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).

Cautions for Bone Strength Practice

by Nina

On Tuesday we posted a sequence designed by Baxter Featured Sequence: Bone Strength Practice. Since then we've had a couple of questions from people about whether the sequence is safe for people who have osteoporosis or osteopenia. We've added a warning to the original post, but for those of you who have already read that post, we're posting the warning here as well. 

Cautions: The Bone Strength Sequence was designed for those with no evidence of osteoporosis or osteopenia. If you have either of those conditions, be mindful to avoid the forward folding action of Cat/Cow pose (the Cat position), although the hands and knees position will lessen the potentially negative force on your thoracic vertebrae quite a bit. Otherwise, the sequence should be safe.

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Featured Sequence: Bone Strength Practice

by Baxter

As part of my continuing series of special sequences, I’d like to offer a sequence for building stronger bones. To start, please see one of my previous post on osteoporosis Healthy Bones for Men and Women Alike. When practicing the poses I have chosen for the sequence today, remember some of the suggestions I made in that previous post: 

“The research data that shows that we can stimulate new bone growth along lines of stress by holding poses for between 8-72 seconds is, for me, the pivotal nuance to add to the yoga practice you are already doing. Because of this, I have been working recently with holding postures for 30-60 seconds, depending on the physical demands of a given pose (for example, holding Downward-Facing Dog for 60 seconds, while holding Hand to Foot pose (Hasta Padangustasana), a much more demanding pose on many levels, for 30 seconds.” 

So, you will want to experiment with holding your poses in that 30-60 second range. The other key concept to keep in mind relates to the following: 

“Remember that engaging opposing muscle groups while doing the pose increases the stimulation of the underlying bone cells that make new bone (this is essentially an isometric contraction around a joint). So, in Downward-Facing Dog I consciously engage the muscles around all the joints I can think of.” 

In standing poses, I am not only taking advantage of the weight bearing part of the pose, the feet and legs, but using this isometric muscle contraction around the shoulder joints, for example, and in the contraction of the muscles of the back spine to assist in keeping the posture actively upright. So, if you want to add more poses to the sequence, you can include any of your favorite standing poses and apply these two principles for bone strengthening.

Cautions: The Bone Strength Sequence was designed for those with no evidence of osteoporosis or osteopenia. If you have either of those conditions, be mindful to avoid the forward folding action of Cat/Cow pose (the Cat position), although the hands and knees position will lessen the potentially negative force on your thoracic vertebrae quite a bit. Otherwise, the sequence should be safe.

Warm-Up

Cat/Cow: This pose warms up your spine and its joints, as you are also bearing weight on your wrists, the second most commonly fractured area in people with OP. Start on your hands knees, with a blanket or other padding under your knees. On your inhale arch into a gentle backbend, and then on your exhale round your spine towards the ceiling. Repeat for about six rounds. 

Hunting Dog: This pose a great one for building strength in the wrists and spine. See Hunting Dog Pose for basic instructions. Be mindful to keep your chest lifting towards your shoulder blades, especially on the side where your hand is on the ground. And strongly reach your lifted arm and shoulder blade forward, as you reach the lifted leg backward. After you come out, be sure to shake out the wrist of your supporting arm.

Downward Facing Dog: Because you are bearing weight on hands and feet and really working around the hip joints, the third most commonly fractured joint in the body, this is a great pose for building bone strength. From hands and knees position, come up into Downward-Facing Dog pose. See Downward-Facing Dog Pose Variations  for variations that might work best for you. 

Downward Dog Variation

High Plank Pose: This is another great pose for your wrists as well as your arm bones, and also for your spine as it engages the muscles attached to your spine. Start in Downward-Facing Dog pose, and then shift your shoulders forward until your shoulder joints are directly over your wrist joints. Keep your ribcage lifting up towards your shoulder blades and your elbows strong and straight. The rest of your body should be in a Mountain pose-like shape, so you need to keep your core and legs engaged, while maintaining a natural curve in your lower back. To come out of the pose, swing back to Downward-Facing Dog, then to hands and knees. Afterward, give your wrists a good shake out and brief rest. 

Active Poses

Extended Side Angle Pose: This is a great pose for your legs and hip joints, your bottom wrist joint, and your spine. You could substitute Triangle or Warrior 2 pose here, if you prefer those standing poses. From Mountain pose, step your feet wide apart, turn your right foot and leg out 90 degrees and kick out your back heel an inch or so. Bring your arms up parallel with the floor and bend your front knee. Then side-bend your hips and torso over your front leg and put your right hand on a block on its highest height, placed snug up against the outside of your front shin. Swing your top arm up and overhead, completing the side angle from your back leg through your torso and into your top arm. Push down firmly into the block with your bottom hand and feel your right shoulder blade firm into your chest and slightly down toward your waist. Reach your top arm and shoulder blade strongly forward towards your fingers. Be sure to actively engage the muscles around your mid-spine to strengthen your mid spine area. Come out of the pose on an inhalation, relax your arms at your sides, and repeat on the other side. 

Warrior 1: This a good pose to strengthen the spine, as it contracts the back muscles that pull on the vertebrae of the entire spine. See Warrior 1 Pose for instructions. You will use this pose to transition into your next pose.

Warrior 3: This pose adds in a balance challenge to weight bearing on the standing leg and isometric work on the lifted hip and along the spine. See Warrior 3 Pose for instructions and easier variations. Since the  pose can be quite challenging, start with shorter holds and gradually work up to 30 seconds or more. 

Forearm Dog Pose to Forearm Plank Pose: See Downward-Facing Dog Pose Variations for instructions on Downward-Facing Dog pose with Headstand Arms for instructions. From that pose, move into Forearm Plank by swinging your shoulders directly over your elbows and bringing your body parallel with the floor. When you come out of the pose, release down onto your belly in a prone position.

Locust: See Locust Pose for instructions. Even though those instructions are for dynamic Locust, practicing this pose dynamically will give you a good way to ease into full, static Locust pose, in which you lift both legs, your chest and your head and hold the pose for 10 seconds to start. Gradually add more time until you can do a 30 second hold. Rest for a few breaths before moving on. 

Simple Seated Twist: It is theorized that twisting helps nourish the spine—movement of the spine helps maintain the health of the discs—and also strengthens the bones themselves as your back muscles pull on the bony insertions of the spine. If you already have osteoporosis, you may need to be a bit more cautious, so I recommend that you twist to a bit less than your potential maximum. Start by sitting in a comfortable crossed-legs position, on a prop such as a folded blanket if needed. Sit tall and on an exhalation, rotate your chest and upper belly to the right, placing your left hand on your right knee and your right hand on the floor behind you. Stay for 30-60 seconds before releasing and changing the cross of your legs and twisting to other side. 

Bridge Pose: This pose will engage your back body muscles, so it's a good one for strengthening your spinal vertebrae as well as your legs. Starting on your back, bend your knees to come into Constructive Rest pose, with your feet about four inches from your hips. Warm up by lifting your hips up as you inhale and lowering them down when you exhale, up to six times. Then inhale and stay in the pose for 30-60 seconds, breathing gently in and out the entire time. Press down evenly into your feet, and lift both from your hips and the lower tip of your breastbone. Optionally, you can turn your upper arm bones under the pose, being mindful not to put strain on your neck. On an exhalation, release your arms and come out of the pose.

Before moving on to Relaxation pose (Savasana), take a moment to do bring your knees to your chest or rock your knees and hips side to side to release your back muscles. 

Cool-Down

Savasana: If time permits, take a generous 10-minute rest before heading into your day. Bring attention to your bones and imagine them heavy, dense and strong. 

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Yoga for Strength: An Overview

by Baxter

Downward-Facing Dog Pose for Upper Body Strength

Our long-time readers will already be aware of one of the essential skills we promote here at Yoga for Healthy Aging: strength building. And the two important types of strength yoga can help build are bone strength and muscle strength.

As a family doctor, one of my many roles was that of doctor to my patients who found themselves admitted to a nursing home. For many of these patients, they were admitted for post-operative recovery and physical therapy following a hip fracture and hip replacement related to osteoporosis. So their underlying issue that led to the broken hipbone was the thinning of the bones that affects the vertebrae of the spine, the wrists and the neck of the femur (thigh) bone, this last one usually causing the most problems. If these patients got to work promptly on their physical therapy to improve strength in the legs, they often had short stays in the nursing home and were happily discharged home to complete their recovery there. However, many patients, for a variety of reasons, would not progress in physical therapy and so began to get very weak from inactivity and quickly began to lose muscle mass. For a younger person, rebuilding lost muscle mass doesn’t take that much time, but for older people, that time could double or triple, so preserving muscle strength is a much bigger issue in these individuals.

In addition to my nursing home folks, I also noticed that as my general patient population began to age, somewhere in their 50s many began to notice an overall loss of muscle mass and strength. We’ve written about this idea in previous posts, such as Strength and Aging, a concept known as Sarcopenia, which in some ways is an expected part of the aging process—that is, unless we chose to intervene with specific practices to maintain our muscle mass or increase it. Our now in-house Physical Therapist Shari Ser had this to add about Sarcopenia:

“The composition of our muscle fibers changes from being able to contract quickly and explosively to slower contraction rates. There are also changes in how the information is transmitted through the central nervous system and the “rate of processing information” slows down. There are also changes in our proprioceptive system, that is, in how we sense where our body and its various parts are in space. Our range of motion may change with a decrease in our stamina and our overall flexibility due to system trauma (acute and chronic diseases, decrease in endurance and cardiovascular efficiency). And our genetic predisposition to disease will also affect our overall strength.” 

You may have personally noticed this sort of challenge in the spring that first time you worked in the garden, or when you decided to store all that Christmas stuff up in the attic one afternoon, and the next day you were surprisingly sore, weak and tired in the muscles you had used the day before. This could be early evidence that you are having a bit of Sarcopenia setting in!

The main culprit on planet Earth that necessitates that we have adequate strength is, of course, gravity. We have to have enough strength, along with that other essential skill, balance, to get up each day and move around to do the things we have to do and want to do! And we have to have enough strength to simply get out of bed, stand well and move about the home, community or work space in easy fashion. This would lead us to want to keep the muscles of walking and standing very strong, and add in decent strength for the arms depending on other activities we engage in. In an early interview for YFHA, Shari Ser noted that, “Strength … has to be reproduce-able and renewable.” So, you have to be able to get up and down many times a day easily, and have ways to maintain, restore and improve your strength from day to day.

A lot of people turn to the gym and circuit training to do isolated muscle strengthening on machines that, for example, strengthen muscles that flex the elbow (biceps and a few assistants!). This is great for building strength in that isolated muscle group, but unless you are doing curls with the milk cartoon as an everyday activity, it may not translate into smooth, strong, balanced movements in your daily routines. For that, yoga asana practice is a great combination of both isolated muscle strengthening and coordinated, graceful strong movement. And because a balanced asana practice includes standing poses, backbends, forward bends, twists and inverted poses, a regular practice that includes a wide range of poses will build strength in the muscles and bones throughout your entire body. 

Isolated strengthening is accomplished via the process of holding poses statically for a certain amount of time. Research has noted that bone strengthening starts around 10 seconds into a held pose and continues for up to 70 seconds or so, and muscle building starts around the 90-second mark. This has led me to recommend working up to a 90 second hold in many of your poses to achieve both goals. Now, if you are starting out on the weak side, you may find that after a short while you lose the ability to hold the pose safely. So, that is your starting point, that amount of time you could go before feeling like you had to come out, and you’d add a few seconds to your hold every few days or once a week and gradually work your way up to the 90 second goal.

Shari also noted, “Repetition of effort with your current range of motion builds strength.” That means you can also get the benefit of the repetitions you see folks doing on those machines at the gym by entering and exiting the poses dynamically with your breath for a given number of times. I often use the timing I learned from TKV Desikachar of coming in and of a pose six times with the breath. For certain poses, this can mimic real life activities, such as Powerful Pose (Utkatasana), which would help with transitions in and out of a chair. When you extend your practice to include the dynamic complex sequences like Sun or Moon salutations, you will add in more practice balancing and improving your agility, so you get even more bang for your buck. Taken all together, these ways of utilizing the asana to build strength will give you quite a complete system for bond and muscle strength as you age.

And you could also extend the benefits of a complete practice that includes pranayama in order to improve the muscular strength of the breathing muscles, whose primary muscle, the diaphragm, needs the assistance of many other muscles when strong breathing takes place, like anytime you exert yourself. So improving the subtle assistant muscles of breathing, such as, the intercostals, and the larger more powerful muscles of breathing, such as, the abdominals, will give your overall respiratory system a work out, too. Of course, your asanas will also strengthen many of the accessory muscles of breathing, so there is a nice synergistic result from including more than just one yoga tool!

And for those of you out their that want to get even more detailed about how yoga improves strength, check out this juicy post by our scientist extraordinaire, Ram, called Yoga Asanas: Endurance Training or Resistance Training?

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