Welcome back to the Healing Pain Podcast with Marlysa Sullivan, PT, DPT
On this episode, we’re exploring the significance of Polyvagal Theory on autonomic resilience as it pertains to the management of chronic pain. Our expert guest is Dr. Marlysa Sullivan. She is an assistant professor at the Maryland University of Integrative Health in both yoga therapy and health promotion. She’s also an adjunct professor at the Emory University in the Doctor of Physical Therapy program where she teaches the integration of yoga and mindfulness in physical therapy. She has a new book out which is co-edited with physiotherapists, Shelly Prosko and Neil Pearson called Yoga and Science in Pain Care, which we’ll be discussing through the lens of Polyvagal Theory. As a researcher, Marlysa has also contributed to the evidence base with regard to yoga therapy and Polyvagal Theory. If you’d like to get a taste of Dr. Sullivan’s work with regards to yoga therapy and Polyvagal theory, she has provided a free download of her paper.
The paper’s called Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience. To download this paper, all you have to do is text the word, 157Download, to the number 44222. You can also open up a new browser on your computer and type in www.IntegrativePainScienceInstitute.com/157download. Before we begin, make sure you take a moment to join the Integrative Pain Science Institute and the Healing Pain Podcast community Facebook group. Here you’ll be able to connect with like-minded health professionals from the world of physical therapy, psychology, occupational therapy, medicine, nursing. Almost every profession is part of this group and you can connect with them with regard to integrative pain care and what’s happening in the world of integrative pain science. To join that group, just go to www.Facebook.com/groups/IPSICommunity. You can send me a quick email. My email address is Joe@IntegrativePainScienceInstitute.com and I’ll send that link to you. Sit back, relax and let’s get ready to learn about Polyvagal Theory and pain science with Dr. Marlysa Sullivan.
Watch the episode here:
Pain Science, Polyvagal Theory And Autonomic Resilience With Marlysa Sullivan, PT, DPT
Marlysa, welcome back to the show. It’s great to have you here.
It’s great to be here. Thanks for having me.
You were on the show way back in episode number six. You spoke to us and shared some great information about the topic called the social domain of pain and health. I know you’re back with lots of great information. You’ve written a paper with Stephen Porges around Polyvagal Theory. I definitely want to talk to you about that. You’ve also written a good book that you’re going to be talking about now, Yoga and Science in Pain Care. You wrote that with Shelly Prosko who I’ve interviewed and Neil Pearson, who will be on soon as well. We’ve got a lot of ground to cover here. I’m excited that you’re here. Let’s start with the paper first. We’re going to talk about the book but let’s talk about the paper that you did with Stephen Porges who’s known for Polyvagal Theory.
To give a little background of Polyvagal Theory and as far as the paper with him, what we wanted to look at was the correlation and connection between what Polyvagal Theory is teaching and with yoga philosophy, to show and to shed light on the underlying foundations of yoga for being able to speak with them through a neurophysiological lens. It’s not saying that they’re the exact same thing but offer this translatable language so that people can begin to understand how yoga therapy works to facilitate health and well-being. In Polyvagal Theory, I don’t know how familiar people are with it, but there’s this idea of it provides complexity and nuance to the autonomic nervous system. A lot of times people think about parasympathetic-sympathetic as this dichotomous, antagonistic relationship.
What Polyvagal Theory looks at is how that’s not the case. We have a continuum of autonomic responses. We have this optimal parasympathetic state where we can engage with other people. We perceive our environment as safe. We have physiological restoration. We have emotion such as calm, peace, equanimity and behaviors like compassion and connection to others. We can have what’s called safe mobilization, which is when we still perceived safety, but we’re mobilized in our system. This would be something like dancing or playing a sport or any creative endeavor where your sympathetic nervous system is activated, but it’s not overwhelming that sense of connection and safety. Then you have the fight or flight. From the fight or flight, you have what’s called safe immobilization, which is when we begin to experience more and more stillness, but we still perceive safety. This happens in meditation when you begin to get still, quiet and calm but you still have safety. The last phase or stage that Stephen talks about is defensive immobilization. This is like death feigning.
The example is always where a cat catches a mouse. The mouse’s blood pressure and heart rate drops low, the cat thinks it’s dead and lets it go, and the mouse runs away. In severe trauma, we can experience an immobilization within our system and a shutting down or dissociation. In his theory, by affecting the autonomic state, we affect physiology, psychology and behavior concurrently. Yoga has a reflective theme, which speaks to this idea that everything in our body, our mind and the world around us is changeable. All of those changeable aspects of ourselves are made up of these three qualities of the Gunas as opposed to that unchanging essence of who we are. Everything in our body, our mind, the world around us is constantly fluctuating. It has very similar Gunas or qualities that are named, that has more clarity, that of activation or that of stillness. In terms of yoga philosophy, we might talk about activating and cultivating a Guna. Whereas in the autonomic nervous system, we would talk about activating a neural platform.
I love those five aspects of Polyvagal Theory because people think, “It’s fight or flight,” and that’s it. It’s either on or off. It’s like yes or no. In some ways, what do you do with that as a practitioner if you have no control over that? Someone’s either in fight or flight or sometimes people throw the freeze in there. I know you work with Stephen Porges and you’ve taken that to a different level. Tell us what the name of the paper is so people can access it.
It’s called something like Yoga Therapy and Polyvagal Theory.
You also worked on a great book called Yoga and Science in Pain Care. I know your two main authors were Shelly Prosko and Neil Pearson and a whole bunch of other amazing physical therapists, psychologists and yoga people. It’s very multidisciplinary. Why did you guys write that book?
All three of us have a lot of experience and interest in working with the complexity of the pain experience. We were all friends and we’ve known each other in the yoga therapy and physical therapy community. We had each thought about writing about pain, but it seems so big that no one person could hold the whole picture. We began to talk about writing a book together and then we began to talk about, “Let’s get experts in each of these facets of pain care to speak about yoga and science in their expertise.” We have a chapter on psycho-emotional well-being written by Michael Lee, who’s the founder of Phoenix Rising Yoga Therapy. We got Tracey Sondik to write about addiction and pain care. We were able to find the people that we wanted to write about each topic. They’re all yoga therapists and some other professionals that have worked with pain for many years.
As you were speaking, by the magic of Google, I believe your paper is called Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience, which is a mouthful. We won’t hold it against you that you couldn’t remember. That last part is quite long. That’s our free gift. People can download that and they can access the link at the beginning of the show. It is written by Marlysa with Stephen Porges, which is a great paper. Segueing from that into your book, which is an incredible feat. I know how much time, effort, blood, sweat and tears go into your book. How does Polyvagal help us take that more holistic perspectives? You already mentioned a couple of them but take us into a little bit more of that.
I think especially coming to this as a physical therapist and seeing people who have any chronic pain condition from back pain, migraines, fibromyalgia, whatever it might be. There’s a way that you can try to address each of their symptoms. The pain experience, the emotions, the stress, all the sleep and all those things they have. We can get lost about which one to start with first. What Polyvagal Theory offers is a way to put that aside for a moment and consider coming underneath to facilitate the social engagement neural platform. From that optimal parasympathetic state, we can then facilitate naturally things like compassion, kindness, non-harming, contentment and relaxation. We can optimize or catalyze these more positive or calm body-mind state through shifting the autonomic state instead of getting lost in the symptoms.
I love that you’re teaching people how to access the autonomic system more because it’s so important for pain care, health and vitality overall. Talk to us about resilience when it comes to the autonomic nervous system in Polyvagal Theory.
A lot of talk about the autonomic nervous system comes into this idea of regulation like coming into this optimal parasympathetic state. That is super beneficial and it’s related to a lot of health outcomes and different diagnoses and conditions. However, the way that yoga would say it is that life is always going to fluctuate. We’re always going to have these Gunas. We’re always going to have these neural platforms. We’re going to have periods of anxiety and worry. We’re going to have periods of deep lethargy and tiredness. That’s part of the life experience of being human. Resilience is about that capacity to return to a state of homeostasis, balance or parasympathetic response in a timely and efficient way. It includes the ability to notice when we begin to get away from that state and then how to get back to it more efficiently and quickly.
In Polyvagal Theory, we can look at it as the capacity for us to access the parasympathetic social engagement and to be able to navigate the other neural platforms. To notice when we come into a sympathetic state, what are the things that contribute to that state and then how to return to a parasympathetic state? I often talk about it as three different kinds of resilience. There’s the resilience about alternating where you first facilitate the strength of coming into parasympathetic and then you offer practices to increase activation and then come back down. The person learns that they can skillfully navigate coming back. The second phase of resilience is what can be called widening the window of tolerance, meaning that the person can begin to be activated but to maintain that sense of connection.
Those neural platforms of safe mobilization and safe immobilization widen. This would be something like doing a posture like bridge and maintaining a calm breath or maintaining a visualization or a meditation of calm that you’re able to experience yourself as physiologically activated but maintain a connection to that calm state. The third resilience is a bit more yogic than it is Polyvagal Theory. In yoga, we learn to experience all stimuli as Eudaimonic well-being or as that sense of calm or equanimity. We begin to shift the way that we relate to the phenomena of the body, mind and world.
You’re placing people in postures using the breath and also using visualization?
Yeah. In that alternating, we can have something like finding whatever movement, posture, breaths or even in physical therapy using modalities to help soft tissue work or manual work to facilitate that sense of ease, and then doing a practice that activates their system a little bit. That could be an actual activating posture like bridge or it could even be something that’s activating for that person. Some people are activated in supported backbends. You explore what is activating for that person and then you come back. You move between the two postures.
Where does psychology fit into this model in this perspective?
I’m going to answer that two ways and let me know if you also mean it different way. In the way that I work with it and my scope of practice as a physical therapist and yoga therapist, what I’m doing is helping the person notice the emotions and thoughts that arise, to notice how they show up in their body and to change the relationship they have with those emotions. It’s very somatically based. For example, if fear and anger arise and they express that, I can ask them how they noticed that in their body. Is there a place, a color, a texture, a vibration? Is there something they can bring to that emotion or thought like maybe a sense of peace or calm or the opposites? Is it just sitting with that emotion while it’s there? That’s the way I would work with it. That would be regulation and resilience.
When someone has an emotion or thought that they ruminate on or becomes overwhelming for them, then I will refer them to a psychotherapist so that they could have both ways of working with it. I’ve worked with several clients who were using psychotherapy or doing psychotherapy as well as seeing me. Sometimes their psychotherapists would refer to me. In our session, we would work with it like this. “How do you notice that sensation in your body? What is the color, the texture, the descriptors of it? Is there something that is wanting to be brought here? How is it that you want to relate to this?” We keep it in those kinds of questions and that in any of the more detail story or history of that emotion is discussed with the psychotherapist.
There is a mindfulness and acceptance piece that’s within this work. It’s important. I’m hearing a lot of overlaps between some behavioral-type therapies, Acceptance and Commitment Therapy and yoga. I hear lots of different flavors in there, which is great because people respond well when they have different types of stimuli. What practices in general help with resilience?
First is finding what it is that helps to relax the person. Oftentimes, it can be Manual Therapy but it could also be something like a constructive rest posture or some position that helps them feel comfortable. For resilience, I tend to use postures or movements like fringe or some standing postures or faster breathing techniques. They’re able to do those postures that activate their system and then they come back down. I was talking to someone, there’s this concept called anxiety sensitivity. It’s used in the personal training world where people will do bike riding or treadmill walking in order to experience the same physiological activation that they have in anxiety, but they’re able to understand that it’s a different safe situation. We can use practices like that as well.
It’s interesting because a lot of studies on anxiety if you look at psychology papers, they have people in low oxygen environments, which caused people to breathe rapidly. It can induce a little bit of anxiety. It’s almost a similar concept, which is interesting. You’re a physical therapist and you’re a yoga instructor. Are you looping all this all together? Is there a way, a tool or a method that you use to evaluate this or is it more like an art form that you’re learning and practicing?
I would say a little bit of both. There is also this developing and evolving field called yoga therapy. I see myself as a yoga therapist and a physical therapist. My evaluation has the physical therapy piece of it, which is looking at things like movement, musculoskeletal imbalances and things like that. There’s the yoga therapy piece of it, which I’m doing through an interview process to notice what is their stress level like, what is their sleep like, what kinds of emotions and thoughts are they dealing with? I’m even asking in my intake form, “Which of these emotions are you working with or are showing up for you right now?” It will be things like anger, fear, anxiety and depression. What is your energy level like? It’s mostly with questions that I’m determining if they seem to be in a heightened sympathetic response and if they have difficulty coming into that social engagements. They’re asking questions like what is your social relationship? How are those? What is your relationship to even spiritual well-being like meaning, purpose and those kinds of things?
In your book, Yoga and Science in Pain Care, was there just one chapter that you wrote or was there more?
I wrote the chapter on Polyvagal Theory and then also a chapter on spiritual well-being. Part of the language I use around that is called Eudaimonia or Eudaimonic well-being. It comes from Aristotle and it means to live a well-lived life. Eudaimonic well-being in the research is about this idea of steadfast contentment and flourishing. They found that the health outcomes of Eudaimonic well-being are things like decreased mortality and co-morbidities, independent of other things like physical activity or diets. That Harvard longitudinal study, that connection to meaning and purpose, increase our lifespan. It also increases our psychological well-being. It has an impact on our inflammatory and immune processes. I see the broader picture of something like yoga therapy as facilitating Eudaimonic well-being. It’s that idea of experiencing a steadfast contentment within whatever things emerge in your life.
That idea of being connected to meaning and purpose and to work with things like non-harming or compassion. Within that, by facilitating autonomic regulation, we can help mediate that experience. By facilitating and taking someone in chronic pain who maybe hasn’t experienced that a lot. A woman I’ve worked with had sickle cell disease and she hadn’t ever experienced her life without pain. Finding what are the ways for this person to access the social engagement system so that we can facilitate Eudaimonic well-being, contentment or equanimity. Even things like music and smells if someone’s okay with it like different oils that can create that. We can create new positive experiences for someone.
They are two different topics in different chapters, but they’re interrelated.
I consider them very interrelated. The one about Eudaimonic well-being was so cool to me in the research. When you read about how people define spirituality versus religion or when they distinguish spirituality from religion, they distinguish it through this idea of meaning and purpose, positive social relationships, values like forgiveness, hope, those kinds of things, and any connection that could be a personal resourcing or existential connection. In the same way, Eudaimonic well-being is measured by those same things, meaning and purpose, values, quality, social relationships and personal connection. That idea to be more authentically who you are, to express who you are and taking that from another place. To me, your Eudaimonic well-being is a secular spirituality and you have also catalyzed those. There’s some neat work right now in yoga where they’re looking at how people start the practice for physical reasons, but they often continue for more spiritual reasons. If we consider like one of the big roadblocks for physical activity is adherence. This idea that if we bring into the session things like a connection to meaning, purpose, peace and contentment and those aspects of Eudaimonic or spiritual well-being, we might help someone to continue to be motivated to do physical activity.
It’s interesting how someone explores a movement practice, something that starts out as purely physical and yet they wind up going down a very different path.
Being able to use things like the autonomic nervous system and Polyvagal Theory, so that we don’t have to determine the language someone uses for it. As they experience that state of peace, that is a social engagement system. We can ask how they experience that personal connection. I’ve had people automatically go into their religion where they say, “This is what comes to mind. This is a phrase from my religious texts that speaks to me.” We can use that or it can be non-religious at all. That’s where they connect to themselves and their body, and access those peace and calm, the more they begin to experience things like that deep personal connection, that essence of who they are and then whatever language they express that we can use.
We know you teach at Maryland University. You’re an assistant professor and you’re talking, and you’re very familiar with the research on this, even at this point, you’ve done some of the research on it. How do you approach others that have a similar message around these types of topics, traditional practitioners, and start to open up this conversation with them as far as practice? There are many physical therapists who may be reading this, who work in a more traditional physical therapy environment where it’s more sports and orthopedics and a biomedical model. This type of information has yet to trickle in.
There are two things come to mind with that. One is I did grand rounds at Children’s Hospital of Atlanta there was a bunch of the doctors. I spoke about yoga as Eudaimonic well-being and they were super excited. I think the medical community is excited to understand how while this stuff can be out there, it’s also not. The Eudaimonic well-being has an effect on gene activation, which affects inflammation immune. This is in NIH research. When they see that, they’re excited. I found that work is out there and you can speak to it in a non out their way. That’s why it is nice to have the language of something like Polyvagal Theory where you don’t have to use yoga lingo or be anywhere in that area, but you could talk about, “We are going to regulate their nervous system. We’re going to help create emotional regulation and that will help you to relax.” It’s talking about how this regulation of the nervous system is going to help you relax your muscles and that will help you have more mobility and activate your muscles more effectively. We can take out anything that seems obscure.
What’s great about this is you can take a theory and a topic like this and you can straddle way over the more traditional yoga world. Be right in the middle for people who are right in the middle like many practitioners are. You can go way to the other side of a very more neuroscience side. People with licenses in healthcare and neuroscientists can start to say, “There’s definitely a theory and science that supports everything that’s going on.” I love that combination.
With the patients I’ve had, they’re excited because most of the patients I see are people that have gone to many medical professionals. They’ve had longstanding pain. The idea of your autonomic nervous system, even very simplistically saying, “Your sympathetic fight or flight response is going to create tension in your body. The way that you’re responding to stress in your life is going to create that repeat attention in your body.” I found people to be very open and receptive and be like, “That’s right.” They’ll come to me through different sessions and say, “I noticed that when I’m at work, this thing happens where I’m sitting all day.” They’ll begin to notice how their reaction to stress shows up as muscular tension in their body.
It becomes intuitive after a while for people. It’s almost like these lessons were there with us through the eons and we lost them and now we’re touching base with them. You’re helping people discover them again.
That’s one of the things I appreciate about Polyvagal Theory. It seems like my autonomic system connects my body, my mind and my behavior. It’s nice to have a theory that says, “This is how it happens. This is how it shows up. These are ways we can play with it and alter it.”
People are definitely going to download your paper and then I encourage everyone to check out the book, Yoga and Science in Pain Care. Marlysa, tell everyone how they can learn more about you.
I’m at the Maryland University of Integrative Health. One of the websites is MUIH.edu and then another website that I’m at is IntegrativeYogaStudies.com. I’m in the middle of creating a website. That’s just MarlysaSullivan.com.
You can go to MarlysaSullivan.com and you can learn more. Check out the book, Yoga and Science in Pain Care. Hit that little share button and share it with a yogi, a PT, an OT, some other pain science geek or someone with pain who would benefit from this type of information.
- Dr. Marlysa Sullivan
- Yoga and Science in Pain Care
- episode number six – Marlysa Sullivan
- Shelly Prosko – previous episode
- Neil Pearson – previous episode
- Yoga Therapy and Polyvagal Theory: The Convergence of Traditional Wisdom and Contemporary Neuroscience
About Marlysa Sullivan, PT, DPT
Marlysa is an assistant professor at Maryland University of Integrative Health in both yoga therapy and health promotion. She is an adjunct professor at Emory in the DPT program where she teaches the integration of yoga and mindfulness in PT. She has a new book out which is co-edited with Shelly Prosko and Neil Pearson- Yoga and Science in Pain Care. She is also working on her second book which will be out next year- Understanding Yoga Therapy: applied philosophy and science for well-being. Her clinical work has focused on chronic pain conditions.
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