Yoga for Menopause: Fatigue

by Nina

Rose Light by Melina Meza

When I was going through perimenopause, the worst symptom I had was fatigue attacks. Although fatigue or exhaustion is a classic symptom of perimenopause, I'm pretty sure I made up the term "fatigue attack" because I needed a special term for how it felt to me. I'm a pretty energetic person who gets a lot of things done in a given day, and my yoga practice during that time was quite athletic. But during that period, once in a while, I'd suddenly feel so drained of all energy that all I wanted to do was collapse into a puddle on the floor. There was something essentially different about these hormonally based episodes of fatigue than normal tiredness, and I remembered that same feeling of utter exhaustion from my pregnancies (although those were combined with nausea). So I knew it wasn't something I could fight with energizing poses, such as backbends or sun salutations. Fortunately, I got some guidance from two different senior teachers, Rodney Yee and Patricia Walden, who both helped me figure out a good way to practice when I was feeling that way.

When I first talked with Rodney about a fatigue practice, he came up with a sequence of supported inverted poses (see Just In Time for the Holidays: Inverted Poses). However, the first pose in the sequence was Downward-Facing Dog with head support (traditionally the beginning pose in a supported inverted pose practice), and I complained to him (whined?) that when I was feeling exhausted, that pose felt like to much. So he changed the sequence to start with a long Legs Up pose (Viparita Karani) so I could have a nice rest to start and then move on to more active inversions. That was a revelation to me who had only done that pose at the end of a practice. Learning I could rest at the beginning of my practice instead of the end—that I could break a rule that wasn't even a really rule— was a revelation. I started to realize I had a lot more freedom to adapt my practice to my particular needs that I had known. And practicing was a good way to get through a fatigue attack and did leave me feeling refreshed.

Later I took a workshop from Patricia Walden on Yoga for Menopause. She, too, recommended a combination of restorative poses and supported inversions. Eventually, when the book she wrote with Linda Sparrow, The Woman's Book of Yoga and Health, was published, I started to practice her menopause fatigue practice on a regular basis. This sequence is quite long and some of the poses may not appropriate for many of you, but I'll list all the poses here just in case.

1. Supported Reclined Cobbler's pose (Supta Baddha Konasana)
2. Supported Seated Forward Bend (Paschimottanasana)
3. Supported One-Legged Forward Bend (Janu Sirsasana)
4. Simple Seated Twist (Bharadvajasana)
5. Downward-Facing Dog with head support (Adho Mukha Svanasana)
6. Standing Forward Bend with head support (Uttanasana)
7. Headstand (Sirsasana)
8. Inverted Staff pose (backbend in a chair) (Viparita Dandasana)
9. Chair Shoulderstand (Sarvangasana)
10. Half Plow pose (Plow pose with chair) (Arda Halasana)
11. Supported Straight Leg Bridge pose (Setu Bandha Sarvagasana)
12. Legs Up the Wall pose (with variations) (Viparita Karani)
13. Relaxation pose (Savasana)

Regardless of whether you try this sequence or not, it's worthwhile to look at the strategy behind it. It begins with Supported Reclined Cobber's pose (Supta Baddha Konasana), which is a very restful and relaxing pose. Next are a couple of supported seated forward bends, which are also quieting and restful but a bit more active than the first pose. The simple seated twist is even more active, and definitely stimulating. So now, after having a rest and being a bit energized, you're ready for the more strenuous poses: Downward-Facing Dog with head support, Standing Forward Bend with head support, Headstand, and Inverted Staff pose (backbend in a chair). From there, with the Chair Shoulderstand, Half Plow pose, Supported Straight Leg Bridge pose, and Legs Up the Wall pose, you are moving into the quieting, soothing supported inversions, ending with the most restful of the group. You are also getting a balanced asana practice, with a combination of forward bends, backbends, twists, and inverted poses. (I should say this my analysis of the sequence, not Patricia's.)

As with any sequence, you could shorten this sequence by leaving out certain poses (especially if there are ones you don't normally practice) but still keep the remaining poses in the same order. Or, you could come up with a sequence of your own that combines restorative and supported inverted poses in a way that allows you to rest in the beginning, move toward more active poses, and then rest again at the end. The important thing is to acknowledge your fatigue, and adapt your practice to your current condition, thinking outside the box as needed. And, remember, doing even just one pose (such as Reclined Cobbler's pose or Legs Up the Wall pose) will very likely make you feel better than doing nothing.

Naturally, if you aren't going through periomenopause or menopause (or aren't a woman!), you can still do a practice like this whenever you feel exhausted.

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Forbes Magazine Gives Yoga a Thumb$ Up

by Baxter

View From Above by Melina Meza

I love it when capitalist magazines find something good to say about yoga, even if it is how it is making someone lots of money. But in this case, Forbes says yoga might save the US trillions of dollars in lost productivity for our economy. How so, you ask? Why, for a start, by reducing the dropout rate from high schools in this country, rates that shockingly range from 30% in most places to over 50% in our urban “war zones.” (I call them war zones because of the continual violent backdrop that these children are subjected to day in and day out; where just walking to and from school, let alone being in school, is a constant cause for anxiety and worry about getting hurt or killed.)

What was a delight to see is one of the featured yoga experts quoted frequently in the article, BK Bose, in whose Niroga Institute in Berkeley, CA, I have had the great pleasure of teaching for the past several years. Bose, who started his career as a software engineer in the high tech industry in Silicon Valley, has more recently focused his work on bringing yoga to under-served communities, and training teachers to work with these special populations. These include classes at the Alameda County Juvenile Hall, low-income public schools and low-income senior centers, to name just a few. His work, as with most small operations around the country, is done as a non-profit venture. Even on its smaller scale, the results of the yoga classes are significant.

And after all, if we can influence the health of our youngest at an early age, that should lead to a longer, healthier life as they age (and, of course, many of our readers have school-aged children). The key underlying factor that Bose identifies as the culprit in so many of the challenges our young face is chronic stress. We have written on many occasions about the ways in which yoga can help us deal with stress. But what about in our kids, and in the growing number of kids that have to deal with gangs, substance abuse, and crime in their neighborhoods? This adds a whole new twist on doing straight up mindfulness techniques. These techniques can work quite well for children who don’t have the kinds of violent communities that Bose’s programs work with, as you will see below.

For me, as I read the article, I found one concept that comes from mind-body research defined in a new way that I could relate to from my own yoga teaching.  I often refer to the mind’s background chatter as “monkey mind” or “restless mind,” and the tendency is for this kind of thinking to have a background feeling of anxiety or stress associated with it. The following paragraph from the Forbes article talks about what mindfulness practices do to the brain, including the new phraseology “default mode network (DMN)” which I find confirming of my own observations:  

“In 2011, a Harvard study showed that mindfulness is linked to increased gray matter density in certain cortical areas, including the prefrontal cortex and regions involved in self-referential thoughts and emotion regulation. There seems to be a strong connection between mindfulness and the brain machinery involved in self-regulation. Other work has shown mindfulness to be linked to relative de-activation of the default mode network (DMN), the brain system that’s active during mind-wandering and self-referential “worry” thoughts, which are generally stressful in nature.”

Mindfulness practices, then, help us change the way we are thinking, or at least the way we are focusing our minds, which changes our stress response. For a young person, this might equate to changed behavior, in which he or she has more control over emotional reactions that might lead to trouble. Bose, however, notes that in his students who live in violent communities and are more often directly or indirectly victims of trauma, mindfulness is not going to work.  As the article points out:

“This is all well and good, Bose adds, but there’s an obvious caveat. When they’re in the midst of stress and trauma, few kids have the ability to sit still enough to take part in a sitting practice. “If you’re not ready to sit in classroom,” says Bose, “you’re not ready to do sitting meditation. If you have drugs and gangs and violence all around you, you simply can’t sit still. Teachers tell us that they often yell at kids 100 times a day to sit and pay attention. It doesn’t work. And to ask them to do this in the context of meditation can have a worse-than-neutral effect – it could be disastrous.”

He says that you have to go beyond mind-body research to trauma research, which tells us that physical activity can help the brain deal with stress and trauma.

“Trauma research tell us that we hold trauma in our bodies… Neuroscience says mindfulness; trauma research says movement. All of the sudden you’ve got moving meditation or mindfulness in motion. Mindfulness alone isn’t going to cut it for these kids.”

Even for adults who carry a lot of anxious energy stored up in their bodies, we here at Yoga for Healthy Aging have advocated for the necessity of movement practices, sometimes more vigorous yoga styles, as an initial stage in leading to deeper relaxation and stress reduction in your daily practice. Turns out to be true for kids with trauma, too.

The take-away from this Forbes exposure of yoga to a larger audience in the US and for us yogis here as well is that it may prove invaluable to teach young and old alike to do yoga, combining active asana and quieter mindfulness practices for maximum benefit. And that it would be a good idea to change policy on a national level to fund such ventures, so everyone at least has access to trying yoga, to see if it works for them. What an interesting, and possibly wonderful, world that could be! 

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Yoga and Menopause: An Overview

by Shari

Mushroom in Winter by Melina Meza

Nina and I were talking a while back and we realized that we hadn't yet written any posts on menopause. Well, considering that this physiological episode is a major event in every woman's life, we thought it was about time to take this on, and decided that I should start the ball rolling so to speak. Although each woman’s experience of menopause is very personal and individual, there are certain similarities that we all experience, including the end of the ability to give birth! Now this is not to imply that all woman make the decision to become pregnant and raise a child, but the physiological ability to become pregnant is age-related.

To begin our exploration of menopause, I read the book Yoga and the Wisdom of Menopause. A Guide to Physical, Emotional and Spiritual Health at Midlife and Beyond by Suza Francina. This book was published in 2003 but the information it contains is still pertinent. It provides good background information about what menopause is, and how yoga can be applied in all the stages that lead up to menopause as well as during menopause to help alleviate some of the more common issues that woman have to deal with. The usage of yoga was the unifying theme throughout the book.

Moving to specifics, I'll start by defining what menopause is and how you know you are in it. "Meno" means "month" in Greek and "pause" comes from the Greek "pausis" for stop. So menopause is the cessation of menstrual periods, an end to the monthly cycle. There are three stages:

1. The first stage is perimenopause (“pre-menopause"), when the change in hormonal functions leading up to menopause occur. Typically perimenopuase begins around age 40 (but remember this is a rough estimate) but can begin in one’s 30’s. This stage typically lasts around 5 years, but sometimes lasts for 15 years. In perimenopause women may notice changes in their menses where they are lighter and longer to heavier and more frequent. There are many hormone fluctuations and sometimes this time is called “puberty in reverse”
2. The second stage is menopause itself because the menses stop. Menopause is considered official 12 months after the last period. The average age of women whose menstrual periods have stopped is 52. Though a woman’s period has stopped, it doesn’t mean that the hormonal levels are stabilized and this period is categorized by emotional shifts, hot flashes, hot surges or flushes.
3. The final stage, which lasts the remainder of a woman’s life, is post-menopause when the woman’s body has adjusted to its hormone levels.

Most often when we think and talk about menopause, we focus on the physical discomforts, emotional roller coaster ride and weight redistribution in our bodies. But it is a time where we all are learning to adjust to our physical changes, energy changes, and mental challenges. Now Nina has written extensively in the past about emotional health and moods as well as management of depression through the usage of yoga. All of her recommendations can be applied very directly to the challenges some women experience during the stages of menopause.

My particular interest in reading this book was usage of yoga and its effect on the endocrine system and easing menopausal symptoms, especially the management of stress. The book provides illustrations of restorative poses to counter the stresses of a body adjusting to widely fluctuating hormonal levels. Supported Relaxation pose (Savasana), Supported Child's pose (Balasana), Supported Backbends with a bolster, Legs Up the Wall pose (Viparita Karani), and Supported Reclined Cobbler's pose (Supta Baddha Konasana) are highlighted repeatedly in personal vignettes as a prescription for health. (not necessarily in this order). Supported standing poses, inversions, and twists are also recommended, with the woman using a wall or a chair to prevent overly exhausting herself during asana practice. A guiding principle that is cycled back over and over again is that our practice of yoga changes as our body changes. This is not just due to physical aches and pains or the limitations in mobility, energy or strength but in how our intuitive self begins to guide us more in our asana practice.

What I liked most about this book was its celebration of the cycles of a woman’s life. Throughout the book there is joy about entering into an initiation that all women are a part of. The usage of asana is as a guiding tool to help us navigate this unknown territory. The author presents her book as a way to nourish one’s soul through the practice of asana.

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More Love for Baroreceptors: Supporting Your Head in Restorative Poses

by Nina

When I first starting taking yoga, I was confused about why my teachers were always rushing put to a folded blanket under my head when I was lying on my back. Something about the position of my head when I was lying on the floor was driving them crazy, but what was it? And why was it such a problem?

Later I learned that they were adding this support because, when my head was flat on the floor, due to tightness in my shoulders, my neck was arching up and back and my chin was tipping away from my chest. Putting the folded blanket under my head allowed me lie with my chin pointing toward my chest like this:

This was considered to be the proper--and healthy—position for the head in supine poses. So I went along with it. But secretly I continued to wonder why. In case you have already noticed, I'm like that—always wanting to know the whys as well as the hows, always wanting to dig a bit deeper. Which is probably why I ended up as a yoga blogger, but I digress.

Anyway, it was only when I learned about baroreceptors that I found a satisfactory explanation. As I mentioned yesterday (see Why You Should Love Your Baroreceptors), when your neck is slightly flexed (the position when your chin is pointing toward your chest), the position puts some pressure on the baroreceptors in your carotid arteries. And this pressure can cause the same response as an inverted pose does on your nervous system—switching you from fight or flight to the relaxation response. The opposite neck position with your neck in extension (a backbend position with your chin tipping away from your chest) can have the opposite effective, stimulating your nervous system.

Of course, this understanding of the role of baroreceptors in yoga poses is very recent. In fact, the understanding of the role in regulating blood pressure in general is pretty recent as well. So the yoga teachers, like B.K.S. Iyengar, who developed restorative yoga discovered the best position for the head through personal observation, not science. (That says a lot about personal observation, doesn't it?) Interestingly, the head position Jalandara Bandha, with neck flexed and chin pointing down toward the chest, used in seated poses for pranayama, which is much older than restorative yoga, was probably adopted for the same reasons. Yoga practitioners noticed that head position enhanced the quieting effect of the practice.

I thought I'd tell you all this not just because you might not have made this connection on your own, but because I also realized there might be some people out there who don't have teachers running to put a folded blanket under their heads every time they lie in a supine restorative pose. So that's both the how and why for you. The how is that when you lie on your back, if your chin does not easily point down toward your chest, always add some support under your head. The why is that having your chin pointing down toward your chest will enhance your relaxation due to slight pressure on your baroreceptors.

Long live head support!

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Why You Should Love Your Baroreceptors: Stress Management Made Easy

by Nina

I found this nice little illustration of baroreceptors that I'm excited to share with you. Okay, I admit it, I'm a little obsessed with baroreceptors. But that's because ever since I found out how our baroreceptors help regulate our blood pressure and I understood how we can use this aspect of our anatomy to switch our nervous systems from fight or flight to relaxation mode, I've not only included supported inverted poses in my practice on a regular basis but I've been on a mission to spread the word. Using supported inverted poses for stress management is one of easiest ways—at least for me—to calm yourself down because all you have to do is set yourself in the pose and stay there for a while. The shape of the pose itself causes the baroreceptors to work their magic.

As I wrote in my post Just in Time for the Holidays: Inverted Poses, the reason that inverted poses trigger the relaxation response is due to the pressure sensors called baroreceptors that are connected to the nerves controlling your heart rate and blood pressure. Your baroreceptors are located in the wall of each internal carotid artery at your carotid sinus (the arteries on each side of your neck that carry blood from your heart to your brain).

And in the wall of your aortic arch (just above your heart).

Aortic Arch

These baroreceptors detect any changes in your blood pressure, stretching when your blood pressure is high and shrinking when your blood pressure is low. If your baroreceptors detect a fall in your blood pressure, they send signals via your nerves to increase your heart rate, constrict your blood vessels to raise your blood pressure, and switch your nervous system to fight or flight mode. Likewise, if your baroreceptors detect abnormally elevated blood pressure, they send signals to slow your heart rate, relax your blood vessels to lower your blood pressure, and switch your nervous system to relaxation mode. And now I have a picture to illustrate this!

In an inverted pose, your heart is higher than your head, the opposite of its position when you are upright. With your heart higher than your head, gravity causes more blood to flow in the direction of your head, creating more pressure than usual on your carotid sinus and aortic arch. As the arterial pressure is increased, your baroreceptors are stretched and signals are transmitted to your central nervous system as if your blood pressure was high throughout your body. Feedback signals are then sent back to your body to reduce the arterial pressure, slowing your heart rate, relaxing your blood vessels, and releasing hormones that decrease adrenaline production. This automatically switches your body to relaxation mode.

Because there are baroreceptors in your carotid sinus (the arteries on each side of your neck that carry blood from your heart to your brain) inverted or partially inverted poses where your neck is flexed (that is, your chin is pointing toward your chest), as in Shoulderstand, Plow pose, or Bridge pose, puts added stimulation on your baroreceptors, which may enhance the calming effects of the inversion.

Any yoga pose where your heart is above your head is considered to be an inversion. Inverted yoga poses include full inversions, such as Headstand and Shoulderstand, where your heart is directly over your head and the rest of your body is also fully inverted. Partial inversions, such as Downward-Facing Dog pose and Standing Forward Bend, where your heart is less directly over your head and your legs are either not fully or not at all inverted, are also considered inverted poses and will have similar calming effects. As long as you are warm, quiet, and comfortable in the inverted pose, all you have to do is let the baroreceptors work their magic. Naturally, supported versions of the poses (such as Shoulderstand with a chair or Bridge pose on blankets) are more relaxing than the versions of poses in which you must support yourself, so if you’re practicing inversions for stress reduction, choose the supported versions. See Just in Time for the Holidays: Inverted Poses for a complete list of the inverted poses.

I'm such a believer in these poses that I recently had a friend (thank you, Erin Collom) take photographs of me doing all the supported inversions, so I could write in detail about the individual poses. For now, here's a photograph of a Supported Standing Forward Bend, a surprisingly calming pose.

Caution: Inverted poses may be unsafe for those with certain medical conditions (see here).

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Yoga Better than Injections for Low Back Pain

by Baxter

A July 18th New York Times blog post entitled Alternatives for Back Pain Relief surprised me when it proclaimed that a modern and widely used treatment method for low back pain is no longer considered effective, especially for chronic or long-standing low back pain. That treatment is the use of injections into the areas of pain. The injections usually contain the inflammation-decreasing drug cortisone, but can also have ingredients like morphine, ibuprofen and vitamin B12 in the mix. Over the years I have had many patients come to me with low back pain, and from their reports, the effectiveness of the injections never seemed particularly strong. For some patients with new acute low back pain, who experienced more serious signs and symptoms, like radiating pain to the leg or actual weakness, the injections more often seemed to provide some temporary pain relief.

However, several new studies have revealed that, when looking back at those patients treated with injections, the injections were not significantly more effective than no treatment at all. And one study indicated that those who did not get injections for a pinched nerve in the lower back fared better down the road than the patients who received an injection course.  In the commentary published in a recent issue of JAMA:

“Based on the available data, the JAMA authors conclude, doctors “should not” recommend injection therapy to their patients with chronic low back pain.” 

That may be a hard pill for some doctors to swallow, as there has been a steady increase in the use of injections for low back pain, mainly because it is relatively inexpensive, can be done as an outpatient in the office, has fewer risks compared to surgery, and makes the docs some bling. The possible one positive use of injections is that is does often provide some temporary relief of low back pain symptoms.

The New York Times post then went on to reference a recent systematic review of yoga for low back pain that we reported on here early this year. This study looked back at all of the best designed studies on the subject and concluded that there was “strong evidence of short term effectiveness of yoga for low back pain and moderate evidence of long-term effectiveness of yoga.”

But although the New York Times post mentions the clear benefit of yoga for short-term back pain, it does not emphasize the second claim that the study discovered: moderate evidence for yoga's help over the long term. I took another look at the study itself, and discovered an important caveat: the authors would only recommend Viniyoga style practice for long-term benefits, as the other yoga methods studied did not demonstrate the same benefits. As they state:

"The American Pain Society's guidelines recommend that clinicians consider offering yoga to patients with chronic LBP (lower back pain). However, this recommendation is limited to Viniyoga-style yoga as the net benefits for other yoga styles could not be estimated."

Now, I love Viniyoga and integrate its methods into my own practice and teachings, along with the wisdom of the Iyengar method and some other modern yoga styles I’ve learned over the years as well. But I suspect that some of the alignment-strong styles, like the Iyengar method, will prove to be helpful in the long run as well, but we will need better studies to bear that out. That said, for those who are not familiar with Viniyoga (a term coined by American yoga teacher Gary Kraftsow for the yoga he learned from T. Krishnamacharya and TKV Desikachar) I would recommend to you two books to learn more:

1. The Heart of Yoga by TKV Desikachar
2. Yoga for Wellness by Gary Kraftsow

For now, this is all good news for those of us dedicated to our practice. As one of my students said to me just this morning after class, it's his regular yoga class that keeps his back in the best shape over time since he first developed low back pain many years ago. I’d love to hear back from our readers about your experiences with yoga for low back pain, so send me your story!

And don’t forget, my live webinar on Yoga for Healthy Digestion starts today, Tuesday July 23, 2013 on Yoga U online! Click here to learn more about it and sign up to join me Tuesday and Thursday from  8:30 EST (5:30 PST).

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Unclear on the Concept: Yoga as a Treatment

by Nina

Wet Handle Bars by Melina Meza

“A comprehensive review published in May in The Clinical Journal of Pain finds that there is “strong evidence for short-term effectiveness” of yoga against back pain, although whether the benefits last beyond a year is less certain.” — Gretchen Reynolds, NY Times Sunday Magazine

In this Sunday’s New York Times Magazine, there was a short article called “Spinal Trap,”
about alternatives for treating back pain. The subtitle was “How do you solve back pain? Don’t ask your doctor.” We’ve already heard from Baxter on this topic, when he confessed that he had little to offer his patients when he himself was a family doctor (see For the Young and Old: Back Care). And you’ll be hearing from him soon about the comprehensive review mentioned in the quote above.

For now, I’d just like to rant a bit about the second half of the sentence:

“strong evidence for short-term effectiveness” of yoga against back pain, although whether the benefits last beyond a year is less certain

At first, I was just confused. What does she mean it is less certain whether the benefits last beyond a year or not. If you’re doing yoga for your back pain and it helps your back pain, why wouldn’t it continue to help your back pain for as long as you kept practicing? But Brad pointed out to me the underlying confusion in this statement. He said, “She’s thinking about yoga like physical therapy. In other words, it’s like a “treatment” you get from the doctor, something you’d do for a couple of months to “cure” your back pain, but then when you felt better you’d stop the treatment. And then maybe the pain would come back eventually.”

Ah, so that's what she meant. But how completely unclear on the concept is that? Naturally, if something in your life is causing you back pain, whether it’s your posture at your desk or in your car, standing all day at your job, too much gardening, lifting your children, lack of exercise in general, stiffness in certain areas of your body, lack of strength in certain areas of your body, you can’t just go back to your old way of life and expect the results of a short session of yoga classes to see you through the rest of your life. That would be like thinking you could do a few months of weight training to get stronger, and then expecting that would keep you stronger for years to come.

Brad laughed and said, “Yeah, and it’s not like there’s a “cure” for aging.”

So, yes, we’re afraid that whether you are practicing yoga for back pain or another condition, or just, you know, for healthy aging in general, it’s going to require an ongoing commitment. But it’s free, has no unpleasant side effects, and oh, yeah, it actually works.

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Friday Q&A: Helping a Student with a Hip Replacement

Hip Joint from Behind

Q: I am a relatively new yoga instructor that teaches Gentle Hatha to (mostly) seniors.  Recently, a gentleman came in with bilat hip replacements from 10 and 12 years previous. He rides his bike and is in pretty good shape for a gent in his 60's. His hips were replaced by a posterior approach. How cautious do I need to be with this man? Do we modify mostly in the early days after the operation? Of course, I've modified the asanas to his ability and told him to not push it to the extreme. So is it fresh post op that we worry mostly about or for decades following? Thanks!

A: This is a great question and I am glad you asked it. In most cases, the hip replacement should outlast an individual’s lifespan. The literature states that total hip replacements typically last from 15-to-20 years after the initial surgery, but in some instances they can last over 30 years. But this is neither a guarantee nor assurance, for the simple reason that life is unpredictable.  Many factors affect the future of a hip replacement, such as accidents, fractures, late infections, and deterioration in overall health. Also, how well you take care of yourself down the road is something the surgeon cannot control. The longevity of a hip replacement thus depends on many factors, including the following:

• Surgeon skill in implanting the components
• Known history or track record of the implants
• How well you take care of yourself and your health
• Understanding and respecting the limitations of a prosthetic lifestyle
• Your activity level and body weight
• Avoiding high impact or extreme sports

Medical literature states that the most common reasons for individuals needing subsequent hip replacement surgery include:

• Loosening of the implant. 
• Dislocation of the implant
• Infection, such as staph infections either around the time of surgery or later through the introduction of the bacteria into the blood stream.

It is believed that the most common reason why hip replacements fail is because the weight-bearing surface wears out and the prosthesis begins to loosen. So, what is hip replacement loosening? When a hip replacement is placed into the body, it is either press-fit into the bone or cemented into position. Either way, it is fit tightly into the bone of the thigh (femur) and pelvis so that the implant cannot move. Hip replacement loosening occurs over time, and can cause problems with the normal function of the hip replacement prosthesis. When implants loosen, the hip replacement can begin to move small amounts. This can be caused by the shaft of the prosthesis becoming loose in the hollow of the thighbone or due to thinning of the bone around the implant.

Loosening of the joint can occur at any time, but it normally occurs 10-15 years after the original surgery was performed. Signs that the joint has become loose include pain and feeling that the joint is unstable and that there is increased loss of hip mobility. Another operation (revision surgery) may be necessary, although this cannot be performed on all patients.

Both physicians and patients are very concerned about the problem of hip replacement loosening because a hip replacement revision surgery (replacement of a joint replacement) is a much more difficult operation and hip replacement revisions are often not as successful as the first operation. After revision operations, patients tend to recover less overall motion of the joint. Also, the longevity of the implant decreases with each revision. Therefore, physicians tend to avoid joint replacement surgery until absolutely necessary, and try to get as much mileage out of each replacement as possible.

In about 1 in 20 cases, the hip joint can come out of its socket. This is most likely to occur in the first few months after surgery when the hip is still healing. But, unfortunately some people’s hips will dislocate very distant to the original hip replacement. My advice here is that a hip doesn’t typically dislocate without warning signs. Pain that increases as an activity is continued is the most prevalent symptom.

So how cautious should you be with your student? The surgical hips will have a certain degree of motion that is limited by their soft tissue, hip capsule, how the prosthesis sits in the acetabulum, and so on. Start by checking your student’s range of motion while he is lying in a supine position. Test all the movements of the hip (hip up toward chest with knee bent, same knee position but bring it out to side for abduction, and turn the hip out in abduction for external rotation by bringing the bent knee up toward the armpit. Then look at his hip mobility while standing: hip flexion, abduction, external rotation and extension. You should also see if he tolerates adduction by having him sit on a chair and cross one leg over the other. If he can't do this, then any pose that has internal rotation must be modified significantly. You should have your student do this for both hips to get a sense of how it feels to his hip and see if there is any pinching or grabbing. Then you can modify the asanas accordingly.

If you ask a surgeon if his patient has any precautions after three months post op, he will generally say no, but he will modify his statement telling the patient to “use your own judgment.” So do we continue with precautions forever? Well, that is an area of disagreement. I err on the side of moderation saying, “If it makes you anxious or causes pain, discomfort, pulling, or pinching, please stop.” A student can have the potential of dislocation forever if they are not mindful on how they move and move repeatedly into discomfort. And remember the combined positions of flexion, abduction and internal rotation are the holy triad. If your student can tolerate the movements separately then you can find his limits and slowly challenge his hips, but both you and he must be aware of how the hip feels. NO PAIN should be elicited from asana and that means soreness after class or the next day. Learning how to ask how a movement feels is tricky because not everyone will say something hurts, so this includes learning which words your student uses to describe sensation changes.

So for your student, keep making sure that he observes his body’s limits and doesn’t push beyond his current activity. And congratulate him for coming to your class and investing in his continued health!

—Shari

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Steroids and performance enhancing drugs in Sports Supplements? By Veeraj V. Goyaram

Steroids and Other Performance Enhancing Drugs in Sports Supplements?

Researched and composed by Veeraj Goyaram
Article published 27 July 2013

It is not uncommon for over-the-counter health and sports supplements to contain steroids and other  classified substances that improve performance. Most of us have certainly heard of several cases in the media about products that have been found to contain controlled substances or athletes who have been tested positive after the consumption of over-the-counter supplements. Although I have been an avid follower of the sports supplements scene for nearly 17 years now I did not fully realise the severity of this problem until I attended a lecture by Dr. Hans Geyer last year. It was one of the key lectures at the International Sports and Exercise Nutrition Conference that took place in Newcastle-Upon-Tyne, England. Dr. Hans Geyer is from the Cologne Doping Control Laboratory Center for Preventive Doping Research (German Sport University Cologne) and is heavily involved with doping control in athletes. He has masterminded research into analytical tools for detecting controlled substances in athletes, over-the-counter and black market sports supplements and therefore a lot of Dr. Geyer's work is cited in this article. 

This article aims to give you a lowdown on the situation of performance enhancing drugs in over-the-counter supplements. We will also provide a few interesting case studies, including an update of the issue of methylhexanamine (DMAA), the popular pre-workout energy ingredient which we are sure may interest you. Finally, as we are editing this article we just read a fresh news release by the FDA of a vitamin B supplement found to containing steroids. This will be covered as well. 

Dr. Hans Geyer

How can classified drugs find their way into supplements?

Sometimes, supplements contain "more than what's listed on the labels". Below are the two major ways by which controlled substances can find their way into supplements.

A. Cross-contamination

Supplements may sometimes be cross-contaminated with controlled substances such that small amounts of the latter may be detected. These amounts may possibly be insufficient to give an athlete any real edge on the playing field but sufficient to have an athlete test positive for particular substances. For example, a number of positive cases for prohormones in athletes who consumed vitamin supplement intake were seen. That was due to nutritional supplements being manufactured on the same production line as prohormones without proper cleaning on the production line between batches.  This can lead to inadvertent doping cases.

In fact, an international research study was carried out in 2001-2002 on 634 different nutritional supplements from 13 countries showed that 15% of the supplements tested contained anabolic steroids that were not declared on the label. Cross-contamination largely accounted for the presence of these substance in the tested supplements which included vitamins, minerals, proteins and creatine etc. (Geyer et al., 2002). The findings are summarised below.

Figure 2:Cross contamination detected in supplements from 13 European countries (Geyer et al., 2002)

Figure 3: Another study in Germany and Spain found traces of classical steroids
in vitamin and mineral supplements. These amounts are enough to have an athlete test positive (Adapted from Geyer et al., 2006)

B. Products "faked" with performance enhancing drugs

On an even more serious note, numerous supplements were detected with high amounts of ‘classic’ anabolic steroids like metandienone (Dianabol), stanozolol (Winstrol), boldenone (Equipoise), oxandrolone (Anavar), dehydrochloromethyl-testosterone (Oral Turinabol) etc. This intentional "faking" of products is done in order to make supplements work better as a means to generate sales. These steroids are either not declared on the labels or are listed under fancy names. These supplements can be easily purchased and pose great risks because of the inherent health risks of steroid usage and the dosages are not listed on the labels so that users have no idea of the amount of steroids that they are ingesting. Additionally, most of these steroids are 17-methylated to make them orally ingestible. The addition of the 17-methyl group increases their liver toxicity and carcinogenic properties. 

As a side note, those in the business know that many steroids are now sourced from Chinese pharmaceutical companies. Underground labs purchase them, reconstitute and dispense them into vials using very basic equipment and oftentimes under non-sterile conditions. You may easily recognise these vials as they differ from the sealed vials of steroids like legit Deca Durabolin from Organon from Karachi, Pakistan. It is worth noting that several products are also faked with other classified substances besides steroids (e.g. Sibutramine and Clenbuterol in weight loss products) as will be elaborated in the case studies below.

"Some companies are really cunning and what they will do is add steroids (or other performance enhancing drugs like stimulants) to the first few batches of a new product in order to "wow" users and get favourable reviews. Then fearing detection they will cease to use these substances so you are left wondering what happened (sometimes you think your body has got used to the product)"

Case#1: Designer steroids and the Novedex XT case 

Designer steroids, as their name implies, are steroids that have been manufactured from existing steroids by small chemical modifications. The resulting designer steroid is thus unable to be detected by doping tests because the doping controllers are not yet aware of these new steroids. In addition, a subgroup of designer steroids are also steroids that have been developed in the 50s and 60s by pharmaceutical companies and universities for a variety of medical conditions but for reasons of safety (among other reasons) were not commercially exploited. There are literally thousands of different such steroids and some of them were given "new life" when steroid suppliers decided to market them. The chemical structure of these steroids may be available fairly easily and pharmaceutical factories, particularly in China, are quite eager to synthesize these steroids. One common example of a designer steroid is Norboletone, also known as "The Clear" because of its ability to fool drug tests. It was marketed by chemist Patrick Arnold who became known as "The Clear Chemist". 

That being said, many designer steroids found their way into supplements marketed as testosterone boosters and aromatase inhibitors. Marketers were able to fool the Anabolic Steroid Control Act of 2004 because these steroids were not on the list of banned steroids. That was until the doping authorities upped their game and began research to develop assays to detect these designer steroids. Perhaps, the most striking case of a common product containing designer steroids was the Gaspari Novedex XT case. Authorities nailed down on Novedex XT after several urine sample testing of athletes showed some signals that indicated steroid metabolites in September 2006. These athletes reported to have taken Novedex XT. After analysis, these positive signals were identified as the "new" steroids androstatrienedione and 6-oxo-androstenedione (Geyer et al., 2007). Novedex XT was advertised as a testosterone booster and aromatase inhibitor and I have heard several reports of the effectiveness of this product. As soon as Novedex would come on the shelves it would disappear and a lot of guys were using it as part of their post steroid cycle therapy. The Rich Gaspari we are a huge fan of is a very decent and nice guy and the products were rapidly taken off the shelves. We can't imagine Rich Gaspari, a highly intelligent man, being silly enough to include steroids in his products. We don't think that he would compromise his reputation in bodybuilding for some easy bucks. Anyway, we now hope that Gaspari's products now conform to WADA regulations.

Figure 4: Gaspari Novedex XT was effective because it contained androstatrienedione
and 6-oxo-androstenedione (Geyer et al., 2007)

Case#2: The Pharm-Tec bust in Germany
The Pharm-Tec bust was a very interesting episode. Pharm-Tec was a German company that was very innovative in terms of the delivery formulations it used for "supplements", namely stamps (paper), powders, pills and effervescent tablets. Two supposedly prohormone effervescent products were busted, namely Stanozolon-S and Parabolon-S (note the similar-sounding name to the classic steroids Stanozolol and Parabolan). These products were tested by a German team (Parr et al., 2006) and were respectively found to contain high amounts of the oral anabolic androgenic steroids stanozolol (14.5mg/tablet) and methandienone (Dianabol, 16.8 mg/tablet). This was a clear case of intentional faking of supplement products.

A quite funny thing also happened with Pharm-Tec: they were selling the product Oxa-17-Dion and the label says that it contains 25mg of 5-alpha-adrostan-2-oxa-17alpha-methyl-17-beta-ol-3-one. That's the chemical name of Oxandrolone (Anavar)! Another product named Testexx listed 1,4-Andro-4-chloro Stadien 17alpha-methyl-17beta-ol-3-one. That's the chemical name of Oral Turinabol! In this case what they used the scientific names of "classical" steroids on the labels as almost nobody understands these names. That's very funny indeed.

Case#3:  Clenbuterol and Sibutramine in weight loss products

Fat loss products are sometimes faked with classified drugs too to make them work better. For instance, German researchers tested a weight loss product named "Anabolic burner" and found that it contained 30mcg of Clenbuterolper tablet (Parr et al., 2007). In another case, Polish researchers (Stypułkowska et al., 2011) found that several Chinese weight loss products contained generous amounts of the the class IV controlled substance Sibutramine and its derivatives. Sibutramine is an anorexic drug that was used to treat obesity until its withdrawal in 2010 after it was found to cause cardiovascular  events and strokes. Of course, Sibutramine was not listed on the labels of these slimming products which could easily be purchased on the internet.  

Figure 6: The Chinese herbal weight loss supplement "Li Da" (Left) was found to contain
Sibutramine. The latter drug was used to treat obesity until 2010.

Case #4: Steroids in B-complex tablets
As I am editing this article I came a "hot off the press" news release by the FDA (26/7/2013) about a vitamin B-complex supplement found to contain the potentially harmful steroid methasterone, and dimethazine. This product is called First B-50 and is made by Healthy Life Chemistry By Purity First B-50. This investigation followed reports of incidents associated with the consumption of this supplement in which 29 people reported effects like fatigue, muscle cramps and pain. Biochemical analyses revealed abnormal liver and thyroid function values as well as high cholesterol levels. Female users reported unusual hair growth and missed menstruation, and males who used the product reported impotence that was confirmed by low testosterone levels. The press release by FDA can be viewed on this link. The FDA runs an online alert program called "MedWatch: The FDA Safety Information and Adverse Event Reporting Program". It can be accessed here.    

Figure 7: One of the products of Healthy Life Chemistry

The Methylhexanamine (DMAA) ban situation

I believe the topic of DMAA deserves an article on its own as I followed the evolution of this supplement ingredient with interest. But here is a brief update of the situation: 1,3 DMAA stands for 1,3-dimethylamylamine. It is also called methylhexanamine. On some supplements you will also find it listed as geranium oil extract (on the basis of its plant origin) and Geranamine, the latter being the trade name held by a company called Proviant technologies. This company belongs to Patrick Arnold, the one who introduced DMAA on the supplements market in 2006, following the Ephedrine ban in 2005. In my personal opinion, it is DMAA which gave the greatest boost to the once-lackluster preworkout business. DMAA worked like a bomb, especially in formulations containing Caffeine. Unfortunately, DMAA has been linked to a number of deaths and subsequently the FDA issued a letter of warning to companies selling DMAA-containing preworkouts.  

Supplement companies resorted to listing Geranium oil extract or Geranium stem as a source of DMAA on products because these botanicals don't fall under FDA. For that purpose, they cited an article by Chinese researchers (Ping et al., 1996) that found that Geranium oil/ stem contains DMAA. As a side note, the same thing happened with Ephedrine. When the latter was under scrutiny, companies resorted to listing MaHuang extract (source of Ephedrine) on product labels in an attempts to keep the bucks flowing while escaping the FDA. Interestingly, recent studies by (Zhang et al., 2012) found that Geranium oil/ stem contains no DMAA and provided evidence that the Chinese study was a flawed study, thereby suggesting that the DMAA in all products is of synthetic origin. There is an ongoing debate among analytical chemists about the tools they use to detect DMAA in geranium extracts. The current stand is that geranium does not contain DMAA while pro-industry chemists state that some cultivars of geranium contains the substance and these cultivars are what the supplements industry uses in their products. Recently, USP labs destroyed a massive amount of Oxyelite pro and Jack3D and had to reformulate their products. Finally, the amount of DMAA in many products was a best-kept secret, falling under proprietary blends. Zhang et al. (2012), was kind enough to analyse these products and disclose the amount of DMAA. In my opinion, it was the amount of DMAA that gave different preworkouts different strengths. For instance, Nutrex Hemorage had 33mg per serving while Jack3D had 142mg per serving. 

Figure 8: Zhang et al., 2012 discloses the amount of DMAA found in common
supplements. In one case the product contained nearly 15 times more DMAA
than what's listed on the label!

Any responsible companies in the business?

Although the supplement industry is largely unregulated there are still several responsible companies who go the extra mile to a) source ingredients from trusted suppliers, b) have their R&D team constantly evaluating product formulations to see if ingredients conform to World Anti Doping Agency (WADA) regulations and c) have their products tested at an independent laboratory for controlled substances.

Summary and take-home message

• The presence of banned substances can either be accidental or intentional.

• Accidental contamination can lead to enough banned substance in the body to produce a positive drug test.

• There are many reliable companies who push the envelope further to ensure their products don't contain banned substances.

• The biggest danger with products that contain banned substances is that these are not disclosed on the label and therefore you are clueless about the amount of drugs you are ingesting. If you don't mind your creatine product containing some Dianabol because you are already taking steroids then you are in a bad situation because you don't know how much total steroids you are taking.

References

Geyer H, Parr MK, Reinhart U, Schrader Y, Mareck U, Schänzer W. Analysis of Non-Hormonal Nutritional Supplements for Anabolic Androgenic Steroids—an International Study -. In Recent advances in doping analysis (10), SchänzerW, GeyerH, GotzmannA, MareckU. (eds). Sport und Buch Strauß: Köln, 2002; 83. eds).

Geyer H, Mareck U, Kohler K, Parr MK, Schanzer W. Cross-contaminations of vitamin and mineral-tablets with metandienone and stanozolol. In Recent Advances in Doping Analysis (14), Schanzer W, Geyer H, Gotzmann A, Mareck U (eds). Sportverlag Strauß: Koln, 2006; 11.

Geyer H, Koehler K, Mareck U, Parr MK, Schänzer W, Thevis M. Nutritional supplements cross contaminated and faked with prohormones, “classic” anabolic steroids and “designer steroids”. Effectivness of the Antidoping Fight. 2006 IAAF World Anti Doping Symposium. IAAF: Monaco, 2007; 95.

Parr, M. K., Koehler, K., Geyer, H., Guddat, S. and Schänzer, W. (2008), Clenbuterol marketed as dietary supplement. Biomed. Chromatogr., 22: 298–300.

Ping Z, Jun Q, Qing L. A study on the chemical constituents of geranium oil. Journal of Guizhou Institute of Technology. 1996. 25(1):82-85.

Zhang Y, Woods RM, Breitbach ZS, and Armstrong DW. 1,3-dimethylamylamine (DMAA) in supplements and geranium products: natural or synthetic? Drug Testing Analysis. 2012:4(12):986-990. Available here. Accessed January 7, 2013.

About the author: I am currently a PhD student in Exercise Science at the University
of Cape Town in South Africa. My MSc research looked at the regulation of glucose
transporters in muscle by exercise and nutritional factors.  For my PhD I am looking at the influence of diet and exercise on mitochondrial function in skeletal muscle. If you enjoy my articles please feel free to recommend them to others. Your comments and suggestions are welcome. For correspondence email me on vicgoyaram @gmail.com.

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©,2013, Veeraj Goyaram, Bodybuilding Mauritius. Any reprinting in any type of media is prohibited.

Disclaimer: The Content on this site is intended to be used for educational and entertainment purposes only. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. BODYBUILDING MAURITIUS is not a medical or healthcare provider and your use of this site does not create a doctor / patient relationship. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. Never disregard the medical advice of your physician or health professional, or delay in seeking such advice, because of something you read on this Site. We offer this Site AS IS and without any warranties.  Correspondence: vicgoyaram@gmail.com

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Yoga and Dementia: Welcome News

by Nina

A Rainbow at the Dam by Melina Meza

"Dementia Rate Is Found to Drop Sharply, as Forecast”

Now that’s the kind of headline I like to see! Yes, an article in the New York Times this week Dementia Rate Is Found to Drop Sharply, as Forecast announced the results of two different studies that showed that the incidence of dementia—in one case in England and Wales and in the other case in Denmark—was declining. And the reasons for this are very exciting to us here at Yoga for Healthy Aging.

“Yet experts on aging said the studies also confirmed something they had suspected but had had difficulty proving: that dementia rates would fall and mental acuity improve as the population grew healthier and better educated. The incidence of dementia is lower among those better educated, as well as among those who control their blood pressure and cholesterol, possibly because some dementia is caused by ministrokes and other vascular damage. So as populations controlled cardiovascular risk factors better and had more years of schooling, it made sense that the risk of dementia might decrease.”

So what they are saying here is that, along with being better educated, controlling blood pressure and cholesterol can help prevent dementia. And that means yoga can help. Foremost, yoga’s stress management tools can help you keep your blood pressure low. As I discussed in Chronic Stress: An Introduction, living with chronic stress can cause high blood pressure. So practicing stress management (see The Relaxation Response and Yoga and Stress, Your Health and Yoga will help you keep your blood pressure in check as it benefits your health in many other ways. Stress management can also help you maintain a low cholesterol diet by reducing stress eating and giving you more willpower to stay away from high cholesterol foods (see Yoga, Stress and Weight Management and Healthy Eating, Stress and Self Control). Healthy eating is also fostered by mindfulness (see Meditation and Healthy Eating) so if staying away from high-cholesterol foods is a problem for you, a meditation practice may be helpful.

For me, yoga even provides an ongoing education. Yoga philosophy is food for my intellect as well as providing inspiration for living my life with greater equanimity. Why, just this week I learned a lot from Ram’s post Hindu, Hundism and Yoga, and the week before I learned from writing my own post Modern Yoga and Hinduism. So if yoga philosophy and history are of interest to you, a whole world of new knowledge and intellectual stimulation awaits you.

The New York Times quoted Dr. Anderson, of the National Institute on Aging, saying:

“With these two studies, we are beginning to see that more and more of us will have a chance to reach old age cognitively intact, postponing dementia or avoiding it altogether. That is a happy prospect.”

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