New CMS rule allows flexibility in certified EHR technology for 2014

Today is my one day of Summer vacation, enabled by the large number of people taking a long labor day weekend.

Some things are worth interrupting your vacation.

This afternoon, CMS published he long awaited final rule on Meaningful Use flexibility.

Here’s my interpretation.

Many CIOs tell me that they will be ready for transition of care and patient view/download/transmit for the full year October 1, 2014-September 30, 2015.   However, the ecosystem (trading partners, patient awareness, policy) is not ready for the period July 1, 2014-September 30, 2014.   Thus, the ONC final rule is a welcome relief.

I do have one concern - the rule notes that Stage 1 criteria can be used by those on Stage 2 timelines for

"Only providers who could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.”

Although certified products may have been introduced into the marketplace, the time to implement, train, and ensure safe use exceeded the Stage 2 time limits.

I hope ONC/CMS/HHS interpretation of delays includes the time needed for successful adoption.

Friday : Practice for All Seasons (Rerun)

Swimming Hole by Brad Gibson

Q: Practice and the seasons: Does your practice change with the seasons and if so how?

A: Where I live, there are seasons (though some people might argue differently), but rarely extremes of weather. But one summer day that was actually hot, I went to my regular Friday morning yoga class, expecting backbends because my teacher always teaches backbends the second class of the month. Our studio, though in a beautiful old building, had no insulation and very little climate control, with poor heating in the winter and no air conditioning in the summer, so it was unusually warm in the studio.

The teacher opened the class with a little smile, saying, “Today we’re going to do some nice cooling backbends.” Everyone laughed, because, of course, backbends are typically not at cooling. But guess what. We did do backbends, but our teacher modified his typical sequence so we did a cooler practice of stretches, passive backbends, and the less effortful, active backbends, rather than a “hotter” practice of standing poses and very active backbends.

That memory of that still makes me smile, but I bring it up today because I don’t necessarily change my practice with the seasons per se, but I’m definitely change my practice to fit the weather and the temperature in the space where I’m practicing.

Today is a cold and rainy day in Berkeley, California and my house is a little bit drafty, so I would incline toward an active, heating practice rather than a passive cooling practice. Trying to do, for example, a restorative practice in a cold room is not only very challenging because you get colder and colder the longer you stay still, but it is also not very effective, because being cold stimulates your nervous system, alerting your body and mind that you may in danger. So it’s very difficult to relax. On the other hand, the active poses warm up both you and the room quite nicely.

Likewise, being too hot is very stimulating for the same reasons; your nervous system warns your body and mind there may be danger. So when it’s hot, it’s a good time to do more passive and relaxing poses. Or, slowly work up to the active poses and take time to rest and cool down.

Naturally you don’t want to do only active practices all winter and only passive practices all summer, but as my teacher did that day, you modify any sequence by adding more cooling poses or heating poses to accommodate the climate, both outdoors and indoor. For your convenience, I’ve categorized the general groups of poses into Heating and Cooling.

Heating Poses:

• Sun Salutations
• Standing Poses
• Active backbends
• Headstand and arm balances
• Twists and abdominal strengtheners

Cooling Poses:

• Restorative poses
• Reclined poses
• Forward bends
• Supported inverted poses

Some other considerations: Your body is stiffer when you are cold, so that’s a time when you may need more stretching. When it’s hot and your muscles are more relaxed, you may not need to stretch as much. The weather also influences how physically active you are outside the yoga room. I also tend to be more physically active outside during warmer, drier months, walking, gardening, and so on. So to balance my body on more active days, I’ll focus more on poses that complement those activities (see Deciding What to Practice). During the rainy season when I spent more time in the house, I’ll naturally gravitate toward more active poses to compensate for being more sedentary. However, some people may spend the winter skiing (yes, I’ve heard tell of that) and the summer hiding out in an air-conditioned apartment (heard of that, too), so each person needs to find his or her own way with figuring out the best practice on a given day.

A Woman Did a Single Yoga Pose and What Happened Next Will Blow Your Mind!

by Nina

Tapas: Working with Dedication

by Nina

Cloud and Sunset by Brad Gibson

When my mother broke her hip in her mid-seventies, she surprised me with her ferocious dedication to working toward a full recovery. She did her physical therapy exercises every day, soon worked her way up toward walking around the block with a walker, and eventually over time regained full use of her new hip. From then on she was able to walk easily and with no aids almost until the end of her life. I was remembering this the other day because I was thinking about how when we get older it can sometimes take a lot of work to stay physically independent. And some people find it easier just to give up.

Another family member recently told me that even though she was not yet 60, she could no longer get up and down from the floor, so she had just stopped trying to do it. Concerned, I asked if she was having knee problems or.... She said it was just that her legs were no longer strong enough to make the movements. Have you tried using a chair for support? I asked. She replied that this seemed too awkward, and shrugged it off, adding that she preferred just to give it up. A bit alarmed at the thought of a woman her age not being able to get up off the floor—what if she fell when no one else was around?—I said that I thought she should reconsider, that maybe this skill was too important to let go of so easily. With practice, this skill is probably something she could regain. You're probably right, she agreed, but I could tell she wasn't fully convinced or perhaps was just unwilling.

While someone like Shari might be able to come up with a yoga routine for my relative to do that would help her build the strength and agility to relearn getting up and down from the floor—and maybe I'll be asking Shari to come up with one—the kind of yoga I had in mind for this woman was the practice of tapas. I imagined her just starting to practice every day or even several times a day getting up and down from the floor with some kind of support until eventually she would need less and less support. In other words, like my mother learning to walk on her own again, she could through grit and determination do the hard work that something like this requires. Babies do this naturally and instinctively of course, but somehow relearning these skills can feel like too much work to some older adults.

In his post on the niyamas (see The Second Branch of Yoga: The Niyamas (Your "To Do" List), Ram defined tapas as "a burning desire or a disciplinary approach to achieve one’s aims and aspirations." Practicing tapas is how we reap the rewards of yoga, whether through a regular meditation practice or doing asana five or six days a week. I sometimes accompanied my mother back when she was walking through her neighborhood with that walker—clearly struggling both with the physical difficulty of it as well as the emotional toll—and even at the time I was struck with admiration at her commitment to the task at hand. She couldn't know for sure that she was going to succeed at learning to walk again but she was going to give it her damnedest.

I've always thought of tapas as the yang to santosha's (contentment) yin (again, see Ram's post on the niyamas). Yes, we need to cultivate contentment with what we have and with what we don't have but we also have our work to do. That's what Krishna explains to Arjuna in the Bhagavad Gita when Arjuna asks why, if we shouldn't be attached to the outcomes of our actions, we should even try to do anything. 

Not by not acting in this world
does one become free from action,
nor does one approach perfection
by renunciation only.
Not even for a moment does
someone exist without acting.
Even against one’s will, one acts
by the nature-born qualities.

We need to work to support ourselves and our families, we need to work for the good of our communities, we need to work on our spiritual development, and we need to do the work required to keep our bodies as strong and healthy as possible to enable us to do the rest of our work. After all, that is why Hatha yoga was initially developed. Ancient yogis knew a strong and pain-free body was helpful for spiritual growth, as being distracted by illness or pain might interfere with spiritual practices (of course, this does not mean that people with illnesses or pain cannot practice yoga). So doing what we can to maintain our health is an essential part of our work.

Set thy heart upon thy work, but never on its reward.
Work not for a reward; but never cease to do thy work.
Do thy work in the peace of Yoga and, free from selfish desires, be not moved in success or failure. Yoga is evenness of mind—a peace that is ever the same. — translation by Juan Mascaro

I don't know if my message got through to my relative but I really hope it did. She's a wonderful, good-hearted person and I would love to see her stay strong and independent for as long as possible.

Yoga for the People (and Healthy Bones)!

by Shari

With the recent passing of BKS Iyengar (the teacher of my teacher, Donald Moyer) and the exponential growth of yoga inspired by Mr. Iyengar, I have been thinking a lot about health outcomes and why yoga is such a powerful self-help tool. You see, in my day job as a home health physical therapist, health outcome is measured very differently than it is in a complementary alternative health care model that yoga falls within.

My patients too often don't get better. My job in aiding their recovery often feels like I am trying to put a small Band-Aid on a gaping wound. I can’t change the situations that lead to their poor health. They suffer from the chronic life challenges of poverty. Years of poor health management, from an uncaring overworked, depersonalized, underfunded health care delivery system, and the chronic stress from living marginalized lives lead to chronic health issues. To often these patients are living in polluted urban environments, where walking is not done by choice because it is unsafe. They also are victims of poor health from years of eating processed, nutritionally void meals. The places where they live are commonly food deserts, where fresh food is unavailable without having to take public transportation via circuitous routes. Many of my patients don’t have cars. My care often feels inadequate because I can’t change their life circumstances even when they are doing all they can do to regain their health.

For example, J was in her early 80's when I met her. She was a homemaker, a long-time smoker who had remained physically inactive though very slim. She had been diagnosed with osteoporosis in her 60's and her family started a walking program with her. They also enrolled her in a senior exercise class at the near by senior center. She was pretty stabile for about 15 years and maintained independent living in her own home. But then her husband became ill, and she couldn't care for him any longer, so he was institutionalized. He died approximately one year later. After that she had a bout with pneumonia and her long history of smoking finally caught up with her; she was diagnosed with chronic obstructive pulmonary disorder and became oxygen- and steroid-dependent for respiratory management. She was also placed in an assisted living facility by her family because of frequent falls due to leg weakness. I was her home health PT. She was compliant with her exercises but wasn't really walking more than a couple of steps because of extreme fatigue. Also, she suffered from several osteoporotic fractures from "hugs" from her family. She was really upset by this because she felt like she was crumbling from the inside out. The pain from the osteoporotic fractures and the immobility from not walking and being pushed in her wheelchair by staff further eroded her overall health. She died in her sleep—with no major medical cause—several weeks after I discharged her. 

So you might be wondering, could yoga have helped J? I believe that if it had been a part of her activity regimen when she started her walking and exercise class that it would have. Yoga could have helped J with her sense of physical and emotional loss as she lost her independence and her home. Guided strength training for specific bone strengthening positions might have slowed her progressive osteoporosis. Unfortunately I will never know for certain because her care was limited by her HMO insurance company and I was only given four visits and told to "get her back onto her feet." 

In my more cynical moments I am disgusted by the public degree of privilege that American yoga seems to support. The visual images of perfect woman and occasionally men shine from the glossy covers of popular mainstream yoga magazines, with headlines urging pursuit of the “perfect yoga body” and touting delicious organic recipes, not to mention hyping over-the-counter supplements for “health” or lovely yoga fashions to enhance your practice of yoga.

So when the accolades of the wonders of yoga are constantly cited sometimes I can’t take it. But then I remember B.K.S. Iyengar and how he really did bring yoga to the people and how he did make it accessible to everyone. I also remember that yoga is more than asana—that it truly is a credo on how to live your life for the greater good.

So in this spirit of inclusivity and my own belief that the best way to deal with health challenges is through personal empowerment, I am starting a new beginner-level yoga class focusing on bone health called Yoga for Healthy Bones, both to honor J and to support my general yoga students who, as they are aging, are being diagnosed with bone loss from either osteopenia or osteoporosis. This class will provide camaraderie, creating a community of mutual support as well sharing, which the class members can engage in if they so desire. There is nothing better in self care than learning what worked or didn't for individuals with similar diagnosis. And, most importantly, this will be a venue where people can practice yoga without fear of hurting themselves.  

I am personally very impressed with the work and level of dedication that Dr. Loren Fishman has provided for his patients through his ongoing medical study on the efficacy of yoga in building bone density. This class will incorporate some of his basic principles of bone stimulation as well as focusing on many of the safe beginner level standing and seated poses for osteoporotic individuals. If you live in or are visiting the San Francisco Bay Area, come and join us on Sunday afternoons from 4:00-5:30pm at the Yoga Room in Berkeley, California (see yogaroomberkeley.com).

Friday Q&A: Yoga for Better Digestion

Q: I tend to suffer from digestive problems, so I was wondering whether there are any yoga poses that I could do after eating to improve my digestion?

A: Although Baxter and I wrote a post about how there are no hard and fast rules about how long to wait after eating to do yoga (see Friday Q&A: When to Eat), if you do tend to suffer from digestive problems, it is probably best for you to refrain from doing active poses immediately after eating.

However, there is one restorative yoga pose that you could try after eating to see if it provides any help, Reclined Cobbler’s pose (Supta Baddha Konasana). Reclined Cobbler’s pose is the classic pose for improving digestion (as well as providing relief for women with PMS or during menstruation).

Baxter includes this pose as the first pose in his three-pose sequence for improving digestion (or just general relaxation), Mini Restorative Sequence. And we just happen to have made our one and only video about how to do this pose!

If you suffer from digestive problems, it is probably best to skip the other two poses in the Mini Restorative Sequence unless you are practicing 11/2 to 2 hours after eating because forward bends, like Child’s pose, and inverted poses, like Legs Up the Wall pose, could cause acid reflux or discomfort. But do give the entire sequence a try sometime when you have safely digested your last meal to see if it can provide help in general.

Finally, many digestive problems are related to chronic stress (see Chronic Stress: An Introduction). So you could experiment with trying some form of conscious relaxation (see The Relaxation Response and Yoga) to calm your nervous system after you eat. After all, the opposite of the Stress response (Fight or Flight) isn’t called the Rest and Digest response for nothing! Rather than lying flat on your back for these practices, I recommend that you prop yourself up on a bolster, as shown in this version of Supported Relaxation pose (Savasana) so your head is higher than your heart, and your heart is higher than your stomach.

In general, pacifying your nervous system through conscious relaxation and gentle yoga practices may help enhance your digestion in the long run.

Baxter Bell Selected One of Top Ten Bay Area Yoga Teachers!

by Nina

Just a quick announcement today to let you know that Yogascapes has selected our own Baxter Bell as one of the top 10 yoga teachers in the Bay Area (that would be the San Francisco Bay Area).  They explain why they love him:

"No matter your age, background or exposure to yoga, once you step into Baxter's class you will immediately feel cared for. Even if the class is full to the edge of the room, he takes time to introduce himself to everyone and give thoughtful adjustments. He understands and teaches that yoga is foremost about your state of mind and encourages everyone to participate in a non-stressful way allowing you to find the right pace and style for your body. Participating in his class helps you deeply internalize your practice through his clear instruction. By practicing with Baxter, yoga merges with daily life deeply and naturally. Not to mention we love how funny he is!"

Unity Farm Journal - 4th week of August 2014

Over the past week, the combination of rain and cool Fall-like temperatures caused our 165 shitake logs to fruit, resulting in over 50 pounds of fresh mushrooms.   We inoculated 5 tons of oak logs last August and throughout the year have had a few pounds to deliver to local farm stands.   We really did not know if our work would be successful, since this is our first effort at growing mushrooms to commercial scale.   We’re guided by this excellent research paper which illustrates how a family can create a 500 log Shitake operation yielding $5000-$10000 in farm income per year.

Now that we know that the combination of our Unity Farm oak, local environment, weather, spawn, and techniques resulted in successful production, we’ll turn our attention to the marketing details - how to package/label them, how to deliver them to local customers, and how to price them.   This year, we’ll dry some and sell some fresh.   We’ve also contacted two local tree maintenance companies, agreeing to take delivery of any fallen/trimmed oak trees and branches to expand our operation.  

I moved the logs from the shade house where they had their spawn run to the laying yard in the forest where they’re leaned upright on wooden stands and are easier to pick.   Our mushroom farm is off and running!    The 100+ Oyster logs will start to fruit in late September and October, so Unity Farm might even become the site of a first in the country “Mushroom” Community Supported Agriculture (CSA) site.

Our apples and other fruit trees are nearly ready to pick.   Our heirloom cider apples will yield commercial quantities in a few years, but  this year we’ll have enough for early cider experiments.   The hard cider we made last year is now fully mature and I’m confident in my cider making skills and the process I’ve chosen which is very similar to making a full bodied Chardonnay.

The hoop house fall plantings have sprouted and we’re expecting to harvest greens, root vegetables, and broccoli through December.

Still no cria - Mint, our pregnant alpaca is enormous and clearly ready to deliver.  Maybe labor day weekend will finally bring labor and delivery.

This weekend includes herd health and all the usual medical care of our herds/flocks, preparing the bees for Fall (it’s nearly time to harvest honey), and some of the final trail maintenance before the leaves begin to drop.

I’m going to try to take off a long Labor Day weekend to enjoy the fruits of our labor - harvest time on the farm makes all the work of Summer worthwhile.

B.K.S. Iyengar, The Teacher of My Teachers, Has Died

by Nina

Although I never studied with B.K.S. Iyengar, the three teachers who have influenced me the most, Donald Moyer, Mary Lou Weprin, and Rodney Yee, all did. I have also been strongly influenced by two other Iyengar teachers, Patrician Walden and Roger Cole. So even though I'm not a certified Iyengar teacher (I am a certified Yoga Room teacher), I've always felt connected to this great man, as a student of his students and a reader of his books. In general, B.K.S. Iyengar was one of the most influential yoga teachers of the 20th century, for he not only helped popularize yoga in the western world, but he introduced the use of props, which allow people of every body type, age, and level of ability to practice the yoga asanas (see Yoga Props: An Introduction), and developed the idea of the asana practice as a moving meditation (see Practicing Yoga Mindfully).

So please take a few moments to honor this man, who made so many lives better, including mine. Here is a wonderful video in which you can see him practicing as well as teaching. Namaste.

The August HIT Standards Committee

The August HIT Standards Committee focused on the work ahead to accelerate interoperability.   It’s no longer about Meaningful Use, it’s about Meaningful healthcare information exchange.

I offered my opinion about the work ahead.  ONC is in the middle of regulation writing for Meaningful Use Stage 3, so the standards work of the next 10 weeks is not going to be incorporated into the NPRM.

Regulation is not the only way that health IT standards are defined, selected, or adopted by industry.
Learning from Stage 2, it’s critical that we decouple regulation writing from creating test procedures and scripts for certification.  I’m confident that our upcoming standards work will result in implementation guides and certification criteria outside the initial NPRM process.   Also, it’s important to remember that the NPRM is a proposal.   If the final rule needs to incorporate the standards work of the next few months, HITSC can recommend specific standards in its formal review of the NPRM.

All of the presentations at the August meeting explored different aspects of interoperability.

Jacob Reider offered opening remarks, reflecting on the timeline and staging of the work ahead, including the transition of workgroups to a new structure that will make us more agile

Steve Posnack presented an update specifically focusing on the new Standards Implementation and Testing Environment that enables robust testing of interoperability including CCDA, QRDA, Provider Directory and Transport (Direct) standards.

Erica Galvez, ONC Interoperability Portfolio Manager, described the interoperability portfolio and timeline for ONC work including the building blocks of the ONC 10 year vision:
1. Core technical standards and functions
2. Certification to support adoption and optimization of health IT products and
services
3. Privacy and security protections for health information
4. Supportive business, clinical, cultural, and regulatory environments
5. Rules of engagement and governance

Vaishali Patel presented a data update on interoperability, highlighting growth in exchange capability and activity.  Interoperability measurement will be a key focus going forward.

Finally, Liz Johnson presented the Implementation Workgroup review of the CCDA, identifying issues such as heterogeneity of CCDAs from different vendors, excessive optionality, mixture of structure/unstructured data, challenges with usability, and a need to evolve to something simpler such as FHIR.    The Standards Committee approved a resolution for the Steering Committee to assemble experts and recommend CCDA improvements or its replacement.

With every Standards Committee meeting we're getting closer to creating a national "Automated Teller Machine" for healthcare.    CCDA and Direct with a few supporting standards such as provenance, provider directory, and query/response will get us started.    FHIR, REST and OAuth2 will take us to the finish line.

Knock-Knees, Lady Gaga, and Yoga

by Baxter

Lady Gaga Bares Her Knock-Knees*

Don’t know if Nina mentioned it yesterday, but this interest in knees all started with the following question we got last week:

I have a student who has knock knees (genus valgus), a condition that I gather is quite common in women. She reports that aligning her knee with her second toe in standing poses gives her knee pain. Do you or Baxter have a suggestion for her, as well as for an appropriate cue in classes that might include people with this condition?

Also, many men have bow legs (genus varus); I have not yet heard complaints about problems aligning their second toe with their knee but suspect that some compensation might be necessary. If so, do you have a suggestion for them?

Whether you are a yoga teacher or a yoga student, if you don’t have knock-knees or bowlegs yourself, you have probably noticed someone in your public class (or a celebrity like Lady Gaga) who has one of these fairly common variations in leg bone relationships. And it turns out that more women are “knock-kneed” than men, and more men are “bowlegged” than women. However, I have seen cases of the reverse for both. 

Without going into to too much detail (but at least a little!), depending on the shape of the upper part of your thighbone, the femur bone, where the short neck of the femur (the part often broken in a “hip fracture,” especially in those with osteoporosis) meets the longer shaft of the lower part of the femur, a person might veer away from the normal angle enough to lead to one of our two conditions. When the femurs move further away from the midline of the space between your legs, referred to as “abduction” in anatomical circles, you end up with bowlegs. When the femurs move closer to the midline space between the legs, referred to as “adduction,” you end up with knock-knees.

In the case of knock-knees, when the femur meets the two lower leg bones, the tibia and the fibula, the inner knee joint tends to open up towards the inside of the knee joint and the outer or lateral joint tends to compress together more than normal. Tight inner thigh muscles and weaker outer hip and leg muscles can contribute to this situation. And with the knees knocking towards one another, you can get more wear and tear on the lateral joint, and the skin of the inner knees can even sometimes rub together in an uncomfortable way on the opposite side of the joint. Julie Gudmestad put it this way in an Taking Care of the Knee for Yoga Journal on keeping the knees healthy: 

“…knock-knees … put increased pressure on the lateral compartment cartilage and strain the soft tissue of the medial, or inner, knee. This problem is more common in our society, and is associated, as you might expect, with arthritis in the lateral compartment.” 

The strain of the soft tissue of the inner knee she refers to could mean an over-stretching of ligament on that side of the joint whose job it is to keep the bones in a healthy close relationship. And the increase in the chance of arthritis is why we care about these variations in anatomy!

In knock-knees, in addition to causing the inner bowing the legs of knock knees, the femur bone tends to roll or rotate inwardly, so that when you are standing in Mountain pose the knee caps end up pointing a bit toward one another instead of pointing straight ahead (or in line with second toe, as some yoga teachers recommend). Many yoga students are told to bring the inner edges of their feet very close together at the same time they are told to align the kneecaps with their second toes. In those with knock-knees, this can exacerbate the alignment even more. So, one of the first things I suggest for these practitioners is to separate the feet about hips-distance apart, sometimes with the aid of a block between the mid-thighs. I suggest they hold the block lightly between their thighs (as they may already have tight adductor muscles and we don’t want to encourage more tightness) and imagine that the block is pushing out against the inner thighs. I’d check in at this point and see if the student’s knee pain has disappeared. If it has, I’d recommend they adopt this new stance for future practice.

For Mountain pose (Tadasana) and variations, Standing Forward Bend (Uttanasana) and Downward-Facing Dog pose, Donald Moyer suggests keeping the feet a bit closer together and using a block between the knees. This closer foot position will let the block push the knees apart in the bowlegged direction.

Another option is to forgo the block, but keep your legs hips-distance apart, and place a looped strap around both legs, either mid-thigh or mid-calf, and press outward against the strap, feeling the strap resist that pressure. You are essentially taking the knees a bit towards the bowlegged direction, encouraging a bit of muscular strength in the outer leg muscles and a bit of stretch to the adductors of the inner thigh. You could apply this to other poses with two straight legs such as Standing Forward Bend and Seated Forward Bend (Paschimottanasana).

In his book Structural Yoga Therapy, Muktananda Stiles notes that those with genus valgus (knock-knees) usually have tight adductors (inner thigh muscles), and parts of gluteus medius often are weak. The external rotators of the hip can also be weak and allow for both the knocking and the internal rotation of the thighbone I mentioned above. Muktananda Stiles also relates his personal experience with long standing knock-knees and a pivotal practice session in which he worked with Warrior 2 pose, holding it with close attention to keeping his desired knee alignment, and consciously softening and lengthening the inner thigh muscles and strengthening the outer thigh muscles of his front leg to exhaustion. He claims that as he continued to work with this over time, his knock-knees resolved! 

In her article, Julie Gudmestad suggests using the Reclined Leg Stretch pose version with the leg out to the side to lengthen the inner thigh muscles. This works in the standing version of this pose as well.

To strengthen outer gluteal muscles and the external hip rotators, she suggests Warrior 2 with close attention to the knee position and the alignment of the front thighbone with the long edge of your sticky mat.

Other poses to stretch the adductors include:

• Triangle pose (Trikonasana), front leg
• Extended Side Angle pose (Parsvakonasana), front leg
• Widespread Standing Forward Bend (Prasarita Padottanasana), both legs, possibly using your elbows to press your inner knees 
• Wide-Angle Seated Forward Bend (Upavista Konasana)
• Cobblers Pose (Baddha Konasana)

Other poses that could assist in strengthening the outer gluteal muscles and the hip external rotators include:

• Half Moon pose (Ardha Chandrasana), both legs (plus, if you get the correct external rotation of the bottom thigh, you will also get some good adductor stretch)
• Tree pose (Vrksasana), top leg
• Pyramid pose (Parsvottanasana), front leg action at hip
• Warrior 1 (Virabhadrasana I), front leg action at hip

I hope these suggestions—while in no way exhaustive—can give you a few ideas on working with knock knees to not only eliminate pain that you or your students have now, but also hopefully reduce the chances of early development of osteoarthritis down the road!