Yoga and Pain Management

by Shari

Since I have been on a “pain alert” myself for the past 10 days (a very cranky knee is having trouble settling down), I thought I would discuss the difference between acute and chronic pain, and how yoga may assist in pain management.

More than 115 million people nationwide (1 in 3 Americans) suffer from some type of long-term pain, according to the Institute of Medicine. People often try to alleviate pain with conventional therapies and medications. According to the CDC, narcotic pain medication addiction and overdosing accounted for over 16,651 deaths in 2010. When conventional treatment fails, people will often turn to complementary medicine techniques, and yoga is often tried to alleviate pain symptoms.

I thought I would first define the difference between acute and chronic pain. An acute injury will typically resolve within three months of the body’s normal healing process. Chronic or persistent pain is pain that lasts more than this time frame. Acute pain is associated with tissue damage. Pain (nerve) receptors are activated with an acute injury because the body is trying to protect the damaged area - this minimizes usage so normal healing can occur.

But with chronic pain, the brain’s perception of the cause of the pain changes. The inhibitory mechanisms of the central nervous system become faulty, and we may avoid physical activity because we have learned “If I do this, it will hurt.” We may be afraid that, because we are in pain, activity will further damage or injure the area. But generally the tissue damage is healed after three months, and avoidance of physical activity is therefore no longer beneficial in the healing process.

However, the brain may now remember stress and pain in an exaggerated way, as if it were in a continuous sympathetic feed back loop of fight or flight. So some of us can become hyper vigilant about everything that causes pain. But one of the beauties of yoga practice is how helpful it can be for people both in acute and chronic pain!

Physical asana has properties of both squeezing and soaking areas of the body. Compressive forces, with and without weight bearing, and long restorative poses move fluid, assisting the body to decrease edema in a joint after an acute injury. Decreasing the edema reduces the pressure on nerves and muscles, resulting in a reduction of pain symptoms. (However, it is key to understand how much can you can move your cranky joint and when you need to stop, so see When to Stop Practicing Yoga for information.) Along with the practice of physical asana, long relaxation poses and Savasana can help because of their restorative qualities and the way they quiet the sympathetic nervous system while stimulating the parasympathetic system (the relaxation response). And at this time, modifying the asanas that you regularly do is important. This way, you can still get the benefit of the asana with modifications, and then as the injury heals you can slowly bring the full asanas back into your regime.

For chronic pain the “prescription” is a bit different. Chronic pain is a global body phenomenon. When your body is in chronic pain you walk differently and you may even sit differently. Your attention is often directed to the painful region because keeping it still may make it worse and positional change needs to be frequent. The individual may be chronically exhausted because the ability to sleep well has been affected. There may be difficulty in completing tasks in a timely manner so things “start to slide” and don’t get done. Because energy is limited, the individual may rush through tasks to get things done and then be in more pain because they hurried. It is a terrible wheel to be on and difficult to get off onto solid ground!

In my own practice and teaching of yoga, I try to share with my students how yoga helps to focus the mind, quiet the breath and improve the mental focus. Yoga meets us where we are NOW. Yoga is nonjudgmental and everyone can do yoga. Yoga teaches us self-awareness. Yoga gives hope where there may be no hope.

Simple grounded breathing while you sit on a chair or lie in bed in your position of comfort is a great way to start. Set a timer and do simple breathing for three to five minutes. Notice how this may affect your mind and sense of self. Progressing to GENTLE range of motion of all body parts within your ability and not pushing yourself is beneficial. You can even do your range of motion activities in your position of comfort. Notice your pain levels (0-10) at start of practice and then again when you are done. If your pain levels stay the same, you are teaching your body NOT to be afraid of movement. Once your confidence has improved, then you might be ready to join a local class. Look for instructors who will be sympathetic to your pain but not overly solicitous. Make sure the teacher understands that you will stop when you need to, not necessarily when the teacher tells the class to release the position. Try to set aside five minutes a day to practice your own breathing awareness and your own Savasana. It becomes your sacred time to care for yourself.

Remember, the results may be slow in coming but persistence and gentleness are the keys to relieving and managing both acute and chronic pain.

Note: For my achy, swollen and hot knee, I am trying to work with my available range of motion, not moving too much into pain but inching into the pain and then backing up and repeating multiple times trying to make the available movement  smoother. Also, stretching related areas like my hip flexors, hamstring muscles, gastroc/soleus is really helpful for pain relief of my knee. In the standing poses, I’m working with gentle isometric contractions but not going into my full knee flexion (bending)—pumping a lot. I’m doing a lot of passive inversions like Viparita Karani (Legs Up the Wall pose) and Chair Shoulderstand, with pumping from my ankles. And, finally, modifying poses, for example, for Virasana (Hero pose), which I was previously able to do without any props, I now use two blocks stacked up high because I have just about 100 degrees of flexion (ability to bend the knee). And, lastly, cautious, aware walking. Patience is the crux though I am not a very patient individual.

When to Stop Practicing Yoga

by Shari

Swan at Rest by Brad Gibson

Sometimes we do things that we think are healthy or beneficial for us, but which are actually not. Even practice of yoga, whether at home or in a class, can occasionally be problematic. Have you ever gone to a class feeling a “bit off” and then walked away from the class feeling drained or in actual pain? Or, have you ever gone to a class feeling a “bit creaky” but hope that the “kinks” will work themselves out, but instead of feeling in less pain, you are in more pain after class? I don’t think this is a situation that only I have experienced in my over 30 years of practice! And I have begun to think of this topic as a means of exploring self-empowerment and non-judgment.

So, why do we continue to participate when we know we should stop? All of my fellow bloggers have addressed this issue in slightly different ways, whether it is in our approach to eating, sleeping, or basic life stressors.

I think we can explore this idea on a psychological /emotional level or on a gross physical level. I will start this discussion with the gross physical level of the body. First off, the practice of asana is not just a physical body moving through space following the commands of our central nervous system. Each time we move into a yoga pose there can be a flurry of self-judgments and criticisms—”Oh no, not this pose again, I can’t ever do this, I hate this…”—the internal psychological dialogue can be unending. It takes a lot of mental discipline to quiet the mind to be fully in the asana. But then the actual physical body can start its own chorus of complaints—“This is making my knee hurt, or my back or my shoulder.” The mind can and does ignore a lot of this noise, “strong arming” the body into submission. But that cranky joint knows when to strike back and it often does. So, when should we listen to the body over the noise of the mind?

I often tell my students that it is extremely important to understand our own physical as well as mental limitations and to respect them. Pushing beyond one’s actual abilities does lead to injuries (see Baxter's post Getting Clearer on Yoga and Risk of Injury). So when and how do we improve our abilities without causing injury or damage? We have to know when to stop!

With that in mind, here is a list of physical warning signs that would be important to acknowledge:

1. Pain progression in both intensity and location. A back pain that is located centrally in your spine that starts to spread outward or downward is a warning sign to stop that activity. Another warning sign is when the area of pain totally changes location from back (spine) to arm or leg.
2. Pain intensity. Pain is usually quantified on a 0-10 point scale where 0= no pain and 10 is excruciating intense pain. Any pain that moves from negligible, like a 3, to a 6-7, is not something you want to encourage. 
3. Loss of sensation in a limb, an increase of numbness, a tingling, or burning that doesn’t stop once the position is changed.
4. Increase in a sense of “unease.” You don’t know why this activity is making your nervous, unsettled or agitated, but it would be wise to stop the activity and ask your teacher afterwards.
5. Any sensation of dizziness, nausea, double vision. These are not symptoms that are a healthy benefit from asana.
6. Any signs or symptoms of heart racing or feeling that your heart beat feels irregular.
7. Physical exhaustion. Instead of feeling better as the class progresses, you start to feel more and more exhausted.
8. Mental exhaustion.

If any of these events occur during a class it would be wise to stop and sit leaning against a wall. Sometimes closing your eyes or going to get a drink of water will be helpful. Other times just stopping and lying down in Savasana will work. Finally, there may be times actually leaving the class is necessary. If this occurs, quietly get up and leave the room. Your teacher may or may not come to talk with you. If he or she does approach you, briefly let the teacher know what is going on with you. If you are concerned about discussing medical issues in front of the class, only discuss what you feel comfortable with. Then, especially if this is a regular class that you attend, consider contacting the teacher afterward to give him or her the complete information. Having complete information about your condition will help your teacher do a better job of making your next experience in class a good one.

For information about what you might want to tell your teacher before a class, see What Your Yoga Teacher Really Wants to Know.

Range of Motion: Yoga's Got It Covered!

by Nina and Shari

Moving the Shoulder Joints

In the spirit of trying to focus on the benefits of yoga practice (see We Didn't Mean to Scare You) and not just potential problems, I’ve asked Shari Ser to work with me on a series of posts about the special benefits of yoga asana practice. One of the special benefits of yoga asana practice that I’ve really come to appreciate in recent years is how helpful it is for maintaining and/or improving range of motion in our joints. Yeah, I know that sounds kinda nerdy—and “range of motion” is definitely a technical anatomical term. But I really feel it is worth understanding this concept and why it is one of the ways in which yoga is such a wonderful and versatile form of exercise. I decided to start by asking Shari to go over the basics.

Nina: What is range of motion?

Shari: Our bodies move through space because of the unique construction of how our bones fit together to form joints. Muscles are what make these joints move through space; physical motion is caused by muscle contractions. All joints in the human body have an optimum amount of motion, but specific joints in the body, such as hip joints or shoulder joints, don’t move the same way due to unique architectural constructs. When we describe joint motion we are talking about how much movement occurs at a specific joint, and this motion is called the RANGE OF MOTION (ROM).

All joints of the human body have a prescribed degree of movement. Range of motion is described very precisely by medical professionals, and they have determined specifically how much motion a shoulder joint has, a knee joint has, a thumb joint has, and. These measurements are considered the "normal" range of motion of the joint.

When a joint moves more than the prescribed degree of normal movement, that joint is called “hypermobile.” (Have any of you had a yoga teacher tell you that one or more of your joints is hypermobile?) When a joint moves less than the prescribed degree of normal movement, that joint is called “hypomobile.” There is also a basic principle regarding joint movements: the more flexibility, the less stability; the more stability, the less flexibility.

For those who have an overly mobile joint, we can practice yoga to gain stability and strength to control our excessive flexibility and ROM.

For those who have limitations in ROM, which can be caused by muscle weakness, muscle tightness, arthritic boney changes where some barrier is stopping movement (like bone spurs), inflammation and swelling from acute injuries, yoga can be used as a therapeutic modality for ROM gain. 

Nina: Yes, I have often heard from my teachers, that students who are overly flexible need to build strength and stability and students who are tight need to work on increasing flexibility. And since we have both stretching and strengthening in yoga, it’s perfect for both groups. But let’s talk now about why range of motion is important for healthy aging.

Shari: A yoga teacher once said to me, “I do yoga so I can do the other things in my life that are important to me.” I don’t think I understood her comment way back then, but now in my 50’s I definitely do! To maintain optimum ROM throughout all my joints allows me to continue to be independent and take care of my business. Several posts back, Baxter talked about independence in seniors when he visited nursing homes or assisted living facilities (see Transferring and Yoga: Wisdom from Jane Fonda). It is the little things that we take for granted, like bending down to pick up a paper clip or tying our shoes. If I didn't have full mobility in my shoulders, hips, back, knees, or the dexterity to do a fine task like tying my shoes, I would either have to change my style of footwear or ask for assistance! The other objective in keeping up your joint ROM is "use it or lose it." Putting your body into positions (asana) that it might not do daily allows for ROM maintenance, keeping arthritis at bay, keeping muscles strong and healthy, and encouraging full body circulation by the squeezing and soaking that asana encourages.

Nina: Why is yoga better than other forms of exercise in maintaining ROM in joints?

Shari: If you have limited time to exercise and are looking for the best type of exercise for ROM, yoga is often recommended. But why wouldn't another type of full body exercise like walking or swimming be just as good? In our yoga practice we rarely do the same routine daily. For a well rounded yoga practice—whether we are in a class or practicing on our own—we vary what we do. We emphasize different motions to cause our joints to move in many different ways and directions. Some days we might choose to do standing poses and focus our practice on hip motions or our spinal motions like twists or forward bends, or backbending. Other days we might emphasize our shoulders and spines in backbends or inversions. Our choices are practically limitless and often depend only on our skill set, time and focus. In other types of exercise like walking, we might vary our walks by emphasizing a hilly walk or a walk with a lot of stairs. We can vary our speed of walking and our stride length. We can certainly walk to increase our heart rate, and we can definitely bring our hearts into a training zone. But walking does not improve our ROM and quite often can actually make us less flexible. Swimming, another full body exercise is also quite popular, and while it definitely can improve ROM through varied strokes and resistance, it does not fully involve all our joint ROM like yoga.

In addition, the beauty of yoga for ROM maintenance and improvement is the adaptability of asana to meet us where we are. With a skilled teacher almost every single yoga asana taught to a beginner can be modified to take into consideration ROM loss. With the usage of different props and static holding of an asana we can improve flexibility and motion significantly over time. The only downside is that yoga changes are slow and take patience.

Nina: That’s a great point about how all the poses can be practiced in one form or another, even by beginners, because that means that all the benefits for joint range of motion are available to every practitioner. So what kind of yoga practice would you recommend for someone who is concerned with maintaining and/or increasing range of motion in their joints?

Shari: Your practice should include a wide array of poses that are kept lively, with focusing on a different concept each time you practice. No daily practice should always be the same because we will not improve our abilities and an unvarying practice can lead to overuse injuries.

To maintain or increase ROM in a particular joint, such as your hip or shoulder joints, we need to challenge the joint we are focusing on. Taking the joint into a stretch and statically holding the stretch for up to 30 seconds will cause scar tissue to begin to stretch. The key point here is to make sure that the stretch feels broad and there is NO RIPPING sensation. This is when props might be suggested to make a pose more accessible, and then once the pose is understood, slowly removing the prop support so you have to "work a bit harder." There are plenty of techniques for stretching which all of us have touched on in the past so you might want to review these posts again (see How to Stretch among others). Also when there are ROM limitations on one side only, please only go into the range of movement for the stiff joint and limit the more flexible side. This will help you keep symmetrical in your practice.

Nina: Thanks, Shari! For me, at this point in my life, I really value how yoga includes such a rich variety of poses and ways of practicing that allow us to take our joints through a variety of motions. For example, the various standing poses, many with a feet-wide-apart stance, take your hips and shoulders through forward bending, twisting, backbending, and so on. I can’t do them all every day, so I try to balance my week by doing different standing poses on each of the days so by the end of the week, I’ve gotten through most if not all of them. I also do regular hip stretches to maintain ROM in my arthritic right hip—and so far, that’s been working well! 

And, dear readers, I hope this discussion helps deepen your appreciation of yoga asana practice. And if your practice isn't already filled with variety, I hope you'll be encouraged to start to mix it up!

What is Osteopenia? And How Can Yoga Help?

by Shari

Last Friday Baxter answered a reader’s question about osteopenia (see Friday Q&A: Yoga and Osteopenia), regarding whether or not yoga practice on its own is sufficient to maintain and/or increase bone strength. By chance, we recently received a request for an article addressing “dangerous” poses for osteopenia. Since most of you probably don’t know much about osteopenia—and its relationship to osteoporosis— we decided it was about time to provide some background information about the condition. I promise I’ll get around to answering the reader’s question eventually! Look for it this coming Friday.

Let’s start by discussing osteoporosis, which is a disease in which bones become fragile and are more likely to break or fracture due to loss of density (not bone strength). It is not painful and many people (both men and women) don’t even know they have it or are at risk for developing it until they take a DEXA scan. The DEXA scan (dual energy X-ray absorptiometry scan) measures bone mineral mass, because medical researchers have discovered that there is a correlation between bone breaking and bone density loss. But the DEXA scan can also cause lot of confusion because it doesn’t take into consideration the different way bones are constructed. Some bones are short and fat, and some are long and thin, and differently shaped bones can have different density readings. Bone mass is affected by both how densely a bone is constructed and by its corresponding physical dimensions.

Femur Bone

The World Health Organization has defined the statistical measurements of bone density through a system of comparing your numbers to women of the same age, height and weight, and then comparing them to the average measurements of women age 25-30 that are at the peak of bone strength. Three areas are measured in the DEXA scan: lumbar spine, total hip, and surgical neck of the femur (thigh bone). Two scores are given:

• T score, which is the measurement of bone mineral density and how your score compares to healthy 25-30 year old women.
• Z score, which is the comparison to women your age, height and weight.

Osteopenia is defined as a T score of 1 to 2.5 standard deviations below the mean (negative numbers), and means that you are at risk for developing osteoporosis. Osteoporosis is defined as a T score of 2.5 standard deviations below the mean (negative numbers). The higher the T score (or the more negative the numbers), the higher the fracture risk.

The correlation between a low bone mineral-density reading in a DEXA scan and a higher fracture risk is stronger than the relationship between high blood pressure and a stroke. But even though the test detects 9 out of 10 people with osteoporosis, the test is not perfect and it wrongly diagnoses healthy bones between 5-7% of the time. Also, readings will differ in different test sites, so for consistency the same test facility needs to be used for repeated scans.

So how does yoga fit into this picture? Bone has two main components: outer bone and inner bone. Bone is a living matrix of living cells and canals that are interrelated. Outer bone, which surrounds inner bone, is called the cortex and it forms a hard outer ring and is a large part of bone strength. Its construction is fairly uniform in individuals. Inner bone is spongy and is called cancellus or trabecular bone. It varies greatly in individuals. For us to improve our bone health we want to not only build outer bone but also inner bone.

Wolff’s law describes bone strength as follows:

1. The architectural strength of a bone develops along the lines of force that the bone is subjected to.
2. If a bone is loaded, the bone will remodel itself over time to become stronger and resist that sort of loading.

In conjunction with Wolff’s law there are some other important forces that act on the bones to improve bone strength and density:

1. Gravity increases bone loading. 
2. Muscle contraction increases bone loading. Dynamic tension occurring between muscle agonist and antagonist affects the bones by applying opposite pressures, and the forces are doubled on the bone.
3. Muscle activity stimulates bones to strengthen themselves more vigorously than weight bearing alone.

In our yoga asana practice, we not only take weight-bearing positions, such as standing poses, but all the active poses involve muscle contraction in some form. And the great variety of poses and movements means that all your bones are involved! In addition, Dr. Loren Fishman cites from his extensive research on osteoporosis that bone stimulation (growth) occurs after 12 seconds of static (isometric) hold but not more after 72 seconds of hold. 20-30 second holds are recommended for bone stimulation. And 20-30 second holds are quite typical for many of the poses we practice.

Now you can see why yoga is recommended for people with osteopenia as a way to prevent the development of osteoporosis and is also considered beneficial for people who already have osteoporosis. And for those of us who don’t have either condition, yoga is a very versatile and adaptable way for maintaining our bone strength. However, because osteopenia means more fragile bones, certain yoga poses are considered risky for people with the condition. Tune in Friday for my answer to the reader’s question about those poses.

Ruminations on Health: What We Can and Cannot Control

by Shari

Branches by Brad Gibson

I grew up in an eastern European Jewish household where dinnertime conversation often centered around health. Family gatherings were punctuated by relatives recounting details of various  ailments and how many doctors they were seeing. They were often pretty graphic in their descriptions during these mealtime conversations. My family’s preoccupation with their bodily functions struck me as odd as a child, and I didn’t understand how people could complain about their health but not really do anything about it. I made a conscious decision at that time to be proactive with my own health, and my lifestyle decisions and pursuits since then have reflected this.

Now I'm at the age where I am regularly receiving AARP notifications, and I'm starting to reflect on how I may be more like my parents and family than I may like to think. How many of you regularly talk with your friends about your health concerns or routine tests that a physician may be prescribing or recommending? We talk about these issues partly to become informed about procedures, but also to commiserate and offer support and empathy when complications occur. We often compare notes on which care providers have been helpful to us. There have even been times where I have looked up providers on YELP to see what their ratings were. During the AIDS epidemic in the 1980’s, my husband and I lost many friends, so we learned that illness isn’t just for “old people.” And how many of us have lost loved ones and acquaintances to cancer or other chronic diseases?

In the yoga community there are many passionate individuals who believe whole-heartedly in a way of health that I feel is fairly rigid. My own personal pet peeve is the often unspoken allegation within alternative healthcare communities of “healthy living” that if you lived a more “pure and holistic life,” this illness or health problem wouldn’t be happening to you. Too many women I have known with breast cancer have felt the twinge of anxiety that they were the cause of their own cancers. But how much do we owe to our own genetic predispositions rather than to emotional and environmental stresses?

My mother, for example, died of multi-infarct dementia, which caused severe dementia in her last years. She was a cholesterol producer, and no amount of dietary restrictions or faithfully taken statins could keep her cholesterol levels within “therapeutic ranges.” And lo and behold, right after I turned 57 and went for my annual physical and blood work, my doctor contacted me to tell me my “bad cholesterol levels were high.” With further blood work, using more sensitive lipid panels and getting a more complete picture, my numbers came back better. But I was still demonstrating risk factors, so my doctor counseled me on good nutrition (which I already practice), exercise (which I already do), and stress reduction (which I already do). She then commented to me, “Well I suppose this is where your genetic history is coming into play and we just have to watch it.” Oh dear, I thought, now what?

In Melitta’s recent post Aging, Diabetes and Yoga I was struck by her self education regarding Type 1 diabetes, and how she had to play an active role in her healthcare management, even educating her physician on the nature of her disease to get a proper diagnosis. Her story emphasized the need to be involved in your healthcare decisions and not be passive in accepting what “experts” tell you. But it was also inspiring to me because here was someone who was both realistic about her condition (yoga cannot cure Type 1 diabetes) but who at the same time found yoga invaluable for helping her live with (and work with) a chronic condition.

It got me thinking about my own situation. I considered becoming more restrictive with my fat intake, but then concluded it would lead to more stress in the long run. I came to the conclusion that I had to accept my genetic heritage. No, I wouldn’t become like my extended family and bemoan the state of my health, discussing it whenever the opportunity arose while taking no responsibility for my actions. Nor would I become strident in regimenting my life with countless restrictions and intentions. Instead I decided to mindfully continue to engage in activities that made me feel good while maintaining an awareness and consciousness of what and when I ate. As in my yoga practice, I will aim for balance and intention. My genetics are a big factor in my health, but my lifestyle and personal practice of yoga seem to be potent tools that I can use in accepting my genetic hand of cards!

Staying Safe with Degenerative Disc Disease

by Shari

I thought I would follow up on Baxter’s excellent post about preventing spinal degenerative disc disease Degenerative Disc Disease and Yoga by discussing how you might practice yoga safely after receiving this diagnosis.

To begin, it is important to understand how to influence the health of your spinal discs in your asana practice. The spinal discs acquire their nourishment from movement. In asana we move the spine throughout a range of motion that includes flexion (forward bending), extension (backward bending), rotation (twists), and side bending. Almost all asanas combine these movements. Rotation and side bending always occur together, for example, in Triangle pose (Trikonasana). And flexion poses (forward bends) will often be counterbalanced with extension poses (backbends) and vice versa. A well-rounded asana practice will include all these motions in almost every single pose, even Savasana (Relaxation pose), depending on how you position your legs.

If you have received a diagnosis of degenerative disc disease, this indicates that your spinal discs have become brittle and thin. Because of the inherent changes in their structure, the spinal discs are more prone to injury. The vertebral body is supposed to be the main weight-bearing surface for the spine while the intervertebral disc distributes the weight and acts as a shock absorber for stresses that occur from gravitational loading. But when the disc is compromised, more weight-bearing through the vertebra will be distributed onto other structures. Some of this weight may be transferred onto your facet joints, which are not weight-bearing structures but mobility structures of your vertebral column. And with this increased weight-bearing, your body may then respond by the formation of “more bone” for protection of these structures, which can be come painful bone spurs.

The Spine with Its
Three Curves

So what is a poor yogi to do? Start by returning to your Tadasana (Mountain pose). Because postural habits are one of the most important factors in developing degenerative spinal changes in the discs, learning to stand well both on and off the mat is critical in maintaining spinal health. When you think about it, even though you practice daily for 30 minutes, eat well, get enough sleep, have a good meditation practice, and are happy and healthy, if your posture is compromised, the result as the years go by is spinal compression. Learning to incorporate Tadasana into your everyday activities of driving, sitting, bending, and so on, will go a very long way in lessening the impact of spinal compressive forces. This means keeping a “Tadasana spine” (with all three spinal curves) as you move from your hips, and learning how to bend and reach and twist without causing excessive pressure through your discs and vertebrae.

In addition to maintaining your Tadasana spine, I would also recommend that you use props when either doing your own home practice or attending class. Using a strap, chair, block or wall can be helpful in teaching you what your own body can do without pain. To keep your body safe and healthy, you should ensure that your asana never hurts.

Those of you who practice Iyengar-style hatha yoga will know what I mean when I say “props” but for those of you who practice different styles of yoga this may be a foreign concept. In that case, I recommend that when you practice you at least pay very close attention to how you are moving. Where do you initiate movement from when you go into or out of a pose? Where do you start when you come out of a pose? How do you use your hips? And your legs? Where is the weight and force coming from? Do you quickly move through a motion because it hurts but once past that “bad spot” you are okay? What happens if you don’t go so low or so deep?

In addition, working on core strengthening, using your legs effectively, breathing correctly, and maintaining (or developing) adequate flexibility will all help in keeping your spine safe.

Finally, I suggest examining how you set yourself up in Savasana. Both Nina and Baxter have talked before about different ways to position yourself in Savasana (see Savasana Variations). The version with legs on a chair (be sure the chair is the proper height for your body proportions) puts your spine into a more “neutral position” than when your legs are straight out on the floor. But this isn’t necessarily comfortable for every one. When we lie on our backs, some of us like to feel the small of the back making more contact with the floor while others of us like a bit more arch. That is the thing with all degenerative conditions: one size doesn’t fit all. So a bit of experimentation is important. It’s also a good idea to consider your sleeping positions and the support of your bed. If you aren’t well-rested and comfortable in your bed, then no amount of yoga is going to make you feel better. So take the awareness you bring to Savasana—and all your yoga poses—into your bed with you to set yourself up for a comfortable and healthy sleep.

Yoga and Shoulder Joint Replacements

by Shari

Nina and Baxter asked me to finish up the total joint replacement series with a discussion about shoulder joint replacements. Like the other joint replacements previously discussed, people will consider shoulder joint replacement when all other conservative approaches have failed. The difference in shoulder joint replacement compared to hip or knee replacements is that this procedure is far less common. So if you are thinking about a shoulder replacement, it is considered a good idea to find a physician who has already done a significant number of these surgeries (one place to look is the American Shoulder and Elbow Surgeon’s Society).

Now let’s review why you might consider this treatment. Pain is often the most significant problem that an individual is suffering from. Other symptoms might include stiffness, loss of functional motion, inability to sleep on that shoulder, decreased range of motion and symptoms that are worsening with conservative treatment approaches (whether western or alternative methodologies).

Healthy Shoulder Joint

Regardless, your first step should be thorough diagnostic and physical evaluation from a qualified surgeon that includes X-rays and whatever other tests the physician orders. There has to be a differential diagnosis that separates out the cause of the pain. Rotator cuff tears or avulsions, frozen shoulder, cervical and thoracic spinal pain, shoulder bursitis and other forms of soft tissue inflammation, avascular necrosis (in which the blood supply to the joint is affected), and infections will all cause shoulder pain that can be unrelenting. Metastatic disease or other tumors can also be the cause of shoulder pain so the differential examination is critical in trying to pinpoint the problem. So only once it has been determined that your shoulder pain is due to arthritis (where the cartilage covering the joint surfaces is affected) should you explore your options for shoulder replacement. After you have determined that you’re a good candidate for the surgical joint replacement, you will probably wonder how is surgery this going to affect your yoga practice, including how longer after the surgery will you be able to do yoga again and, when you do resume practice, which poses should you avoid and for how long?

Shoulder With Joint Replacement

According to my research as well as my personal experience as a physical therapist, yoga practitioner and yoga teacher, this procedure has significant post-operative protocols. This means that there is a very specific healing algorithm that your surgeon will adhere to. It does not help if you are a “fast healer” because if you push too much and too fast, for this surgery in particular, you will be setting yourself up for significant problems in the future. This surgery is very complicated because the subscapularis is detached to expose the glenohumeral joint and then reattached after surgery. The rotator cuff may also need to be repaired because often in severe shoulder arthritis, the soft tissue ligaments and muscles are severely affected and may also need repair due to compromised biomechanics and impingement in the shoulder joint.

The literature I reviewed states conservatively a three-month recovery but more common is six to twelve months post-operative recovery with very strict dos and don’ts. And unfortunately I cannot go into what you can and can’t do here on this blog because that is totally dependent on your surgeon and which type of procedure he or she deems is appropriate for you (there are four different types of shoulder replacements).

But from a yogic perspective, here is what I can recommend. Start by being in the best possible health you can be before surgery. Understand that you will have a lot of work to do in your post-operative recovery, but believe 100% in your ability to recover and in your surgeon.

Have stress management techniques that you do regularly as part of your healing repertoire. Pain medication is not something to be shunned but used responsibly and respectfully as part of your healing process. But, because pain is a very subjective experience, yoga and stress management techniques, though not substitutions for pain medication, can be an adjunct in allowing you to “relax into the pain.” Deep breathing in particular does a world of good for your body post operatively and into your healing process. It allows your lungs to be used to prevent post-operative complications, and is also calming and a good focus for your mind when you might be counting the minutes until you can take your next pain medication dosage. Simple deep breathing also assists in decreasing muscle tension from unconscious holding and splinting because you are in pain. You may also want to work with lengthening your exhalation to assist in stimulating your parasympathetic system (triggering your relaxation response). Other stress management techniques you could explore include: meditation, Savasana (Relaxation pose), and Yoga Nidra.

Be familiar with restorative poses, such as Reclined Cobbler’s pose (Supta Baddha Konasana), Legs Up the Wall pose (Viparita Karani), and Supported Relaxation pose (Savasana) that you can do while adhering to the post-operative protocol. Shoulder positioning and propping is very important for your post-operative pain management, and your physical therapist or surgeon (or their support staff) should be able to assist you in ways to position for improved comfort. Once you understand how to position your arm in these poses (for example, using support under your arms and shoulders or having your arms in a neutral position) then you should be able to figure out how to set yourself up for restorative poses without putting your shoulder into a compromised position. Remember, how you go into and out of poses, including restorative poses is important. You may find that your bed is a perfect place to practice restorative poses because it is easier for you to position yourself.

Once you are allowed to start exercises with your physical therapist, be very clear in asking when you can do which poses, bringing pictures to demonstrate. Taking your arms out to your sides in standing poses may or may not be possible because just the weight of your arm being statically held may be contraindicated. Then, before you return to your yoga class, please contact your yoga teacher and explain your limitations and restrictions. It is your responsibility to educate your yoga teacher on your particular needs and then he or she can help you keep your practice safe within the guidelines you understand from your physician.

Finally, please be gentle with yourself and don’t overuse your arm even just a little bit. When you are allowed to stop wearing your sling, you might find that you can practice with your sling on more successfully then with your arm out of it. Stay away from weight-bearing poses like Downward-Facing Dog pose until you have medical clearance (even Half Dog pose at the Wall). Night-time positioning and pain management are often the most challenging. Make sure you understand your pain medication recommendations and do what ever your surgeon tells you. After all, you only want to do this surgery once. So be patient and creative. And good luck!

Keeping Your Sacrum and SI Joints Happy and Healthy

by Shari

Keeping His Sacrum Happy and Healthy

Now that I’ve described how the sacrum moves (see Yoga and the Sacrum), let’s look at how the sacrum and sacroiliac joints work in some of the typical yoga poses we encounter in a class, and how to keep your SI joint healthy and happy while you do them. Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

Note that if you think you might be having sacroiliac join problems but are not sure, I would recommend that you should not try to diagnose yourself. Instead, please try to consult a health care professional for a diagnosis. And although this injury is more common in women, it definitely occurs in men as well, so you guys should also get yourself checked out. Finally, for any of you pregnant yoga practitioners or teachers who teach pregnant women, all of these suggestions that follow are beneficial for pregnant women.

Now let’s get started at the beginning of a typical class. Warm ups are often asymmetrical because we work first with one leg and then the other. A typical warm-up series might include hip openers, reclined leg stretches (Supta Padangusthasana), Figure Four pose, and so on. Any type of hip opener that is asymmetrical will put different stresses on your SI joints. So for our Figure Four pose, when we stretch the piriformis on the right, the sacrum will be turned to the side that is being stretched, the right side. And conversely the sacrum will be turned to the left when we stretch the left piriformis. That’s all well and good, except if you have a piriformis that is already in spasm. Stretching it more only inflames that poor little muscle, so avoid this asymmetrical position if it hurts (or if starts to hurt while you’re in the pose, come out).

Leg stretches are also poses you may need to approach with care. If you are really tight, when you stretch your hamstrings, the hamstrings pull on your ischial tuberosities ( the sitting bones of the ilia), which flattens your lumbar spine and pulls your sacrum into a flexed position. This may cause you pain because as your sacrum is pulled down into the ilia, the two sides may not be moving equally (one side will be moving more than the other side).

When you take your leg out to the side and are stretching your adductors, try not to roll onto the SI joint of the raised leg and have the opposite side of the pelvis roll forward. Learn to move from your hip joint and limit the stress through your sacrum. If one side is tighter than the other, this may also create an asymmetry in the sacrum that will cause pain. In this case, less stretch is better (use a wall to stop the stretch on the raised leg, or use a block, chair, or bolster to limit the stretch).

For standing poses, if you are having SI problems, focus on symmetrical poses and using props. Also, be kind to yourself—think I am going to do 50% not 125%. Standing poses which are done with wide legs and an asymmetrical pelvis position may strain the ligaments holding the sacrum in place, which can then cause subsequent pain. Try firmly contracting the back leg to give some stability to the sides of the sacrum. Although Wide Legged Standing Forward Bend (Prasarita Padottanasana) is a symmetrical pose, how deep you go into the pose and what position your spine is in will all contribute different problems to the sacrum. So, when in doubt, try to keep your spinal curves in neutral and use a chair to take the torso’s weight and do less stretch than more.

In seated poses, spinal position is paramount. You want to keep your spinal curves in neutral and have enough height under your ischial tuberosities (sitting bones) to encourage your ilium to rotate over the femoral heads (hip joints). And never use your arms to pull yourself into pose, but instead rely on your abdominal muscles and spinal stabilizers. This applies to all practitioners, as both a preventative approach for those of you with no current problems as well as a therapeutic approach for those of your with SI problems. As Baxter mentioned, you want your sacrum to move with the ilia, not to be “held back.” If you are currently having symptoms, I would avoid revolved seated poses for quite a while until the symptoms are gone and you understand your vulnerabilities.

Backbends will either feel great or terrible, depending on your issues. Backbends and forward bends position the sacrum into very different positions. In forward bends the sacrum is less stable. In backbends the sacrum is more stable. But stability doesn’t mean it is going to feel good if the inherent alignment of the bones is not congruent.

If backbends feel good, pay attention to symmetry in how you go into and out of a pose. And be careful not to tuck the bottom of your spine—you lumbar spine needs to be in lordosis (curved) when you do backbends, which then puts the sacrum into a more optimum position. And less is better than more as you are healing.

However, if backbends feel terrible, don’t do them. Rather than putting a block under your sacrum in an easy Bridge pose, try an active Bridge pose and slowly evaluate how you feel afterwards. Less lifting is also crucial.

I hope this advice is helps you keep your sacrum happy and healthy!

Yoga and the Sacrum

by Shari

Nina asked me to expand a bit on Baxter’s previous post on sacroiliac challenges with asana practice (see Friday Q&A: Sacroiliac (SI) Joint Injuries). I wanted to start by giving a little more background on sacroilac anatomy. As Baxter previously stated, the sacrum is nestled in between the two ilia bones that comprise the pelvis. The front of the pelvis is the symphysis pubis and the back is where the sacrum is located.

The sacrum is affected by many different forces. Along with the pelvis, it forms the bridge between your head, spine, torso and arms with your legs and feet. All forces from the top of your body pass through your sacrum and out to your lower limbs, and at least sixty muscles directly or indirectly affect the sacrum.

However, the sacrum does not move on its own but moves only because of the connections it has to the two ilia bones as well as the muscles that either directly insert onto it or cross over it. This means that the sacrum can only be passively moved. The sacrum’s passive motions caused by muscle action directly onto the pelvis and coccyx (think pelvic floor muscles also) include pivoting (forward and backwards motion) and rocking (spinning on a certain axis).

When you go into a yoga pose, how you set your legs and pelvis up is going to directly affect forces on your sacrum. So if you are turning your pelvis to the right, unless your legs are in the same direction as your pelvis, your sacrum will get conflicting forces through it. There are too many muscles to go into in here, but it’s important to understand that the leg muscles that cross from your pelvis to your femur and the abdominal muscles that attach to your pelvis will have a profound affect on the position of your sacrum. The spine also has a direct effect of moving the sacrum, especially L5 (the lowest of the five lumbar vertebrae) as well as the two ilia bones.

Why the sacrum is so important for yoga students is that we put undue strain on the ligaments that are firmly holding the sacrum in place with the two ilia and on the ligaments that hold the sacrum to the L5 vertebra, particularly when doing asymmetrical poses. And one of the main muscles that has a direct affect on the sacrum is the pesky piriformis. Now why, of all the 66 muscles, am I singling out the piriformis? Well it is one muscle that many yoga students have heard about, and it is one of the main muscles that we stretch when we do Thread the Needle or Figure Four pose. The following figure shows the muscle in red (and you can see how it connects the sacrum and to the leg):

That's it for now! Tomorrow, we'll look at how the sacrum and sacroiliac joints work in some typical yoga poses (see Keeping Your Sacrum and SI Joints Happy and Healthy). Hopefully this will provide help for people who are already suffering from sacroiliac joint problems as well as for people who would like to avoid developing problems.

Knee Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s previous post Arthritis of the Knee and Yoga about what the next step might be when your own self-care management techniques are not as effective and your quality of life is severely impacted. So I thought I would you give some background about the elective procedure total knee replacement and why you might elect to have it done. Professionally, I see a lot of total knee replacements in my work as a home health physical therapist, and I also have yoga students who come to my class either after the procedure or beforehand as they are preparing themselves for the surgery.

Although many people will never need surgery for arthritis of the knee, if you have severe joint damage, extreme pain that isn’t helped by other treatments, or very limited motion as a result of the condition, knee replacement surgery may be necessary. So if the arthritis pain in your knee worsens, and the exercise that once helped you feel better has become unbearable, your doctor may recommend a total knee replacement (TKR). Surgery for osteoarthritis can provide several benefits, including :

• improved movement
• pain relief
• improved joint alignment

When you research the procedure, you will discover there are gender-specific knees, which are knee replacement models designed for women, and dozens of other options, too, including different materials, sizes and models from a variety of manufacturers. How do you choose? Generally, you don’t. Surgeons typically determine which implant they’ll use when they are in the operating room and actually looking at the structure and size of your bones.

X-Rays of Knee Replacements (from Wikimedia)

Prior to surgery, however, you should have an informed conversation with the doctor about your options so you can ask good questions about why a particular model might be chosen, and determine if you’re comfortable with the doctor’s approach and experience or whether you’d like a second opinion.

When only a portion of your knee has severe arthritic wear and tear symptoms, as confirmed by diagnostic testing as well as subjective complaints, you may be recommended to undergo a “partial or unicompartmental knee replacement.” This may be recommended because it helps to straighten up the joint, which has changed its position as a result of osteoarthritis. Partial knee replacement can be more effective and durable if appropriate and are less invasive. Recovery time is less because there is less surgical trauma.When the entire knee joint is replaced that is called a total knee replacement, and the ends of the femur, top of the tibia and often the patella (knee cap) are fully replaced.

When you are ready to return to your yoga class, you should take time to talk with your teacher about your knee replacement. I will routinely ask these students a series of questions:

1.    How long ago was the surgery?
2.    Are you still in pain?
3.    Are you still in physical therapy?
4.    Do you have any hip or back pain (either before or after the knee replacement)?
5.    How much mobility do you currently have? Can you get up and down from the floor?
6.    Do you have arthritis in any other joints?

So be prepared to provide your teacher with this information. Knee range of motion will vary widely both in a recent post-operative knee as well as a knee replacement that is over one year old. A lot depends on how much motion you lost prior to the surgery and how hard you worked postoperatively. The answer to the question “Can you get up and down from the floor?” is important because it tells the teacher a lot about a student’s flexibility and strength. Knee flexion will vary considerably, but I have never seen a knee replacement with 155 degrees flexion nor have I ever seen someone able to do a deep squat. Whether this just happens to be my student demographic or not, I don’t know.

When resuming yoga practice, alignment is a big deal with knee replacements because post operatively you want to avoid torque forces through the joint because that affects cement in the joint. “Closed chain activities,” where your weight is shifted with your foot remaining on the floor,” where your foot is lifted off of the floor with subsequent weight bearing will affect the joint differently. For standing poses, I teach students with recent knee replacements to pick their feet up and then replace and position as opposed to pivoting to change directions. Down the road, you can introduce pivoting if it doesn’t cause pain or discomfort. Liberal usage of props; walls, chairs, blocks will assist the student in not over-doing too quickly.

Strengthening all of the muscles that cross the knee joint as well as secondary stabilizers is also important. This means front, back and side leg muscles. Attention to hip alignment and strength also translates to protection of the knee replacement. Kneeling is problematic but not necessarily injurious to the new knee. Finally, pay attention to the feet—where is the weight on the foot? A lot of individuals who suffer from arthritic hips and knees have feet that need some tender loving attention. Baxter in his prior posts talked about feet (see Your Feet on My Mind), and I agree that where the body meets the ground and how we stack up from there is crucial in protecting our joints for longevity, especially when we become bionic.

I would like to add that lot depends on your pre-surgical state of health. If you have been active up till the day of the surgery then your recovery time will take about three months till you feel like you have integrated the new knee into your body. This is a rough estimate, but it seems about right for a traditional total knee replacement. Minimally invasive and partial knee replacements have less trauma, so healing and function comes more quickly. For those individuals who have lost a lot of mobility and have developed severe range of motion loss and significant loss of muscle strength, the recovery time will be more arduous because of all the structural as well as cardiac changes.

Finally I want to emphasize this: talk to your surgeon before and after surgery to know what your particular limitations and precautions may be, and remember to share them with your yoga teacher. Remember this is an invasive surgical procedure and everyone heals in a different manner. Be kind to yourself and remember that with a lot of hard work you will regain function and improve the quality of your life. This the reason why you decided to undergo this surgical option in the first place.

Total Hip Replacements and Yoga

by Shari

Nina asked me to add to Baxter’s post Arthritis of the Hip Joint about what the next step might be when your own self care management techniques are not as effective and your quality of life is severely impacted. I thought I would give some background about the elective procedure of total hip replacement and why people might elect to have it done. I see a lot of total hip replacements in my work as a home health physical therapist, and I also do have yoga students who come to my class either after the procedure or before hand as they are preparing themselves for the surgery.

X-Ray of Hip Replacement from Wikimedia

As background, here is what the Mayo clinic says about hip replacement surgery:

"Hip replacement surgery, also called total hip arthroplasty, involves removing a diseased hip joint and replacing it with an artificial joint, called a prosthesis. Hip prostheses consist of a ball component, made of metal or ceramic, and a socket, which has an insert or liner made of plastic, ceramic or metal. The implants used in hip replacement are biocompatible — meaning they're designed to be accepted by your body — and they're made to resist corrosion, degradation and wear.

The goal of hip replacement surgery is to relieve pain and increase the mobility and function of a damaged hip joint. If a stiff, painful hip joint has forced you to cut back on everyday activities, successful surgery may allow you to resume them. Conditions that can damage the hip joint, sometimes necessitating hip replacement surgery, include:

• Osteoarthritis
• Rheumatoid arthritis
• Broken hip
• Bone tumor
• Osteonecrosis, which occurs when there is inadequate blood supply to the ball portion of the hip joint

To perform a hip replacement, your surgeon:

• Makes an incision over the front or side of your hip, through the layers of tissue
• Removes diseased and damaged bone and cartilage, leaving healthy bone intact
• Implants the prosthetic socket into your pelvic bone, to replace the damaged socket
• Replaces the round top of your femur with the prosthetic ball, which is attached to a stem that fits into your thighbone

Your new, artificial joint is designed to mimic the natural, gliding motion of a healthy hip joint. "

Artificial Joint from Wikimedia

Techniques for hip replacement are evolving. As surgeons continue to develop less invasive surgical techniques, the hope is that these techniques might reduce recovery time and pain compared with standard hip replacements. However, studies comparing the outcomes of standard hip replacement with those of minimally invasive hip replacement have had mixed results.

Choosing an orthopedist to perform your surgery is a very personal decision and we all research our concerns in different manners. Please, though, when you have found a surgeon that you want to work with, make sure you discuss the different types of hip replacement surgeries that they may perform so you understand clearly the advantages and disadvantages that each surgical procedure presents. Be particular that the surgeon understands your own particular yoga practice and what it entails. Bring pictures of poses that you currently do (or have done) and make sure the doctor understands the stresses you place on your hip joint. Telling a physician who doesn’t do yoga “I do yoga” isn’t enough, so show him or her the positions your hip needs to be able to move through.
The surgical options that exist are very different in what the post operative limitations are and the longer standing limitations that the post replacement hip might present you with.

The basic categories of total hip replacement are either:

• posterior lateral approach
• anterior lateral approach
• anterior approach
• minimally invasive anterior approach or minimally invasive posterior approaches

These are all different, but as far as hip precautions go there are no hip precautions for the anterior approaches.

Now this important for the practice of yoga. Which approach is recommended for your particular situation is going to affect your asana practice. Please ask your surgeon what your post-operative physical limitations are and for how long. Make sure you learn how to safely get up and down from the floor so as to not dislocate your new hip and that you learn the specific precautions associated with your category of hip replacements. The key is that you learn to identify what position is your hip in when you do your poses and you need to think of both legs when you do each side (don’t just focus on the surgical side).

In the more traditional posterior or posterior lateral approach there are limitations on hip flexion, adduction and internal rotation. That means that if you combine these three positions you are more apt to dislocate your prosthetic hip because the muscle support is weakened by the surgical procedure. That is definitely going to affect your asana practice. Poses you might want to not do for approximately six months would be: Standing Forward Bend (Uttanasana), Eagle pose (Garudasana), Cow-Face pose (Gomukhasana), and Child’s pose (Balasana). Gentle backbends generally are okay for posterior/posterior lateral hips.

For anterior lateral hips the precautions will be very different. Typically hip extension and hip abduction will be affected and you don’t want to be aggressive in these combined movements. So start thinking about your backbends and standing poses. Remember that the position of the front and the back legs are very different in the standing poses. The front hip may be placed into positions of flexion and external rotation and abduction but the back hip may be in extension with external rotation.

For anterior hip replacement surgeries the doctor will typically tell you that you have no restrictions but that doesn’t mean you are going to jump back into your asana practice. The hip is going to be sore and painful because of the surgical trauma (though it is less in this procedure than some of the other ones I talked about because there is no actual muscle cutting in this procedure but the muscles are certainly stretched as they are moved for the surgery).

So now armed with your knowledge of what type of hip surgery you have had, and what your physical restrictions are and for how long, consider the critical importance of studying with a teacher who can assist you in practicing safely. Knowing what props to use and when are important, and so is knowing how deep to go into a pose. In addition, different surgeries have different time frames for returning to asana practice but the rule of thumb to return to any activity post operatively is how you feel. You can get time estimates on when to resume an activity but the bottom line is your own healing process and energy level. As always respecting your energy level and not be overly aggressive as you return to your asana practice is crucial.

In my clinical experience I have never had a client tell me that he or she is sorry to have undergone this surgery. In all medical procedures, knowledge, mental and emotional preparation and conviction in your choice of action go a long way towards healing. That certainly sounds like an engaged yoga practice off of the mat!

Planning a Practice for Improving Balance

by Shari

We've had a question about how to practice when you want to work on balance. We're going to take our time addressing this issue because there are several factors involved in balance. When you plan a daily balance practice, it is important to include all six basic balance components:

1.  Strength: Strengthening your legs is critical. Leg muscles that need to be strong for good balance include the quadriceps, hamstrings, adductors, gluteal, and ankle muscles. (Please see Baxter’s recent posts on feet and ankles). In addition, the back muscles specifically the back extensors, are also important.
2. Proprioception: The ability to sense where we are in space is critical for balance. Practicing with an emphasis on proprioception can help maintain or even increase this ability.
3. Central Nervous System Reactivity: The ability to coordinate movements of your eyes is essential to seeing objects in your environment clearly while you are in motion, and other central nervous system reactions help you maintain balance.
4. Postural Control: Standing well is the critical component for maintaining balance.
5. Gait: Varying how fast and slow you walk, as well as the sizes and directions of step, can help you stay more nimble and avoid falling.
6. Vestibular System: The vestibular system is the sensory system that contributes to movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of the inner ear in most mammals, situated in the vestibulum in the inner ear.

You can target your specific “challenge” areas by varying how you incorporate these components in your practice.

Strength

We need dynamic as well as static strength to prevent falling. Simple ways to strengthen your legs can be standing up and down from a standard height chair without using your arms to assist you. How slowly or quickly you do this can add to the variability for the muscles. Holding the position at various points in going down and coming up is also good. Working until your legs feel fatigue is the key to strengthening these muscles. But please remember these types of quadriceps exercises load the knees significantly and they could potentially aggravate an arthritic knee. So be careful.

Another way to build leg strength is a stair-stepping routine of stepping up and down one step with one leg and then changing and doing it on the other leg. You can also side step up and down with one leg as well as back stepping up and down with one leg. Try not to use the handrails unless you absolutely need to. Varying the speed of the step is good, too.

So now to translate this to yoga poses: think Warrior 2, Warrior 1, Extended Side Angle pose (Parvakonasana) and Powerful pose (Utkatasana). Move into and out of these poses first as a flow, pivoting your feet to keep changing directions. Then move into and out of these poses more quickly. Having a friend call out the poses so you can’t anticipate them can be fun—putting together your own sequence to delight your practice buddies! Then working to hold the poses with a timer to build strength. Start with a doable time, for example, ten seconds, and then increase it slowly. Thirty seconds is actually an eternity to hold a pose that is difficult for you. Varying how low you go into a pose is also valuable. Stepping into poses but not taking the actual pose also will challenge your reactions especially if someone else is also calling it out to you.

For back strength (this also includes gluteal muscles), try Locust pose (Salabasana) with arms and legs, as well as an all-fours position with opposite arm and leg lefts (Baxter calls this Hunting Dog pose—see Hunting Dog Pose for complete information on how to do this pose).

For ankles, try lunges with an emphasis on the back foot, toe rises and rocks with no hands (with both legs or one at a time). 
 
Proprioception

Closing your eyes while you practice can help with proprioception. For example, do toe rises and heel rocks but now close your eyes.

You can also work on an unstable surface, such as a foam mat (thick), an inflated air bed, your own bed or a couch (be creative and safe when choosing the unstable surface). Try standing in Tadasana (Mountain pose) with your feet hips-width apart and then with feet together on an unstable surface (first with your eyes open and then closed). After Tadasana, try heel-toe rocks on your unstable surface, first with your eyes open and then closed if possible. If you feel really adventuresome, try some standing poses on this surface, such as Warrior 2, Triangle pose, and Downward-Facing Dog or Hunting Dog pose as shown above. If this is doable, try closing your eyes and doing these poses on an unstable surface. Please make sure that you don’t fall off of whatever you are on because that would really be counterproductive.
 
Central Nervous System

Now let’s add the central nervous system challenge. Standing on an unstable surface, use your eyes to track a moving object. If you are doing this with a friend, he or she can hold a bright object in their hands while you use your eyes to follow their movement in front of you. Do not move your head or body, just use your eyes to track the object’s movement.

Now you can do a dynamic resistive exercise together. Stand facing each other palm to palm with your hands at shoulder height. One person is the leader and the other is the follower. The leader slowly starts to push into the follower’s hands and the follower matches their push into them with an equal push toward them. The leader keeps slowly increasing the force and the follower continues to match it. Then, without warning, the leader with quickly releases the force and move away from the follower. The follower is trying not to fall when the force has been removed. The leader is close enough to steady the follower so they don’t really fall. Change roles and repeat.

Another partner idea is to stand front to front again, but this time one person is holding a light object just out of their partner’s reach. The reacher is trying to lean to grab the object but the partner continues to slowly move the object just out of reach. The reacher cannot move his or her feet but can shift weight or turn without moving his or her feet. High reaching as well as below waist level reaching is good. There will be a point of reach when the reacher will lose his or her balance—that is the whole idea and the person holding the object should be able to assist their partner so no actual fall occurs. Change roles and repeat.

Postural Control

When working on postural control the key is to learn axial (skeletal) elongation as well as peripheral (arm and leg) elongation. The practice of Tadasana (Mountain pose) is difficult because of its simplicity. But learning your own postural habits is something that does affect balance and the ability to right yourself when a fall occurs.

You can address this component with a friend. Get a stick, such as a dowel, that is approximately six feet long and have your friend stand in Tadasana. Place the stick along his or her back body and see how many points of contact there are. Does the back of the head touch the stick? The upper back? The lower back? The buttocks? Do the backs of the knees touch the stick? Then look in an anatomy book to see what ideal posture is. Once you understand what your own issues are, then if you work with a yoga teacher, he or she can help you start to work on those areas that may need some attention.

Another component to address is the ability to safely lift an object off of the floor without falling forward onto your face when doing so. You can try this first with a friend and a light object like a newspaper. Each of you can do the task, which may be easier for some to do than others. Talk with each other to see if you can identify what makes it easy for some of you and more challenging for the others. With this information then you can decide if your personal issues are strength deficits, mobility or flexibility challenges, or other balance issues.

Now back to yoga poses that combine strength proprioception, and posture. Think Tree pose (Vrksasana), Mountain pose (Tadasana), Half Moon pose (Ardha Chandrasana), and Powerful pose (Utkatasana) with eyes open and closed, and with a stable and unstable surface. I am also particularly fond of the all-fours routine (Hunting Dog pose) on an unstable surface with eyes open and closed. Really you could pick one standing pose a week and work it through these variables of changing the surface you practice on, and whether you have your eyes open or closed. Moving into and out of the posture slowly or with variability in the degree of depth of the posture. The choices are endless actually.
 
Gait and Vestibular System

Try varying the speed of your walking—very fast or slow, big steps or small steps, quick changes in directions. You can also try stepping over items and around items, with quick changes again in direction after stepping over objects. Vary the objects you step over; some can be high and some can be low. You could do this with a group of friend, and have one person calling out what to do and the others following the directions. You could add music (like musical chairs) but when the music stops a pose might be called out for you to do.

And then there is what I call the “Queen Elizabeth walk” Walk at a stately pace while waving with alternating hands and turning your head to look at your adoring subject. The idea here is to make your practice fun!

Active vs. Passive Yoga Practice

by Shari

August Flowers by Nina Zolotow

I have been thinking a lot about this topic and how I vary my own practice daily. Common sense would dictate that when you feel energetic you do an energetic practice and when you feel tired or exhausted a restorative or passive asana practice would be appropriate, but it isn’t as clear cut as that. There is this small impediment and it is called your conscious mind.

Now many different disciplines, schools of thought and medical approaches call “your conscious mind” by different names. But I call it that pesky unrelenting little voice in my head that is constantly directing me nonstop. I have noticed though that my pesky little voice has changed from my teens now into my 50’s because of its attention to unending details. What dictated my days then is very different from now. But let me reassure you that my own personal aging process has changed its focus but not its insistence.

Now both Nina and Baxter have very eloquently talked in past posts about meditation, stress reduction, and anxiety management. What I am talking about is different. It is the need or compulsion to be in motion from the time that I wake up till the time I go to bed. I am not the type of person that can “do nothing.” My husband is very good at this activity and often can’t understand why I can’t “just sit down and rest.” This inability to stop motion gets translated too often into my daily asana practice. It is not a frenetic obsession with activity but the time-honored adage: “you don’t rest until all your work is done.” This mind set is very pre-industrial agrarian age when farm work was never done because there always was something more.

But in our computer age with so many technological tools to assist us the busy work really doesn’t stop unless you make yourself stop. It is the same with housework or caring for your family. There never is an end to the work that must be done unless it is your mindset that sets the limit.

So how does one set time aside for a daily practice and then decide what your practice should consist of? It is like do you eat dessert first or dinner? Complicate that with one’s own personality type, the type of yoga that you practice, and your time limitations. If you only have five minutes should you do a quick, one-time abbreviated sun salutation or should it be a Viparita Karani (Legs Up the Wall Pose?) Active vs. Passive. What to pick?

Now here is where the self-introspection comes in and the ability to look critically but without judgment at yourself. What do you feel like doing? Now that is also a very revolutionary question. Our days are filled with doing stuff that we really may not want to do but have to for many various reasons. But when we roll out our mat and give ourselves the gift to make this decision it is very powerful.

There are so many “shoulds” now associated with yoga. Do we do yoga for an external goal? Or is it internally driven? How do we learn to know what we need or what we want? I have learned through my many years of practice that sometimes the decision isn’t obvious and you have to search a little to find the solution.

When I start my practice, I will usually lie on my mat on my back with my knees bent and eyes closed for several breaths as I just check into how I feel that day. I tend to do my practice in the morning (after a 35-minute aerobic treadmill walk and shower), so that is my stiffer time of day even after my own warm up. I might have a vague thought that “oh it is forward bends this week” but that isn’t what I focus on.

I try to listen to how my hips are feeling, or my low back or shoulders, and so on. It always starts on the physical plane. As I start my warm ups (I tend to do a 30-minute practice), I generally try to target those areas in my own body that may be chronically stiff. After my warm up I always do some standing poses. Standing poses can be made challenging by either moving through them quickly or more methodically when one is paying attention to the orchestration of movement. Observing one’s body unfold into and out of an asana is not only mentally engaging but it is a period of immense gratitude.

Then I move onto the main focus of the practice. Is it to be a pose that I love to do, or is it a pose that I struggle to attempt? How hard do I want to work? Is it okay to not want to work? Those are questions that always arise for me in my daily practice. Sometimes if I am sick or getting sick or recovering from some type of cold or flu, it is plainly obvious that a restorative practice is what I need because I literally don’t have the energy or stamina to be vigorous. But it is the other times that are frankly more challenging. I don’t want my yoga practice to fall into the “shoulds” because then I lose the nurturance of the practice.

When I go to a yoga class and the teacher directs my practice it is very different from when I am at home directing my own practice. I don’t have the external guidance of the teacher, but instead I have my own monkey mind that guides me and I have to learn how to acknowledge it but also be a bit firm with. Through the usage of breathing (simple pranayama), I have learned to create my own stress reduction response and I have learned to do it in under five minutes!

The gift of yoga isn’t the complicated poses that I can never accomplish but the ability to work within my own body with the time that I have available. In my practice I try to combine both active and passive asana depending on the day, the room temperature and my own energy level. It is never repetitive and it is always amazing the simple things that you perceive when you give yourself the opportunity to do so.

Yoga for People with Medical Conditions

by Shari and Nina

Carol Krucoff’s post last week Yoga May Be the Best Activity for the Elderly inspired me to interview Shari Ser about the Yoga for Health class at the Berkeley Yoga Room that she and Bonnie Maeda, RN teach on a weekly basis. This class is special because it’s for seniors with medical conditions as well as general aging dysfunction, and current students include those bilateral total knee replacement, severe osteoporosis, coronary artery bypass graft and other heart issues, stroke, vertigo related conditions, severe arthritis, fibromyalgia, and several hip fractures.

Nina: Why did you two decide to start your Yoga for Health class?

Shari: We started this class because we wanted a safe venue to offer to seniors who couldn't participate in a regular gentle yoga class or a Yoga for Seniors class due to individual medical conditions that might make it more challenging for them to safely participate. We intentionally organized the class so there would always be two trained teachers present at all times. One teacher primarily teaches and the supporting teacher assists students who might need modifications other than the way the pose was being taught.

Nina: How is yoga helpful for people with medical conditions?

Shari: Yoga is helpful for all that ails you! It builds strength, stamina, and balance. It also builds confidence and the mental equanimity that you can face anything. The fact that yoga is portable and can be done anywhere is also extremely attractive. You can do yoga in bed, sitting in a chair, driving in a car. Your mat doesn't have to be confined to a physical space but your practice situation can truly be anywhere.

The ability to face any critical illness is aided by stress reduction techniques that Baxter, Timothy and Nina have addressed in previous posts. Being able to monitor your breathing allows you the mental clarity to think things through in a more methodical and calm manner. Learning to find your own focus point whether it is learning how to stand on your toes or dealing with obtuse health insurance adjusters when contesting a claims bill is equally important. I can't overemphasize the importance of the relaxation response when living with chronic health issues.

Furthermore, for so many people their preconceived notions of what they can or can't do is astonishing. People very often tend to underestimate their abilities because no one has ever taken the time to help them break down a series of movements into bite size pieces that they can and do hungrily consume. The look of joy and astonishment on a student's face when they can successfully participate in class continues to be both Bonnie's and my guiding light in our teaching!

But people who are living with chronic medical conditions apart from general aging do present particular unique challenges for the yoga teacher. You literally are thinking on your feet at all times during class because modifications need to be individualized and often times that may precipitate a lot of prop hauling to get the asana just right for the student to begin to reap the healing benefits. An extra set of hands or two is invaluable!

Nina: I love the idea that you help people learn they are capable of more than they think—that's good for the spirit as well as the body. So, what are your classes like?

Shari: All of our classes work on the entire body as well as encouraging a practice space that feels safe and nurturing. It is our circle of practice that invites the student to join us. Also, we try to adequately challenge the students within their abilities. So every class has a balance component with lots of strengthening. We work a lot on developing core stability with flexibility in our shoulders, hips, spine, knees and ankles. Working on upper body as well as lower body strength is also critically important. We also talk about the carryover in their own lives, like being able to turn their heads when they are changing lanes if they still drive, reaching for the item overhead in their kitchen, or as mundane as being able to tie their own shoes.

Nina: I think we'd all agree that helping people stay independent as they age is absolutely invaluable! What should people with medical conditions consider when they look for and/or start to take a yoga class, or start practicing on their own at home?

Shari: Certain medical conditions may warrant formal physician clearance for participation in a yoga class. Our personal opinion is all recent surgeries need official clearance. Other than that it is the teacher's responsibility to keep the student safe but it is equally important that you, as a student, pay attention to how you are feeling during class and to inform the teacher if you notice any sudden changes in yourself during class.

We also think as a student you should ask the prospective teacher specifically what their training is, are they experienced with dealing with your medical condition and can you stop as needed during the class. Also can you decline to participate in an activity that you do not feel ready to do? This is an important question because it tells you how adaptable the teacher will be if special circumstances arise during class.

You should also consider the size of the class. We think a class needs to be small, with no more than 10-12 with two teachers, because this type of population needs close monitoring and frequent rest and hydration breaks. Lastly, the class needs to be fun! Joking and having people share with each other builds a sense of community among the students.