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!

Delaying Joint Replacement

by Nina

Did any of you read Jane Brody’s latest article on arthritis Relief for Joints Besieged by Arthritis in the New York Times last week? Well, I did. And as someone who had an orthopedist say to me, “You are heading for a joint replacement. It could be months or it could be years, but there is nothing you can do about it,” I was very struck by her discussion of joint replacement, especially the following quote:

 “People with osteoarthritis are relying more and more heavily on surgery,” Dr. David T. Felson, a rheumatologist and epidemiologist at Boston University School of Medicine, told me. “The rate of knee replacement is just skyrocketing, out of proportion to increases in arthritic changes seen on X-rays, and replacement surgery is contributing greatly to the rising costs of Medicare..”

She also quoted Dr. Felson saying that although hip replacement is “dynamite,” knee replacement may be far less helpful. “For 10 to 30 percent of patients, the improvement never comes.” Brody goes on to recommend to people, the same way we at Yoga for Healthy Aging do, that people try to postpone joint replacement if possible and states, ever so clearly and concisely, the reasons why:  

Artificial joints usually last 10 to 15 years. Delaying surgery is helpful because the earlier in life a joint is replaced, the more likely a subsequent replacement will be needed. And both devices and surgical techniques are constantly being improved; by delaying a joint replacement, you may end up with a simpler operation or more durable device.

Snails and a Bee on the Same Flower by Michele Macartney-Filgate

That’s it in a nutshell! So how exactly can you delay surgery if you’re having pain in your joints? Why yoga, of course. Although Brody doesn’t specifically recommend yoga, she does quote Dr. Felson again when talking about the importance of exercise for arthritic joints:

“The severity of pain is directly correlated with the degree of muscle weakness."

Well, that’s pretty clear, isn’t it? In fact, I’ve never seen it put that bluntly before. And the yoga standing poses, because they are weight bearing, are excellent for building strength in your knees and hips. For your knees, the poses where one or both bent knees are particularly beneficial (Warrior 1 and 2, Extended Side Angle pose, Powerful Pose, and so on). Although we have not yet addressed arthritis of the hip (note to self: good idea for future topic), most, if not all, of the standing poses would be beneficial for your hips. For arthritis of the shoulder joint, yoga provides a number of simple poses where you bear weight on your arms, including Downward and Upward-Facing Dog, Upward Plank pose (Purvottansana), and Side Plank pose (Vasithasana), so don’t think that if you can’t do Handstand yet, you can’t work on your arm strength (note to self: another good idea for future topic).  

Sometimes being slow is a good thing. 

P.S. Thank you Michele for this perfect photograph (isn't it amazing everyone?) as well as the rest of the other ones you've shared with us in the past and plan to share in the future. I can't wait for the next batch!

Strength and Aging

by Shari and Nina

I recently wrote a post (see Aging: Terms and Theories) about how little scientists understand about the aging process. However, even if scientists don't understand why we age, medical professionals observe the results of the aging process in our changing bodies. Because strength is such an important factor in our ability to continue to be healthy and independent as we age, I decided to talk with Shari about the relationship between strength and aging. —Nina

Q: Is it true that as we age, we tend to lose strength?

A: How does one define strength? Is it a combination of ease of movement throughout space? Is it how much weight we can lift or push? Is it our mental acuity and belief systems? Is it the capacity for action? Strength is a concept that can be addressed on multiple levels when we discuss the process of aging.

Some people have such indomitable will that they force their bodies to do what they want with utter conviction Some people have the mental strength to take what life throws at them and always put a positive spin on it no matter what the circumstances may be. Some people always appear to be at ease in whatever situation they find themselves. And some people are vital and engaging, and radiate joy.

However, if we talk about it in only muscular skeletal concerns then, yes, there is a change in physical strength as we age. The term “sarcopenia” refers to the degenerative loss of muscle mass and strength that is associated with aging.

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

Q: Why is it important for us to keep up with strength building as we age?

A: The common adage “use it or loose it” should be our mantra for healthy aging. Our bodies need to keep moving in whatever capacity we can! To continue to move builds strong bones. To continue to move encourages cardiovascular health and respiratory health. To continue to move diminishes depression. To continue to move allows us to maintain our independence. The list of the benefits of movement goes on and on.

But I think attitude is primary in healthy aging. Acceptance is a very yogic principle and we don’t need to give it a fancy Sanskrit name. Graceful acceptance of our changes as ways to embark on new paths is different from mourning what you can’t do, and looking to the past instead of the present is overwhelmingly demoralizing. Positive thinking and acceptance is healthier overall, all while not ignoring any changes. To find equilibrium, we need to progressively continue to “push our limits” while also respecting our limitations.

Q: How can yoga help us maintain strength as we age?

To answer the question on how to maintain strength as we age with yoga I would say commit yourself to a one-pose practice daily. When that is easy and doable because you don’t miss a day, then increase it to two poses, then three poses, and so on. I would say work on something that challenges your balance first and then work on something that challenges your strength. Isometric holds in yoga build strength so do whichever pose you want and time it for 20 seconds to start. Yoga is not on the fast track. It is slow, consistent practice that pays off.

Q: Which are some of your favorite strength building poses and why?

A: My favorite pose right now is Plank pose on your forearms (rather than just on your hands). This version builds core strength and doesn’t hurt your wrists. But my “favorite” strength building pose changes depending on how my body is feeling on any particular day.

For simple leg strengthening, Utkatasana (Chair or Fierce Pose) is a favorite. If the full pose is not accessible to you, you can practice it by learning how to get up off a chair without using your arms. And if that variation isn’t possible, you can learn to sit down without using your arms.

Warrior 2 (Virabhadra 2) is another good leg strengthener. If you can’t do the full pose in the middle of the room, you can start by sitting on a chair. While still seated, position your legs into the Warrior 2 stance, and then slowly lift up off the chair.

Side Plank pose (Vasithasana) done standing up with one hand on the wall builds lateral torso strength as well as arm strength. If you have wrist problems, you can place your entire forearm on the wall, rather than just your hand.

Balance and Strength

Today we’re pleased to present a second interview with Shari Ser, a practicing physical therapist and yoga teacher. This time we asked her about strength and balance, as a follow-up to our original conversation about balance in general (see here). 

Nina: Why is strength an important factor in our ability to balance?

Shari: Balance and strength need to go hand in hand like cookies and milk! Muscle strength has to be present in sufficient amounts for us to resist gravity and move our bodies through space, allowing us to sit, to stand, and to walk efficiently. When we are weak, we can’t move efficiently and smoothly, and our effort is often more than the effects we can produce. Strength also has to be reproduce-able and renewable. But muscle strength is very concrete, and it is something that can be improved. Just the act of standing up from a chair 10 times will build your strength. Learning to use your legs instead of your arms to stand from a chair builds strength.

Repetition of effort with your current range of motion builds strength. From coming up from a chair with no arms, you can progress to Powerful pose (Utkatasana) to build back strength as well as arm and leg strength (see here). Using a wall to pike forward over bent knees to come down into Powerful pose is easier than fighting gravity to come up into the pose. But how you use gravity will work differently on your strength. Powerful Pose trains muscles differently depending on how you do it.

For good balance, your muscles have to be both strong enough and coordinated enough to fire on demand, not with a lag time till “everything is set up just right.” So isolated strength training doesn’t translate to improvement in balance. Smoothly transitioning between positions with repetitions will build strength better. Think sun salutations, with countless modifications.

Nina: Are there particular muscles we need to keep strong?

Shari: In order for us to maintain our balance, all our postural muscles need to be kept strong. But gastroc-soleus (one of the calf muscles) is a really big deal in balance, as are hamstring and quadriceps (the backs and fronts of our thighs), quadratus lumborum (a lower back muscle), and the hip abductors, and hip adductors (the inner and outer thighs). And we need the strong back extensors to keep us upright (which is especially important if there is a pendulous abdomen pulling us forward). 

Nina: Can you list some of the key yoga poses for building strength, and explain why you've chosen those particular poses?

Shari: I have touched on Powerful pose already and mentioned Tree pose in a previous post (see here). Warrior 1 and Warrior 2 (see here) are also favorites because any standing pose that puts you into an isometric hold position with a bent knee is going to build strength in the legs. And any pose where a limb is raised up is going to build strength in that limb, and both Warrior poses have raised arms. Warrior 1 is also a backbend, which helps strengthen back extensors.

Nina: This is one of the many reasons why yoga is so wonderful. A well-rounded yoga practice, with an assortment of standing poses, backbends, and twists, helps strengthen the postural muscles you need to maintain good balance as you age. Add to this moving smoothly between poses in some form of sun salutation or moving with your breath between two poses (viniyoga style), and you’re all set!

Shari Ser has over 25 years of orthopedic experience as a physical therapist and has been teaching yoga for a wide range of medical conditions since 1999. She graduated from The Yoga Room Advanced Studies Program in 1999, and was certified as a “Relax and Renew” teacher by Judith Hanson Lasater. She currently  teaches ongoing beginner level and back safe yoga classes, and co-teaches Yoga for Chronic Health Issues at The Yoga Room in Berkeley, California. For information see here.