen and strengthen the muscles of your legs and hips. When these muscles regain their function, it can help your pelvic floor muscles to back off any chronic holding patterns. Backward bends like cobra (Bhujangasana) or camel pose (Ustrasana) help restore the natural curves of your spine while lengthening any tension in the abdominal muscles. This may make it a little easier to keep your body in an upright posture throughout your day. Supine stretches like butterfly (Baddha Konasana) or happy baby (Ananda Balasana) can help ease tension in the muscles of the inner thighs (adductors) while you are supported by the floor. When these muscles relax, there can be a noticeable reduction in pain since trigger points in the adductors can refer to the genitals and pubic bone. In a study performed in India, 30 women who attended a 1-hour yoga class five times weekly for eight weeks saw significant reduction in their pelvic pain ratings compared to the start of the intervention. These women also showed a significant reduction in pain scores compared to women who only took NSAIDS for pain relief over the same time. The researchers theorized that the intervention was effective not only due to the effects of the stretching and strengthening, but also because of the relaxation exercises which “modify neurological pain perception which could be the mechanism for pain reduction” (Saxena, 2017). This research suggests that yoga is doing something more than addressing the muscles. It may actually change the brains of those who practice.
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Psychological factors: How can yoga help? Ask any regular yogi and they will tell you that there is much more to the practice than just the asanas. It turns out, there is some really interesting science behind the feel good vibes you might experience after a yoga class. Yoga is different from many other forms of exercise because there is an intentional focus on your breath. In Hindu philosophy, prana means not only breath, but “life force.” It is believed that one’s breath has tremendous power and in performing pranayama (breathing exercises) we can strengthen and harness that energy. Today, we understand that breathing does more for our bodies than move air in and out and we have even greater appreciation for this ancient philosophy. You are probably familiar with the idea that slow, deep breathing can help to calm you down. The mechanism that drives this response is called the parasympathetic nervous system (PNS). Deep, slow breathing sends a message to your brain that you are not under a direct threat. The PNS then works to shift you out of “fight or flight” mode and into a calmer, more peaceful state. If you have CPP, your body might live in a constant state of fight or flight. Pranayama exercises have been shown to help quiet those signals and strengthen the signals from your PNS. With a consistent practice of slow, deep breathing you can actually shift your whole body towards a parasympathetic dominant state (Gerritsen, 2018). Depression and anxiety are common comorbidities for people with CPP. Yoga can help to shift your mood which may also have an effect on your perceived pain. A randomized control trial evaluated the levels of a neurotransmitter called GABA in people with Major Depressive Disorder (MDD) and in a healthy control group. GABA is an inhibitory neurotransmitter that helps to regulate important cortical functions including mood. When compared to the control group, those with MDD had significantly lower levels of brain GABA. After completing a 12-week yoga program however, there was no difference in these levels between groups. Even more importantly depressive symptoms decreased significantly in the MDD group and anxiety levels improved for both groups (Streeter, 2018). These stunning changes do not seem to be attributable to all forms of exercise. In comparison to people who walked for one hour, those who did yoga for the same amount of time had greater increases in GABA as well as improvements in mood scores (Streeter, 2010). While this study was small, it makes a great case for future research to determine if yoga may be a suitable alternative to medication for those with serious anxiety or depression. Social factors: how can yoga help? Persistent pain can have a profound effect on how you interact with the world. Symptoms of CPP are not visible to others and we tend to not talk about them with most friends and colleagues. Throbbing, aching, and stinging sensations can make you more irritable, less willing to put on certain clothing, or cause you to avoid aggravating activities. This can put a real strain on all your relationships. Emotional distress from fraying relationships can be difficult to manage when you are trying to heal and could even stress you to the point of making your symptoms worse. If you are limited in your daily functions or feel that your quality of life suffers due to CPP symptoms, there is evidence to support using yoga to intervene. Women with pelvic pain had improved emotional well being and sexual function scores after a 6-week yoga course consisting of about 3 hours of yoga per week. At the end of the program, 75% of the participants indicated they felt the yoga program was something they could continue to do without guidance (Huang, 2017). It can be quite empowering to feel like you have control of your symptoms and are not reliant on a doctor or PT to “fix” you. Additionally, a yoga class can be a nice way to socialize while doing something positive for your body. Yoga may not totally eliminate the pain you feel, but it may help you to manage your symptoms more elegantly. Breathing techniques can assist when symptoms strike at work. Mindfulness about your body can help you determine when it is appropriate to push yourself and when you need to rest. Mastering a tricky posture is very rewarding and may encourage you to open up to other novel challenges. Ready to give it a try? As with all new forms of exercise, if you are looking to try yoga for CPP you should seek out a class with a knowledgeable instructor who can offer modifications and cue your alignment appropriately. Start slow and never be afraid to ask your teacher a question if something does not feel right in your body. At first, the hardest part might just be learning to be still and breathe deeply: that’s ok, and it will get easier! Please consider joining me for our virtual yoga class every Tuesday at 7pm. Click here for more details. References Gerritsen RJS, Band GPH. Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Front Hum Neurosci. 2018;12:397. Published 2018 Oct 9. doi:10.3389/fnhum.2018.00397 Huang AJ, Rowen TS, Abercrombie P, et al. Development and Feasibility of a Group-Based Therapeutic Yoga Program for Women with Chronic Pelvic Pain. Pain Med. 2017;18(10):1864‐1872. doi:10.1093/pm/pnw306 Saxena R, Gupta M, Shankar N, Jain S, Saxena A. Effects of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga 2017;10:9-15 Streeter C, Gerbag P, Nielsen G, Brown R, Jensen JE and Marisa Silveri. The Effects of Yoga on Thalamic Gamma-Aminobutyric Acid, Mood and Depression: Analysis of Two Randomized Controlled Trials. Neuropsychiatry Journ. 2018;8(6). Streeter CC, Whitfield TH, Owen L, et al. Effects of yoga versus walking on mood, anxiety, and brain GABA levels: a randomized controlled MRS study. J Altern Complement Med. 2010;16(11):1145‐1152. doi:10.1089/acm.2010.000 Zhang R, Chomistek AK, Dimitrakoff JD, et al. Physical activity and chronic prostatitis/chronic pelvic pain syndrome. Med Sci Sports Exerc. 2015;47(4):757‐764. doi:10.1249/MSS.0000000000000472