Chronic pelvic pain (CPP) is a persistent, often disabling pain within the pelvis. Surprisingly common, CPP presents a major challenge to healthcare providers because of its unclear etiology, complex natural history, and poor response to treatment which tends to focus on symptomatic relief.
To further complicate the treatment of CPP, is its association with gastrointestinal, urinary, sexual, and menstrual symptoms, and a higher incidence of depression, anxiety, and sleep disorders. This grouping of problems calls for less of a biomedical approach which focuses on how the body alone contributes to illness and more of a bio-psycho-social approach which considers the people’s psychological and social factors along with their biology. Indeed, a multidisciplinary and integrative approach to CPP is needed to achieve significant improvement (1, 2)
Is yoga a bio-psycho-social approach? According to many scholars, yes! Yoga is indeed a biopsychosocial approach, essentially an approach that can address a person holistically, which has been demonstrated to help reduce chronic pain and improve well-being (3, 4, 5).
Can yoga be a helpful strategy for CPP? Yes! Clinical trials by Gonclaves et al 2017; Huang et al 2017; and Saxena et al 2017 have shown that yoga can help
significantly reduce pain and improve the quality of life in women with CPP (6, 7, 8).
At this point, you may be hoping that YogiAnatomy will follow in the footsteps of others and simply tell you “Top 5 Yoga Poses for Chronic Pelvic Pain”. But typically, that’s not what we do. We stay grounded firmly in the best-available scientific literature and hold onto the truth that people integrate their own biological-psychological-social factors in very personal ways.
So, for the rest of this article, we'll provide explanations of how yoga goes beyond the postures (asanas) and employs a biopsychosocial approach to help people manage their physical and mental health through an exploration of koshas, chakras, and vayus. But don’t worry, in a follow-up article, we’ll get to the postures (asanas) tested in the clinical trials (6, 7, 8)
Koshas
One way yoga addresses the bio-psycho-social model is through the concept of the Koshas. Many describe the koshas as 5 energetic layers or sheath of physical and mental being that are interwoven and interactive. What happens at one layer or level affects all the layers. In Sanskrit, the outermost layer is called Annamaya and is known as the physical body (bones, muscles, organs, etc.) The energetic layer is the Pranamaya Kosha and is composed of prana (life-force energy), which is governed by breathing practices (pranayama). The 3rd Kosha is associated with the mind, thoughts, feelings, and emotions and is called the Manomaya Kosha. The 4th or wisdom layer referred to as Vijnanamayer contains one’s higher intelligence or inner knowing and is where we develop deeper insight into who we are and how we relate to the world around us. The last energetic layer is the Anandamaya Kosha (Ananda meaning bliss) relates to one’s highest self or spirit where freedom and joyousness of one’s true nature can be realized.
Now let’s think about the Koshas relative to chronic pelvic pain (CPP). People with CPP may be helped by postures, exercises, and soft tissue treatments which address the physical body (Annamaya Kosha), but often this is not enough, because people with chronic pain are often also dealing with a change of prana (life force) energy and in this realm, Pranayama Kosha, breathing practices are indicated. Yoga includes many breathing practices that can address either the amount and/or flow of life force energy.
A combination of pranayama and asana practice may be enough to help people reach their goals. But if that’s not enough, the Manomaya Kosha, which addresses the mental or emotional body may need to be considered. From a yoga perspective, the recommended intervention might be chanting, a yoga practice that can strengthen the Manomaya Kosha.
And if a person is still striving to achieve their goals, a yoga approach would lead us to the Vijnanamaya Kosha otherwise known as the wisdom body. Here is where non-attachment and acceptance can be cultivated through meditation or other mindfulness-based techniques.
Chakras
We should also consider the effect the chakras can play in CPP. Chakras are energy centers and are thought to be at the crossroads of many energy channels and located along the central axis of the body.
Three of 7 chakras are located below the diaphragm and are commonly associated the chronic pelvic disorders. The first, or Root Chakra (Muladhara Chakra in Sanskrit) is located in the area of the perineum. The Sacral/Svadihishthana Chakra is thought to influence the ovaries, prostate, kidneys, and bladder, and the Solar Plexus/Manipura Chakra is located near the vicinity of the diaphragm. From an anatomical perspective it’s easy to appreciate the role the first 3 chakras can play in CPP and often specific postures/asanas and breathing practices are recommended to restore energy flow and balance through these chakras.
However, CPP can result in alterations of energy flow at any of the other chakras due to their interconnectedness. For example, the emotional strain of dealing with chronic pain can most certainly affect the relationship a person has with others (Heart/Anahata Chakra) and communicating their own thoughts and self-worth (Throat/Visudha Chakra) which can interfere with awareness and feeling connected to reality (Crown/Sahasrara Chakra). Energetic disruptions at these chakras may call for meditation in addition to or instead of certain asanas and breathing practices.
Vayus
Another component of a yoga tradition that we think is worth considering for people with CPP is the Vayus or winds. There are 5 Vayus that govern different areas of the body via the flow of prana (vital life force). When functioning harmoniously, they promote health and vitality of the mind, and similar to the Koshas and Chakras, when there is a disruption of energy flow, there can be poor health and dis-ease.
Image from https://sequencewiz.org/2014/09/03/5-vayus/
Based on their location and the movement of wind and energy, the Apana Vayu and Samana Vayu are often implicated in pelvic dysfunctions. The Apana Vayu is primarily located in the lower abdomen and genital area and is associated with functions of elimination (carbon monoxide, urination, defecation, menstruation, ejaculation, childbirth), and reproduction and bone health (regulating the absorption and retaining of minerals). Balance and flow of the Apana Vayu is important for a healthy mind and body with imbalances associated with constipation, diarrhea, IBS; menstrual, sexual, and reproductive issues; and urinary problems.
Samana Vayu is concentrated around the navel and governs digestion and assimilation of all substances including food, air, experiences, emotions, and thoughts. The Samana Vayu unites the upward energy of Prana and the downward energy of Apana creating a powerhouse in the core which supports self-confidence and the potential for real transformation. When Samana Vayu is functioning in a balanced way, it allows for wise and healthy choices, but when out of balance, metabolism issues, poor digestion, and bloating can occur.
To keep Apana and Samana Vayus in balance, breathing (pranayama) practices that focus on the exhale and engagement of the pelvic floor and abdominal muscles through certain asanas (postures) and activation of Mula and Uddiyana Bandhas.
We think it’s pretty clear that yoga encompasses the bio-psycho-social elements relevant to the management of CPP. Through the principles of Koshas, Chakras, and Vayus and the interventions including postures (asanas), breathing practices (pranayama), meditation, and chanting yoga is an approach worthy of consideration for people with CPP.
Stay tuned for more information about the asanas that have been studied in chronic pelvic pain.
References
(1) Centemero, A., Rigatti, L., Giraudo, D., Mantica, G., De Marchi, D., Chiarulli, E. F., & Gaboardi, F. (2021). The role of the multi-disciplinary team and multi-disciplinary therapeutic protocol in the management of chronic pelvic pain: There is strength in numbers! Archivio Italiano Di Urologia E Andrologia, 93(2), 211–214. https://doi.org/10.4081/aiua.2021.2.211
(2) Grossnickle, K., Wiley, S., Zipple, TJ., & Kegerreis, S. (2019). Experiences of Physical Therapists Working With Women With Chronic Pelvic Pain: A Phenomenological Qualitative Study. Journal of Women's Health Physical Therapy 43(2),61-72, DOI: 10.1097/JWH.0000000000000119
(3) Hapidou, E. G., & Huang, T. Q. A. (2022). East Meets West in Therapeutic Approaches to the Management of Chronic Pain. International Journal of Yoga, 15(1), 70–75. https://doi.org/10.4103/ijoy.ijoy_104_21
(4) Ross, A., Bevans, M., Friedmann, E., Williams, L., & Thomas, S. (2014). "I am a nice person when I do yoga!!!" A qualitative analysis of how yoga affects relationships. Journal of Holistic Nursing:, 32(2), 67–77. https://doi.org/10.1177/0898010113508466
(5) Evans, S., Tsao, J.C., Sternlieb, B., & Zeltzer, L.K. (2009). Using the Biopsychosocial Model to Understand the Health Benefits of Yoga. Journal of Complementary and Integrative Medicine, 6.
(6) Gonçalves, A. V., Barros, N. F., & Bahamondes, L. (2017). The Practice of Hatha Yoga for the Treatment of Pain Associated with Endometriosis. Journal of Alternative and Complementary Medicine, 23(1), 45–52. https://doi.org/10.1089/acm.2015.0343
(7) Huang, A. J., Rowen, T. S., Abercrombie, P., Subak, L. L., Schembri, M., Plaut, T., & Chao, M. T. (2017). Development and Feasibility of a Group-Based Therapeutic Yoga Program for Women with Chronic Pelvic Pain. Pain Medicine (18(10), 1864–1872. https://doi.org/10.1093/pm/pnw306
(8) Saxena, R., Gupta, M., Shankar, N., Jain, S., & Saxena, A. (2017). Effects of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. International Journal of Yoga, 10(1), 9–15. https://doi.org/10.4103/0973-6131.186155