As we age, there are inevitable effects of the wear and tear on our bones and joints including disease, degeneration and thinning of the bones. Most of us who practice Yoga want to be doing it in 10…20…30 years and more time so we need to become aware of how we can modify our practice in order to incorporate postures, and gentle somatic flows that will maintain our bone health and avoid worsening affects of arthritis (where the bones become misshapen and limit our range of movement) and osteoporosis (where the bones become more porous and thinner and we risk breakages) in particular and keep our yoga practice safe and effective.
Osteo = bone. Porosis = porus. It is a disease in which the density and quality of bone are reduced. As bones become more porous and fragile, the risk of fracture is greatly increased. The loss of bone occurs silently and progressively. Often there are no symptoms until the first fracture occurs. Osteoporosis occurs when there is an imbalance between new bone formation and old bone resorption. The body may fail to form enough new bone, or too much old bone may be reabsorbed, or both. Two essential minerals for normal bone formation are calcium and phosphate.
Worldwide, osteoporosis, the bone thinning disease causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 seconds according to Johnell O and Kanis JA (2006). Worldwide, 1 in 3 women over age 50 will experience osteoporotic fractures, as will 1 in 5 men aged over 50. In women over 45 years of age, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes, myocardial infarction and breast cancer (Kanis JA, Delmas P, Burckhardt P, et al. 1997). Culturally we are trained to worry about breast cancer far more than Osteoporosis but according to Cummings SR and Melton LJ (2002) for white women, the lifetime risk of hip fracture is 1 in 6, compared with a 1 in 9 risk of a diagnosis of breast cancer.
At first there may be no signs or symptoms and it is often referred to as a silent disease since the first warning may be the first fracture and even then, according to Nguyen TV, Center JR, Eisman JA (2004) the great majority of individuals at high risk (possibly 80%), who have already had at least one osteoporotic fracture, are neither identified nor treated.
Prolonged use of corticosteroids is the most common cause of secondary osteoporosis. It is estimated that 30-50% of patients on long term corticosteroid therapy will experience fractures with an increased in risk of hip fracture by 2-fold in women and 2.6-fold in men. Further to this, physical inactivity and a sedentary lifestyle as well as impaired neuromuscular function (e.g., reduced muscle strength, impaired gait and balance) are risk factors for developing fragility fractures so in our Yoga class this week, designed to increase our bone mineral density, we will be a little more active than normal. Having Rheumatoid arthritis, being on chemo, having anorexia, Chrohn’s, Celiacs or thyroid disease (and being on a high dose of Thyroixin) are also risk factors for Osteoporosis.
The focus is generally on maintaining an adequate calcium intake – 100 – 1200 mg per day (along with Vit D that helps you absorb it – 800 – 2000IUs – it’s best to get tested to get the right level) in order to protect the bone mineral density. However what is often neglected is to educate those with high risk and diagnosis of Pre-Osteoporosis with regard to the type of substance that leaches calcium from the bones. According to Kanis JA, Johansson H, Johnell O, et al. (2005) a high intake of alcohol confers a significant risk of future fracture (e.g., over 4 units of alcohol/day can double the risk of hip fracture). Caffeine and fizzy drinks are also culprits. Use of anxiolytics, sedatives, neuroleptics and antidepressants has been shown to increase risk of hip fracture.
Low body weight and weight loss is associated with greater bone loss and increased risk of fracture and even in some young females, particularly those training for elite athletic competition, who exercise too much and eat too little, there is a consequence of amenorrhea (lack of periods) which makes them at risk for low bone mass and fractures as demonstrated by Warren (1999). Middle-aged and older men and women with annual height loss >0.5 cm are at increased risk of hip and any fracture (Moayyeri A, Luben RN, Bingham SA, et al. (2008).
You would think that Yoga is possibly not the best activity for someone with reduced bone mineral density since they require high impact activities in order to stimulate the bone to build more strength. However, standing work in Yoga can be just as strength building as going to a gym and using weights, especially if you can hold the pose long enough to build strength in muscles to support the weakened bones. The other good thing about Yoga is that you can do it every day, which is a requirement if you want to reverse the effects of diminished bone mineral density. The emphasis on building balance strategies in Yoga is also very beneficial to prevent falls and further to this, reducing stress is one of the major ways to contribute to stronger bones. Betterbones.com explains that depression and anxiety are linked to weaker bones and they even identify “stress-induced osteoporosis.” The research quoted focused on the production and activity of stress hormones such as cortisol, epinephrine and norepinephrine which takes it’s toll on the bone re-formation mechanism.
There are some cautions to the practice of Yoga for someone with full blown Osteoporosis (as a opposed to the pre-curser to the full disease, known as Osteopaenia). The National Osteoporosis Foundation cautions people with osteoporosis in the spine to avoid certain kinds of movement that could lead to vertebral compression fractures, a hallmark of the disorder that can result in shrinking and a stooped posture—the so-called dowager’s hump. But only about a third of vertebral fractures are diagnosed, often because the pain may be mild or mistakenly thought to come from something else. Risky movements include bending forward from the waist, twisting the spine to a point of strain, and doing toe touches and sit-ups.
The important coaching regarding Yogi’s with fracture risk is to align the body correctly in poses; to focus on awareness, balance, & weight bearing activities. Try not to focus too much on forward flexion as this contains a risk of fracture and can put strain on the lumbar region also. In many ways it mimics slumping. In fact all Yogic practice needs to avoid compounding the rounded back and focus on posture and length through the spine. Most useful are modified Cobras (lying back bends). I would not advise any post menopausal woman to take an ordinary Hatha Yoga general class without having an BMD test to ensure there is a safe level of density in the bones before you participate.
Many don’t realise that they are having vertebral fractures. They are often precipitated from forward bending or twisting or both. A tell tale sign of Osteoporosis being present is a loss of height of more than an inch and a half. This is an indication that the person should be checked and there is probably a presence of Kyphosis and sometimes breathing difficulties and digestive problems as the organs become compressed.
Of course Yoga isn’t my only recommendation. It’s very important to use weights and is one of the reason’s I introduced them in my daytime Dance Fitness programmes for Senior Citizens. It is more important to work with heavier weights, up to 10 repetitions if the work is in gym and perform the exercise 2-3 times a week to build up your muscular strength and endurance and stimulate the bone growth.
The good news is the a low bone mineral density is reversible because bone isn’t some static hard stuff – it’s actually metabolically very active! We may have passed our big bone building years but we can preserve and even build on bone mass, rather than accept bone loss (usually associated with a drop in Oestrogen) as inevitable. I am living proof of this since I had very low BMD as a 35 year old due to lack of Oestrogen (I was born without ovaries). I was told I would be in a wheelchair before long. I have taken on board a lot of bone mineral building behaviours including Yoga and Dancing and ensured that my diet has little caffeine and other bone mineral zapping ingredients and have now completely reversed my Osteoporosis!
Osteoarthritis is a condition that affects your joints. The surfaces within your joints become damaged so the joint doesn’t move as smoothly as it should (see Figures 1 and 2). The condition is sometimes called arthrosis or osteoarthrosis. Older terms are degenerative joint disease or wear and tear.
When a joint develops osteoarthritis, some of the cartilage covering the ends of the bones gradually roughens and becomes thin, and the bone underneath thickens. All the tissues within the joint become more active than normal – as if your body is trying to repair the damage:
- The bone at the edge of your joint grows outwards, forming bony spurs called osteophytes.
- The synovium (the inner layer of the joint capsule which produces synovial fluid) may thicken and make extra fluid. This causes your joint to swell.
- The capsule and ligaments (tough bands that hold the joint together) slowly thicken and contract as if they were trying to make your joint more stable.
Sometimes your body’s repairs are quite good and the changes inside your joint won’t cause pain or problems. But in severe osteoarthritis, the cartilage can become so thin that it doesn’t cover the ends of your bones. Your bones rub against each other and start to wear away. The loss of cartilage, the wearing of bone and the bony spurs can change the shape of your joint, forcing your bones out of their normal position.
Normally when you see itis after a word, it means inflammation of something and that usually means the thing is hot and swollen. So for instance, if you have tendonitis, then ice packs will help when resting on the tendon. With O/A the opposite is true. Gentle heat is the order of the day because the cold can irritate the joint more. It is the most common joint degenerative disease and there are more than 200 different types! It happens to athletes as well as being part of the ageing process. Even being dehydrated can put a strain on the joints! The bone on bone pressure is what causes the pain in the joints as the cartilage begins to wear from over use.
Osteoarthritis is a chronic (long-term) disease (see the Arthritis Foundation for more info). There is no cure, but treatments are available to manage symptoms. Long-term management of the disease will include several factors:
- Managing symptoms, such as pain, stiffness and swelling
- Improving joint mobility and flexibility
- Maintaining a healthy weight
- Getting enough of exercise
The key way Yoga can help is to work with tracking patterns of the joints. Typically there is asymmetry in the muscles pulling on the joints where one side is weaker than the other, pulling the joint out of alignment as the stronger side takes over. Compression of the joint is not the friend of the person with O/A and our aim in Yoga is to keep things flowing and smooth, creating space, rather than holding a pose for a long time. This increases the availability of synovial fluid which keeps the joint moving well. We also aim to increase the strength of the supporting muscles around the joints and we aim to help heal irritated joints by increasing the circulation which in turn reduces pain.
The largest joint in the body is the hip which is often prone to O/A because it is weight bearing and under such strain, particularly in very overweight people. Where the sacrum attaches to the hip bone, the SI joint (where the cute little dimple is in your back) can also be affected by O/A. This transfers the body weight when we walk. I have talked in a previous blog about how there is play in the SI Joint although there isn’t supposed to be a lot of play in it.
If you have O/A it’s important to keep your Yoga practice gentle. Of course I feel that Gentle Somatic Yoga is best for arthritis but I will admit that because I have to use cold church halls, the issues with the lack of heating is contraindicated for people with O/A. So my advice is to wrap up warm, with lots of layers and make sure you have a thick mat, nice warm blanket and slipper socks
Although O/A is less commonly in the smaller joints (which are more likely to be affected by Rheumatoid Arthritis, a less common auto immune condition) but as the disease progresses, you will see the evidence of misshapen hand and foot joints being affected by O/A. Many times the disease will be more than one joint, such as spine, knees and hips.
So how do you know when it is time to get a diagnosis of O/A and how is the condition diagnosed? It’s important to get advice from your GP if you experience persistent joint pain anywhere in the body. I have done so many assessments lately where the person tells me they have self diagnosed their Arthritis. However, there are many different types and the treatment and advice is different for each one so its good to know properly what diagnosis you have. When you see the GP, make sure you give a good description of pain, any stiffness and joint function. Your GP may examine your joints including checking for bony swellings, joint tenderness, instability, excess fluid, creaking joint (crepitus) and restricted movement. They may check your muscles too, especially for muscle thinning.
The factors which may lead the GP to suspect OA include:
- being over 50 years of age
- persistent joint pain which gets worse if you use your joints more
- having stiffness in the joints in the morning lasting less than half an hour
If your symptoms are slightly different from those listed above, your GP may think you have another form of arthritis. For example, if you have joint stiffness in the morning that lasts longer than an hour, you may have a more inflammatory form of arthritis. Further tests such as X-rays can confirm osteoarthritis, although an X-ray may not be needed. An X-ray can show bony spurs, the narrowing of spaces between bones or whether calcium has settled into a joint. X-rays cannot indicate the degree of pain you might feel.
VERTEBRAL DISCS ARE THE JOINTS OF THE SPINE
As usual in Yoga, much of the focus is on the spinal column. The intervertebral discs are large cartilaginous structures situated between the vertebral bodies, occupying around one third of the length of the spinal column. They act as the joints of the spine and carry mechanical load arising from body weight and muscle activity. Loads change with every alteration of posture and activity and the discs thus undergo a diurnal loading pattern with high loads on the discs during the day’s activity and low loads on it at night during rest. As the disc is an osmotic system, around 25% of the disc’s fluid is expressed and re-imbibed during each diurnal cycle with consequent changes in the osmotic environment of the disc cells. Somatic flows involving tilting the pelvis, for instance, in Cat Cow, and work done on the belly are useful in re-imbibing the vertebral fluid. This research demonstrates how hyperextension is useful for vertebral health and height increase (although it is temporary of course).
When you are not doing your practice, keeping properly hydrated by drinking lots of water, as demonstrated in this article is another way to keep your spinal discs healthy and hydrated
LIFTING ON TO TOES
Avoid being on a thick mat to do this or you’ll loose the balance. You can always be by the wall if need be. When we come up on to our toes and reach up to the ceiling, we are creating axial extension and space through the vertebrae of the spine. This also increases our balance which helps prevent falls – so important if the bones are weakened, since you are more prone to fracture if this is the case. We are also strengthening the ankles as we balance and working the knees and strengthening muscles around the joint. As you rise up, press on to the ball of the foot to prevent the foot sickling (bowing outward) and try to drop the tailbone, especially as you lift the arm and the chest expands (as that would normally cause the tailbone to lift). Try coming only half way down and pushing back up again.
WARRIOR ONE – WIDE LEGGED FOWARD / BACK STANCE
Caution: You may need to have your legs nearer together if you have issues in your SI joint. However you need tovoid taking the knee beyond the ankle if you stance is narrow. Align the legs hip width apart, especially if you have osteoarthritis. Avoid having the back foot on an angle as most Hatha Yoga teachers would coach you to do as this puts strain on your hip joint and stresses the lower back too much if you have arthritis there. Rather than holding the W1 pose for a long period, we are going to come in and out of it, which is working your leg muscles and gently moving the knee joint.
Many of the strong standing poses are great for stressing the bones – in a good way! In this next Warrior pose we are warming up by lifting and lowering the arms, keeping the back straight and long to avoid stress on the low back, especially if you have O/A here as the stance aggravates the condition if the low back is scooped (pelvis anteriorly tilted). When we hold the position with the heart pushed forward, elbows bent at shoulder height, we are putting this positive stress on the bones which helps in treatment and prevention of Osteoporosis since it is a bone loading posture.
ADAPTING CHAIR POSE – HALF CHAIR
The full pose can aggravate O/A in the spine and cause pain. It’s also an uncomfortable position if you are Lordotic. In that pose, the back is higher, the belly away from the knees and the weight pulling on the low back. To avoid this aggravation we can adapt the pose in a couple of ways. You can do this with your bottom against the wall if you need the support. Bend the knees and keep the tailbone tuck down. You can stay here with the hands on the knees if that is enough for you – listen to your body. Or you can bring the torso down toward the knees (back is horizontal now) and you can bring the arms up by your ears as a counterweight which may help you to sink down a little further. Half Chair is therefore with the back lower than the full chair, with the belly touching the thighs – there is less stress on the back in this position. The pose works the quads. Ensure your shoulder blades are pulled down and the back is straight, not rounded up in the upper back. It’s a bit of a compromise because if you have the tendency to round shoulderedness, you will be likely to round the back too much in the adapted pose so you may be better to stick to the full chair pose with the back higher up – if that is what it takes to get the back straight. What we are trying to avoid is an overly arched lower back and an overly round upper back so you need to work on what is best for your own back.
We are coming in and out of this pose this week which builds up the muscle in our quads. This kind of weight bearing activity is brilliant for building up your bone mineral density and preventing Osteoporosis. Using our knees in this way will also help with O/A in the knees by strengthening the muscles around the joint.
The benefits of the Warrior poses are that in addition to gravitational resistance we are building up muscle resistance to build up strength in the lower extremities. Our hips are very vulnerable as we age so hugging in and squeezing the glutes and blossoming open the inner thighs helps us to build stability in the hip joints as well as building up muscle strength in the glutes. Press down into the heel of the front foot and into the baby toe side of the back foot which activates all the muscles of the legs. Ensure you don’t pronate in the front foot or the knee will fall inwards and misalign.
STANDING FORWARD BEND AND ROLL UP
Rolling up from a forward bend is fine if you are 20 and your spine is very healthy. However, the action creates a lot of anterior pressure on the spinal discs and isn’t recommended especially if you have Osteoporosis as it can even cause a fracture if the bone density is very low. It is important to bend your knees coming into and out of forward folding if you have tight hamstrings so that the hinging movement of the pelvis isn’t compromised. From the forward folded position, you can draw the hands to the hips and draw the shoulder blades together. Keep the chin slightly tucked, then you are bringing the chest away from the belly, like you are coming up in a bit of a backbend, with a nice long spine. However, if the hamstrings are long, you can have strong straight legs and press through the floor. This makes the top half of the body light and easy to lift up. We will begin this section with the Somatic Forward bend to lengthen the hamstrings. First check in to see your current range of movement by touching your toes (or thereabouts) whilst your legs are straight. Whilst doing the pose however, you can bend your knees a little if the hamstrings are really tight. Begin in the forward folding position with arms folded. Move the head first, then pause before moving the arms (not past your nose). Do this three or four times. You don’t have to engage the back muscles too much to gain benefit. As you start to come higher in the pose, you’ll feel the load on the hamstrings. The whole movements re-patterns the brain to awaken the back muscles, allowing them to lengthen and increase your range of movement in forward bending movements as well as releasing tight hamstrings.
When coming in and out of forward fold, if the hands are above the head, an extreme load is put on the low back – fine if young and healthy but not advisable otherwise. We can place our hands on the bottom and slide the hands down the back of the legs as you come forward, on an exhale, letting the head hang at the bottom. You can do a full head roll in this position as there is no weight on it. Draw the chest away from the belly to come back up with hands on the backside, elbows drawing together so that the shoulder blades are squeezing in. You can stop half way with a flat back (an L shape, chin tucked in), then fold back down. Try coming up and down with attention to the chin and shoulder blades tucking and notice how this loads the hamstings and makes the legs work instead of taking the strain on your back.
If you have been gardening for a long time with a rounded back and hanging out of the fascia in your low back, it can be useful to come up to a straight standing position by first paying attention to getting the weight in your legs and straightening your back first in this way to avoid hurting your back, especially if you have Lordosis or either of the bone conditions we have been discussing.
CAT COW CHILD
This smooth flowing movement is great for increasing the vertebral fluid. Breaking the movement down into parts and pieces by doing it slowly will show up parts of the spine in which you are experiencing Sensory Motor Amnesia. This shows up when the movements become a little jerky or even without sensation where it may not even be possible for you to instruct the brain to move just one part without another being involved. This week we are going to join up the Cat Cow to Child pose but we need to be mindful of the knees during this process and place a bolster, block or pillow on the top of the calf to stop the knees getting into an obtuse angle, especially if you have arthritis in them. We spend a little time in Child squeezing the thigh’s together so that you can feel the release of the legs that allows the chest to come forward more fully into the full pose.
Child’s pose is often referred to as the ‘Millionnaires’ Pose’ as many an Osteopath / Chiropractor has charged vast sums to simply get you into this posture to relieve all manner of back problems!
BENEFITS OF SPINAL EXTENSION
We are going to work on our belly during class this week and bring the spine into hyperextension. This work is extremely useful to increasing the fluid to the spinal column, for plumping up the vertebral discs and for giving you height. This is good news for the vertically challenged. This is where Osteoporosis and Osteoarthritis differ in their requirments in Yoga. The former requires load to help increase bone density, whereas too much load for the latter may cause further wear and tear. Knowing your own body is the key.
When lying on your belly, focus on keeping the tops of your feet on the floor as well as pressing the pubic mound into the ground to keep the low back long. As you come into extension, draw the shoulders together and lengthen through the crown of the head. You can leave your hands on the floor or lift them if that feels ok. Peter Blackaby argues that you can increase the extension in the back by exhaling on the extension, where previous practice has been to inhale on the way up. You can see that the belly distends into the floor on the exhale and it’s logical that if you inhale and the belly flattens, there is more room to lift up and back into further extension. Hold in the extension to increase your bone mineral density as the spinal column is compressed in this position and the weight bearing nature of the hold will assist in new bone development. However, for those with O/A in the spine, the pause is not recommended.
For those with O/A, we want repetition.
Place the back of the hands on the low back. The opposite arm and leg. Lift the left leg (straight, ie don’t bend at the knee) as you come up into extension as you salute with the right. Look away from the hand as it swoops out to the side and down to your side you come down and turn head to the left. Repeat on the same side a few times, then perform the flow on the left.
In a useful article in the online Yoga Journal, Carol Krukoff points out that not everyone is in agreement on which postures are safe and effective for people with compromised bone mass. In Yoga for Osteoporosis, the authors—yoga therapist Ellen Saltonstall and Dr. Loren Fishman, medical director of Manhattan Physical Medicine and Rehabilitation—caution against a convex rounding of the spine, as in Cat-Cow Pose, which can cause tiny fractures in the spine. Twists have the potential to do the same, but Fishman contends that twisting poses are “the only way I know to strengthen the anterior part of the vertebral body.”
REFERENCES AND USEFUL INFORMATION
Johnell O and Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17:1726.
Kanis JA, Delmas P, Burckhardt P, et al. (1997) Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporos Int 7:390.
Nguyen TV, Center JR, Eisman JA (2004) Osteoporosis: underrated, underdiagnosed and undertreated. Med J Aust 180:S18.
Cummings SR and Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761.
Kanis JA, Johansson H, Johnell O, et al. (2005) Alcohol intake as a risk factor for fracture. Osteoporos Int 16:737.
Bainbridge KE, Sowers M, Lin X, Harlow SD (2004) Risk factors for low bone mineral density and the 6-year rate of bone loss among premenopausal and perimenopausal women. Osteoporos Int 15:439.
Warren MP (1999) Health issues for women athletes: exercise-induced amenorrhea. J Clin Endocrinol
Moayyeri A, Luben RN, Bingham SA, et al. (2008) Measured height loss predicts fractures in middle-aged and older men and women: The EPIC-Norfolk prospective population study. J Bone Miner Res 23:425.
All the key facts regarding osteoarthritis are on https://www.arthritisresearchuk.org/