Yoga for Chronic Pain and Central Sensitization

Pain Is Not Damage: The Revolution in Pain Science

The most important advance in pain science in the past three decades is the recognition that chronic pain is not a reliable indicator of tissue damage. Acute pain serves as a warning signal — a nociceptive alert that tissue is being damaged or threatened. Chronic pain, by contrast, often persists long after tissues have healed, reflecting a reorganization of the central nervous system itself rather than ongoing peripheral injury.

This reorganization — central sensitization — involves the amplification of neural signaling within the spinal cord and brain that produces pain hypersensitivity. Neurons in the dorsal horn of the spinal cord become hyperexcitable, responding to normal sensory input (touch, pressure, movement) as if it were painful. Descending inhibitory pathways from the brainstem that normally modulate pain signaling become impaired. Cortical pain networks expand, recruiting brain regions not normally involved in pain processing.

The result is a nervous system that has learned to produce pain — independent of peripheral damage. This is why structural imaging (MRI, X-ray) so often fails to correlate with pain severity: the problem is not in the tissues but in the neural processing of sensory information from those tissues.

Yoga addresses chronic pain at the level of the central nervous system — not by “treating” damaged tissues but by retraining the neural circuits that process and amplify pain signals. The evidence base for this approach is substantial and growing.

The Evidence: Key Trials

Low Back Pain: Saper et al. (2017)

Saper et al. (2017) published a landmark randomized controlled trial in JAMA Internal Medicine comparing yoga, physical therapy, and education for chronic low back pain in 320 predominantly low-income, racially diverse adults. Key findings:

• Yoga was non-inferior to physical therapy for pain reduction and functional improvement at 12 weeks
• Both yoga and physical therapy were superior to education alone
• At the 52-week follow-up, yoga and physical therapy maintained their advantages
• Yoga participants reported greater use of non-pharmacological pain management strategies at follow-up, suggesting a lasting change in pain-coping behavior

The significance: yoga matches the gold-standard physical rehabilitation for the most common chronic pain condition, while additionally providing autonomic, psychological, and social benefits that physical therapy alone does not.

Fibromyalgia: Carson et al. (2010)

Carson et al. (2010) conducted a randomized controlled trial of Yoga of Awareness (an 8-week program combining postures, breath, meditation, and didactic content) for fibromyalgia — a condition defined by widespread pain, fatigue, sleep disturbance, and cognitive difficulties, with central sensitization as its primary mechanism.

Results:

• Significant improvements in pain, fatigue, and mood compared to waitlist control
• Improvements in pain catastrophizing — the tendency to magnify, ruminate on, and feel helpless about pain
• Improvements in pain acceptance — the willingness to experience pain without avoidance or struggle
• These psychological changes (reduced catastrophizing, increased acceptance) mediated the improvements in physical symptoms, confirming that the mechanism is central (neural/psychological) rather than peripheral (tissue-based)

Arthritis: Moonaz et al. (2015)

Moonaz et al. (2015) studied yoga for osteoarthritis and rheumatoid arthritis in a randomized controlled trial and found improvements in physical function, pain, and disease activity scores. Notably, the yoga intervention did not exacerbate joint inflammation — addressing the legitimate concern that physical activity might worsen inflammatory joint conditions.

Mechanisms: How Yoga Retrains the Pain Brain

1. Descending Pain Modulation

The brainstem contains descending pain-modulatory circuits — the periaqueductal gray (PAG), rostral ventromedial medulla (RVM), and locus coeruleus — that can either amplify or suppress pain signals at the level of the dorsal horn. In chronic pain, the balance shifts toward facilitation: descending signals amplify rather than dampen pain.

Yoga may restore inhibitory descending modulation through:

• Vagal afferent activation: The vagus nerve projects to the nucleus tractus solitarius (NTS), which connects to the PAG and RVM. Vagal stimulation through breathing practices activates the descending inhibitory pathways.
• Endogenous opioid release: Deep relaxation, meditation, and the sustained mild physical effort of asana promote the release of endorphins and enkephalins — the body’s natural analgesics — which activate descending inhibition through mu-opioid receptors in the PAG.
• Serotonergic modulation: The RVM uses serotonin as its primary neurotransmitter for descending pain modulation. Yoga’s effects on serotonin metabolism (through exercise, breath, and cortisol reduction) may influence this pathway.

2. Cortical Reorganization

Chronic pain is associated with measurable changes in brain structure and function:

• Gray matter loss in the dorsolateral prefrontal cortex (dlPFC), which is involved in top-down pain regulation
• Expansion of pain-related cortical maps in the somatosensory cortex — the brain devotes more neural real estate to the painful region
• Increased connectivity between the DMN and pain-processing regions, producing the ruminative quality of chronic pain (“thinking about pain”)

Villemure et al. (2015) found that experienced yoga practitioners had greater gray matter volume in multiple brain regions compared to matched controls, including regions involved in pain modulation (insular cortex, cingulate cortex). This suggests that yoga practice protects against — or reverses — the cortical atrophy associated with chronic pain.

3. Interoceptive Recalibration

Interoception — the perception of internal bodily signals — is distorted in chronic pain. The insular cortex, which processes interoceptive information, becomes hyperactive to pain-related signals and hypoactive to other bodily signals. The result is a perceptual field dominated by pain, with reduced awareness of neutral or pleasant sensations.

Yoga asana practice systematically recalibrates interoception by:

• Directing attention to non-painful body regions during body scanning and asana practice
• Providing the experience of the body as capable, strong, and functional rather than fragile and damaged
• Training the capacity to notice sensation without automatically categorizing it as painful
• Enhancing insular cortex function through the interoceptive demands of balance, proprioception, and breath awareness

4. Autonomic Regulation

Chronic pain is associated with autonomic dysregulation: reduced heart rate variability, elevated sympathetic tone, and impaired parasympathetic function. This autonomic imbalance contributes to pain through:

• Increased inflammatory signaling (sympathetic activation promotes pro-inflammatory cytokine release)
• Reduced endogenous analgesia (parasympathetic activation is required for descending inhibitory pathway function)
• Impaired sleep (sympathetic dominance prevents the deep sleep stages in which tissue repair and pain processing occur)
• Muscle tension (chronic sympathetic activation maintains muscular hypertonicity that produces secondary pain)

Yoga’s well-documented effects on autonomic regulation — increased HRV, reduced sympathetic tone, enhanced vagal function — address the autonomic component of chronic pain directly.

5. Psychological Mechanisms

Pain is not merely a sensory experience. It is a sensory-emotional-cognitive event. The same nociceptive signal can produce dramatically different pain experiences depending on the emotional and cognitive context. Fear amplifies pain. Catastrophizing amplifies pain. Acceptance reduces pain. Distraction reduces pain.

Yoga addresses the psychological amplifiers of pain through:

Pain catastrophizing reduction: Carson et al. (2010) found that reduced catastrophizing was a primary mediator of pain improvement in fibromyalgia patients. Yoga cultivates the experience of present-moment awareness without catastrophic interpretation — “this is sensation” rather than “this pain is destroying my life.”

Self-efficacy enhancement: The progressive mastery of yoga postures builds the belief that the body is capable and resilient. This self-efficacy counteracts the learned helplessness that chronic pain produces.

Acceptance: Acceptance and Commitment Therapy (ACT) for chronic pain emphasizes acceptance of pain as a present-moment experience rather than resistance to it. Yoga’s meditative components cultivate exactly this acceptance — the willingness to be with what is, including discomfort, without struggle.

Fear-avoidance reduction: The fear-avoidance model of chronic pain (Vlaeyen & Linton, 2000) proposes that fear of pain and re-injury leads to avoidance of movement, which leads to deconditioning, which leads to more pain. Yoga breaks this cycle by providing a graduated, safe context for re-engaging with movement. The practitioner learns experientially that movement does not equal damage — the most important lesson in chronic pain rehabilitation.

Condition-Specific Protocols

Low Back Pain

Avoid: Deep backbends, unsupported forward folds, any pose that produces sharp or shooting pain

Emphasize:

• Cat-Cow (Marjaryasana-Bitilakasana): Gentle spinal flexion-extension mobilizes the lumbar segments, promotes disc hydration, and reduces protective muscle guarding
• Supported Bridge (Setu Bandha Sarvangasana): Strengthens gluteals and spinal extensors — the muscles that support the lumbar spine
• Modified Warrior poses: Build lower body strength and hip mobility without compressive lumbar loading
• Supine twists: Gentle rotation promotes disc hydration and reduces lateral muscle asymmetry
• Pranayama with emphasis on diaphragmatic breathing: The diaphragm shares fascial connections with the psoas and lumbar spine. Restoring diaphragmatic function reduces the compensatory breathing patterns that strain the lumbar spine.

Fibromyalgia

Avoid: Vigorous practice, rapid transitions, competitive or demanding class environments, any practice that produces post-exercise malaise

Emphasize:

• Restorative poses: Supported Savasana, Supported Child’s Pose, Viparita Karani — practices that promote deep parasympathetic rest without physical demand
• Gentle movement: Slow, flowing sequences at the practitioner’s own pace, with permission to rest at any time
• Breath practices: Extended exhalation breathing, Nadi Shodhana — gentle vagal toning
• Yoga Nidra: The theta-state consciousness modulates central sensitization and promotes the deep rest that fibromyalgia patients are chronically denied
• Warm environment: Warmth reduces muscle guarding and promotes parasympathetic activation

Migraine and Headache

Avoid: Inversions during active migraine, Kapalabhati (which can increase intracranial pressure), poses that compress the cervical spine

Emphasize:

• Neck and shoulder release: Gentle stretches for the upper trapezius, levator scapulae, SCM, and suboccipital muscles — the muscles that create the cervicogenic component of many headaches
• Forward folds with head support: The head rests on a bolster or block, promoting venous drainage from the head without active inversion
• Cooling pranayama (Shitali): Inhale through the curled tongue, exhale through the nose. The cooling effect may reduce vascular inflammation.
• Shavasana with eye pillow: Blocks light (a common migraine trigger) and promotes relaxation of the frontalis and orbicularis oculi muscles

Polyvagal Theory and Chronic Pain

Chronic pain traps the nervous system in a state that Stephen Porges would recognize as defensive mobilization (sympathetic) or collapse (dorsal vagal) — neither of which permits healing. The sympathetic state produces muscle tension, inflammation, and hypervigilance. The dorsal vagal state produces fatigue, dissociation, and the withdrawal from life that chronic pain enforces.

Recovery requires the transition to ventral vagal engagement — the state of safety, social connection, and optimal function. Yoga facilitates this transition through:

• Co-regulation: Being in a yoga class with a calm teacher and other practitioners provides the social nervous system engagement that shifts the autonomic state
• Vocal practices: Chanting, humming, and extended exhalation with sound activate the pharyngeal and laryngeal muscles innervated by the ventral vagal complex
• Breath regulation: Slow, extended-exhalation breathing directly activates the vagal brake
• Predictability: A consistent practice with familiar sequences signals safety to the brainstem

TCM and Functional Medicine Perspectives

In traditional Chinese medicine, chronic pain is typically diagnosed as Qi and Blood stagnation — the vital energy and circulatory force have become stuck, producing the aching, heaviness, and stiffness that characterize chronic pain conditions. “Where there is no flow, there is pain; where there is flow, there is no pain” is a fundamental TCM aphorism.

Yoga moves Qi and Blood through:

• Physical movement (the most direct way to move stagnation)
• Deep breathing (Qi moves with breath)
• Heat generation (Blood flows more freely when warm)
• Emotional release (Liver Qi stagnation, which often underlies chronic pain, is released through movement and expression)

From a functional medicine perspective, chronic pain is investigated through multiple lenses: inflammatory markers, nutrient status (vitamin D, magnesium, omega-3 fatty acids), gut health (gut inflammation produces systemic inflammation that amplifies pain), sleep quality, hormonal balance (cortisol, estrogen, progesterone), and mitochondrial function. Yoga synergizes with each of these interventions by providing the autonomic, inflammatory, and psychological conditions in which they can work most effectively.

The Four Directions

Chronic pain is a disorder of being trapped — trapped in the body, trapped in the present moment of suffering, trapped in the fear of future pain, trapped in the grief for the pain-free past.

The Four Directions offer pathways out:

• East: New beginning. The first pain-free moment in a yoga class — even just one breath of relief — is a sunrise. It proves that the body can feel something other than pain.
• South: The body as ally, not enemy. Chronic pain turns the body into the adversary. Yoga reconnects the person with the body as a source of sensation, strength, and pleasure — not only pain.
• West: Letting go of the fight against pain. Resistance amplifies pain. The West teaches surrender — not to the pain, but of the resistance to it.
• North: The long view. Pain is a signal, not a sentence. The elder’s wisdom sees that this too shall pass, that seasons change, that the body heals when given the right conditions.

References

• Carson, J. W., Carson, K. M., Jones, K. D., Bennett, R. M., Wright, C. L., & Mist, S. D. (2010). A pilot randomized controlled trial of the Yoga of Awareness program in the management of fibromyalgia. Pain, 151(2), 530-539.
• Moonaz, S. H., Bingham III, C. O., Wissow, L., & Bartlett, S. J. (2015). Yoga in sedentary adults with arthritis: effects of a randomized controlled pragmatic trial. Journal of Rheumatology, 42(7), 1194-1202.
• Saper, R. B., Lemaster, C., Delitto, A., Sherman, K. J., Herman, P. M., Sadikova, E., … & Weinberg, J. (2017). Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Annals of Internal Medicine, 167(2), 85-94.
• Villemure, C., Ceko, M., Cotton, V. A., & Bushnell, M. C. (2015). Insular cortex mediates increased pain tolerance in yoga practitioners. Cerebral Cortex, 24(10), 2732-2740.
• Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317-332.