To Sit or Not To Sit (on the floor)?

by Ram

Getting Married Sitting on the Floor

As a child growing up in India I remember sitting on the floor for all kinds of activities, including eating, writing, reading and playing several indoor games. Growing up in a family of moderate means, owning several furniture items or a dining table or a cot was considered a luxury, and the pleasure of having these items at home was similar to the pleasure one achieves owning a Benz or Lexus. The dining table and its associated cutlery items were used only when there was a guest at home. On a daily basis we sat on the floor to eat, often off of a banana leaf.

Eating off of Banana Leaves

Sitting on the floor and performing all the above mentioned activities required us to lift our backs, arch our spines slightly and fold forward a few inches in order to complete the activity successfully. We could assume any sitting position, including Sukhasana, Siddhasana or Ardha Padmasana (without involving the hand mudras). Full Padmasana posture (Lotus pose) was adopted only when we sat to pray or meditate. My paternal grandfather always extolled the benefits of sitting or squatting on the floor and decried the use of chairs and tables. But peer pressure and being scoffed at by friends for sitting on the floor, often compelled us to use the chairs in the absence of grandfather’s glaring vision.

Now the benefits of sitting on the floor as advocated by my grandfather comes in the form of a published scientific paper that links sitting on the floor to overall health and life span extension. In the December 13, 2012 issue of the journal European Journal of Preventive Cardiology, in the article Ability to sit and rise from the floor as a predictor of all-cause mortality, de Brito, et al strongly suggest that the ability to sit and rise unaided from the floor serves as a predictor of mortality. The Brazilian researchers discovered that subjects who scored poorly on the “SRT score” (sitting-rising score) were at the risk of being 6.5 times more likely to die in the next six years.

The study involved more than 2,000 people ages 51 to 80, who had to sit on the floor and then rise to a standing position using as little support as possible. While the speed with which the subjects sat and stood wasn’t a factor in the scoring system, using a support to rise was a big factor in the scoring system. The more support a person required to rise (for example, placing the hand on the floor or knee or both for support), the lower the score for such action and points were deducted for using support. Rising up with an unsteady gait from a seated position or looking wobbly on the way up or down resulted in deduction of scores. A perfect score of five for each action (sitting and standing) was the goal. The final SRT score varying from 0 to 10 was obtained by adding sitting and rising scores and divided into four categories: 0-3; 3.5-5.5, 6-7.5, and 8-10. More than half the participants with ages from 76 to 80 who scored 0-3 were 6.5 times more likely to die during the course of the study (the study lasted for 6.3 years), compared to people who scored in the higher categories. Thus, during the course of the study 159 of the 2,000 volunteers died, with the majority of the deaths coming from the group that had the most trouble getting up and down. Interestingly, a 1-point increment in the SRT score was related to a 21% reduction in mortality.

The authors believe that muscle wasting and sarcopenia leading to lower limb muscle strength and poor trunk flexibility may influence the ability to sit and rise from the floor. (Baxter has already highlighted this article and mentioned several poses to strengthen the quads, lower back and hamstrings that would help in a smooth sit-rise transition. See From Independence to True Longevity.)

The work and results of the Brazilian researchers were so interesting that the editor of the journal suggested that simple tests like SRT are warranted in general health examinations in order to assess an individual’s mobility, flexibility, functional capabilities, health-related quality of life and outcomes in non-hospitalized aged adults. Meanwhile, I realized that my grandfather, who insisted and inculcated on us the practice of sitting on the floor daily, may just have been a temple priest but he sure possessed unrecognized scientific instincts!

My take home message? Spend more time sitting on the floor! Below are my ten tips for building or maintaining a daily sitting schedule. You can think of adapting one sitting pose and incorporating others gradually, or you can dive into doing most of the activities all the while sitting down. Practice rising up first with a suitable support until you are able to stand up unaided.

10) Sit and watch TV or listen to your favorite music
9) Sit and make all your phone conversations
8) Sit on the floor and do your bills
7) Sit on the floor and read your favorite book
6) Sit and browse the computer or send SMS
5) Sit and do your homework
4) Sit and do the yard work
3) Sit and play some indoor games (Uno, chess, cards, Monopoly, etc)
2) Sit on the floor and start practicing the art of eating (snacks and meals)
1) Sit in the bathtub or shower cubicle and take a shower 

The Groom With His Parents

Note from Nina: If you haven't already spent a lot of time sitting on the floor in a crossed-legs position (or any seated position where your legs are externally rotated), it might be best for you to start with shorter time periods on the floor and work up to longer periods, rather than simply changing all your seated activities to the floor. This is to prevent the possibility of injury due to over-stretching your hip and thigh muscles. Also, consider using a cushion or folded blanket under your sitting bones. And if you have hip, knee, or any other problems that prevent you from being comfortable in a crossed-legs position, feel free to experiment with propping or other seated positions that work for your body (or get some advice from your yoga teacher about alternatives). The important thing is for you to be comfortable!

From Independence to True Longevity: More on Transferring and Yoga

by Baxter

The other day, I received an email from one of my teaching colleagues at the Niroga Institute’s Yoga Therapy program, Adi Shakti. Through her work at Stanford, she had come across the results of a new study that she thought, appropriately so, was a perfect promotion for the benefits of yoga. It turned out to be directly related to my post from last week about transferring (see "Transferring" and Yoga: Wisdom from Jane Fonda). In fact, while I merely suggested that yoga could improve your ability to transfer, and therefore allow you to be more independent as you age, this new study states that the ability to transfer (in this case, to sit and rise from the floor) actually has an influence on life expectancy. The study determined that the better your transfer ability, the greater your life expectancy:

“If a middle-aged or older man or woman can sit and rise from the floor using just one hand - or even better without the help of a hand - they are not only in the higher quartile of musculo-skeletal fitness but their survival prognosis is probably better than that of those unable to do so.”

One of the researchers, Dr Araújo, explained the close correlation between the test scores and survival as follows:

“It is well known that aerobic fitness is strongly related to survival, but our study also shows that maintaining high levels of body flexibility, muscle strength, power-to-body weight ratio and co-ordination are not only good for performing daily activities but have a favorable influence on life expectancy.”

This seemed so important than I decided to include the news release from the European Society of Cardiology here, almost in its entirety (see full news release here), as it is not very long and the statistical part is fairly straightforward. A few of my recommendations for yoga poses to help you sit and rise from the floor follow the news release.

“Ability to sit and rise from the floor is closely correlated with all-cause mortality risk: Test of musculo-skeletal fitness is 'strong predictor' of mortality in the middle-aged and older

A simple screening test of musculo-skeletal fitness has proved remarkably predictive of all-cause mortality in a study of more than 2000 middle-aged and older men and women.  The study, performed in Brazil by Dr Claudio Gil Araújo and colleagues at the Clinimex - Exercise Medicine Clinic in Rio de Janeiro, is reported today in the European Journal of Cardiovascular Prevention.(1,2)

The test was a simple assessment of the subjects' ability to sit and then rise unaided from the floor. The assessment was performed in 2002 adults of both sexes and with ages ranging from 51 to 80 years. The subjects were followed-up from the date of the baseline test until the date of death or 31 October 2011, a median follow-up of 6.3 years.

Before starting the test, they were told: "Without worrying about the speed of movement, try to sit and then to rise from the floor, using the minimum support that you believe is needed."

Each of the two basic movements [standing to sitting, and sitting to standing] were assessed and scored out of 5, with one point being subtracted from 5 for each support used (hand or knee, for example). Subjects were thus assessed by a composite score of 0 to 10. A [3 minute] film of the sitting-rising test can be seen at youtube.com.

Over the study period 159 subjects died, a mortality rate of 7.9%.  The majority of these deaths occurred in people with low test scores - indeed, only two of the deaths were in subjects who gained a composite score of 10.  Analysis found that survival in each of the four categories differed with high statistical significance. These differences persisted when results were controlled for age, gender and body mass index, suggesting that the sitting-rising test score is a significant predictor of all-cause mortality (emphasis mine); indeed, subjects in the lower score range (0-2) had a 5-6 times higher risk of death than those in the reference group (8-10).

Commenting on the results, the investigators said that a high score in the sitting-rising test might "reflect the capacity to successfully perform a wide range of activities of daily living, such as bending over to pick up a newspaper or a pair of glasses from under a table".  However, in this study a composite score below 8 (that is, requiring more than one hand or knee support to sit and rise from the floor in a stable way) were associated with 2 fold higher death rates over the 6.3-year study period. By contrast, scores in the range of 8 indicated a particularly low risk of death during the tracking period. "Even more relevant," reported the investigators, "is the fact that a 1-point increment in the [sitting-rising] score was related to a 21% reduction in mortality." They added that this is the first study to demonstrate the prognostic value of the sitting-rising test.

Offering an explanation for the close correlation between the test scores and survival, Dr Araújo said: "It is well known that aerobic fitness is strongly related to survival, but our study also shows that maintaining high levels of body flexibility, muscle strength, power-to-body weight ratio and co-ordination are not only good for performing daily activities but have a favorable influence on life expectancy.

"When compared to other approaches to functional testing," added Dr Araújo, "the sitting-rising test does not require specific equipment and is safe, easy to apply in a short time period (less than 2 minutes), and reliably scored. In our clinical practice, the test has been shown over the past ten years to be useful and practical for application to a large spectrum of populations, ranging from pediatric to geriatric."

Dr Araújo emphasized the great potential of the sitting-rising test among primary care physicians looking for a quick appraisal of musculo-skeletal fitness in clinical or industrial settings. "If a middle-aged or older man or woman can sit and rise from the floor using just one hand - or even better without the help of a hand - they are not only in the higher quartile of musculo-skeletal fitness but their survival prognosis is probably better than that of those unable to do so."”

Maybe the sitting-rising test has potential for yoga teachers looking for a quick appraisal as well!

Now for some practical suggestions on how asana practice can improve your score on the above test. In addition to the poses suggested last week, I’d add full or modified versions of Garland pose (Malasana) and Eagle Pose (Garudasana) for the legs. For core and back strengthening, Boat pose (Navasana), and Locust (Salabhasana) would be great choices. In addition to improving quad strength, strong hamstrings and calves are an important part of the equation, so Bridge pose (Setu Bandha) either practiced dynamically or statically, would do a nice job of strengthening these areas. I hope we will see a study done in the near future on yogis and non-yogis, age-matched, to see what their sit-stand scores would look like. I’m putting my money on the yogis! Go Team Longevity!

"Transferring" and Yoga: Wisdom from Jane Fonda

by Baxter

Nina recently shared with me some fascinating information about Jane Fonda, who has lived many lives, from actor to fitness guru to political activist, just to name a few.  Fonda reportedly used to practice a more strenuous yoga two hours a day. “But” she says now, “those days are long gone. It got to be too hard.” All of that hard work has paid off even as Fonda approaches her golden years, though. She puts it this way:

“Every single time I go to get out of a car now, I say ‘Thank you, Lord, I have strong quads. Because if I didn’t have strong quads, I couldn’t be independent. You have to keep your back and legs strong so you can remain free and independent.”

Truer words could not be spoken! In my years as a Family MD, I cared for a lot of seniors, seeing them in my office if they were still living independently, or making trips to the nursing home if they needed special care. And one of the key skills that often allowed my aging patients to remain at home, which is were they all preferred to be, was the ability to “transfer” independently. By this I mean that they could go, typically, from a sitting or reclining position, such as their bed, to a standing position without any assistance. And they had to be able to do the reverse, that is, safely transfer from standing to sitting. Obviously, if they could do this from the floor to standing or vice versa, they would be way ahead of most of their peers! I have a 75-year-old student who does just that each week in class with me.

I found this expended definition of “transfer” at the medical web site medicine.jrank.org:

“"Transferring" is the term used for moving from one condition to another, such as out of a bathtub, chair, or car, or getting into bed. The ability to transfer depends on many factors, including strength, balance, vision, and flexibility.”

Because of the physical benefits of a regular yoga practice, specifically maintaining flexibility, promoting muscular strength, improving balance and keeping the body agile, students who maintain a regular yoga practice are likely to remain independent much longer than their age-matched community, all other factors being equal. And even if they don’t have a vigorous practice like Jane did in her younger years, even a moderate or gentle yoga practice is likely to have the same four categorical benefits listed above.

Many of the standing poses would be likely to help with such daily activities such as getting in and out of the car.  Any standing pose that requires the knees to bend and straighten, such as entering, holding and exiting from Warrior 1 or 2, is simulating the action the knees, legs and hips perform for our car example (see Warrior 1 and Warrior 2 Mini Vinyasas). Even better would be Fierce pose (Utkatasana), also called Chair pose!, especially if you added in a twist. One of the more challenging transfers for older people is using the toilet in a standard bathroom. It is usually lower than a typical chair, and so presents more potential challenge for most. Yet, if you continue to practice in an intelligent, age-adjusted yoga class, such situations may be non-issues for the aging yoga practitioner.

In classes designed for seniors with no previous yoga experience, it is quite common to utilize chairs to modify many yoga poses. So, just by virtue of getting in and out the chair in class a few times in class, with mindfulness and attention to detail, the student is again performing a similar movement to other important daily activities. The stress-reducing practices of yoga, as well as the mental sharpening skills of dharana, or concentration practice, are also likely to improve our chances of remaining independent well into our later years. So, let’s follow Jane’s example and keep our body and mind strong and agile via a regular yoga practice, so that we won’t even need an extra thought as we push away from the dinner table, stand and move onto the next activity of our full and satisfying day!