Yoga Helps Both Rheumatoid Arthritis and Osteoarthritis: New Scientific Evidence

by Nina

A Poppy Bud by Melina Meza

“Preliminary evidence suggests yoga may help sedentary individuals with arthritis safely increase physical activity, and improve physical and psychological health and HRQOL.”

Well, I really like everything about that sentence except that last acronym, which turns out to stand for “health-related quality of life.” (I not only wouldn’t have guessed that’s what HRQOL stood for in a million years, but as just looking at the acronym is causing my stress levels to spike a bit, it is causing the opposite effect of its own meaning.)

But, anyway, that sentence is the conclusion from the abstract of a scientific study Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial by Moonaz, et al  that I wanted to tell you about. We have written a number of posts about arthritis in the past (see Arthritis of the Hip Joint, Arthritis of the Spine, Arthritis of the Shoulder, and Arthritis of the Knee, among others) so it’s obvious we’re convinced of the benefits that yoga provides for people (including me!) with this condition. But still it is always good to have a scientific study to back us up. And this new study is both the largest randomized controlled trial of osteoarthritis and rheumatoid arthritis and the first to “assess physical health and fitness using self-reported and performance measures along with psychological function and HRQOL.” 

The goal of this study was to contribute evidence about outcomes associated with yoga practice in sedentary people with arthritis. The researchers hypothesized that yoga would improve physical health, fitness, psychological function, health-related quality of life (HRQOL), and arthritis self-efficacy with no worsening of rheumatoid arthritis (RA) disease activity. They thought that yoga would be well suited for arthritis because it combines physical activity with potent stress management techniques, including breathing, relaxation, and mindfulness. So they asked a registered yoga therapist, with input from the Johns Hopkins Arthritis Center faculty, to develop an 8-week yoga program emphasizing individualized adaptations and monitoring, which they could introduce to beginners who had either rheumatoid arthritis or osteoarthritis of the knees.

Although the full study isn’t available to the general public, I was able to obtain a copy (thank you, Brad). So here’s a basic summary: 

1. The study was done on 75 sedentary adults 18 years or older, with rheumatoid arthritis or knee arthritis. Participants were mostly female (96%), white (55%), and college-educated (51%), with a mean age of 52 years.

2. The subjects either participated in 8 weeks of Integral-based hatha yoga (two sixty minute classes and 1 home practice) or were waitlisted. (Eight weeks was selected for the intervention because this provides sufficient time to introduce independent practice and is a common duration of introductory classes.)

3. Two yoga therapists with 10+ years of experience led the yoga classes, and they provided close supervision and individual attention. 

4. The yoga classes included breath work and chanting (5 min), warm-up and moving sequence (surya namaskara, 15 min), and isometric poses (asanas, 20 min) to increase strength, flexibility, and balance. Classes ended with deep relaxation (sivasana, 10 min), a closing chant, and meditation (5 min).

Poses included gentle forward bends, backbends, twists, balances, standing, sitting, and lying poses, and were modified for individuals at the discretion of the teacher and/or participant. Props included blocks, straps, blankets, and chairs. Participants were encouraged to try new skills, but to remain safe and avoid discomfort. Written instructions with pictures for home practice and selected readings describing potential benefits of yoga components (breathing, meditation, mindfulness) were provided weekly. Home practice evolved gradually to develop the skills and confidence for long-term adherence. 

5. Participants were asked to keep arthritis medications constant and were queried regularly by coordinators about any changes. 

6. The waitlisted group received usual care for eight weeks. (They were asked to maintain current levels of physical activity and inform coordinators of changes in health or arthritis medications. After Week 8 assessments, they were invited to participate in upcoming classes.)

7. After eight weeks and again after 9 months, both groups were measured fitness, psychological function, and HRQO using standardized protocols

The researchers concluded that eight weeks of yoga classes and home practice was associated with “clinically significant improvements in physical and mental health, fitness, psychological function, and HRQOL, with no adverse outcomes.” And they said that the strongest evidence of benefit was for reducing pain and improving mood, both of which were carefully tracked in the two groups. 

Less pain and a better mood sounds pretty good to me! And an additional benefit that yoga provides, which wasn’t measured in this study, is that by moving your joints through their entire range of motion, yoga keeps your arthritic joints nourished (see Yoga for Osteoarthritis). I know from personal experience that practicing yoga with an arthritic joint (a hip in my case) can be pretty challenging, but I'm more convinced than ever about how it important it is not to give up.

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Knee Replacements and Yoga

by Shari

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

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

• improved movement
• pain relief
• improved joint alignment

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

X-Rays of Knee Replacements (from Wikimedia)

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

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

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

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

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

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

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

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

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

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Arthritis of the Knee and Yoga

by Baxter

While in Montreal for a weekend workshop, I found myself attending a modern dance performance. I’d say the average age of the performers was about 30, and all looked very fit and flexible. As part of their performance, they did a move in which they leapt forward while spinning and landed on the floor in a Pigeon-pose like stance. The first time they did this, I found myself wincing, as I imagined the impact on their knees on the firm, uncarpeted dance floor. I’d have to guess they did this at least five more times, and usually always landing on the same knee. My host and I spoke about this after the show, and we were both of the opinion that no good could come of this for the future health of these dancers’ knees.

Trauma to the knee is one of several risk factors for the development of arthritis of the knees later in life. It was no coincidence that one of the attendees at my weekend Anatomy and Yoga workshop has arthritis in his knees at the ripe age of 40, as he had been dancing for over 20 years and had suffered numerous injuries to both knees over that time. But since starting his yoga a few years back, his knee pain had improved to the point that after a hiatus of almost 10 years, he was gradually returning to some dance.

In addition to trauma, other risk factors for developing osteoarthritis (the most common form of arthritis) of the knee include: 

• weight, as in more body weight, more stress on the knee joint 
• sedentary lifestyle, as it seems that some activity is better for the knee joint than no activity 
• work or hobbies that involve repetitive demands on the knees, such as horseback riding, which encourages a bowing outward at the knee joint and places unusual stress on the knee joint 
• bone abnormalities, which some people are born with and could include skeletal issues such as bow legs or knock knees 
• other diseases like hypothyroidism and Paget’s disease, which could lead to arthritis over time advancing age 
• gender, that is, women, for reasons that are not yet clear, have a higher incidence of arthritis than men 

Typically, in a healthy knee joint, just as in the hips, the surfaces of the top bone, the femur, and the bottom bone, the tibia, are covered in a layer of protective connective tissue known as cartilage. The cartilage acts as both a shock absorber when the bones move close to one another, as when you are walking or running, and also as a smooth, slick surface for the bones to slide over one another when you are doing any knee bending activities.

If any or several of the risk factors are present, the usually smooth surfaces can become rough, like sandpaper, which may or may not produce pain, but could produce some grinding sounds from the knees. Eventually, the cartilage could wear through and expose the underlying bone, which is even rougher. When bone on bone contact starts to occur, it usually results in inflammation in the joint, which then swells, can become hot to touch and limited in movement and painful. Since the condition usually worsens over time, especially if you don’t seek help for it, it could eventually lead to significant immobility and pain. I am going to assume you have had the common sense to see you family MD to get an accurate diagnosis and have tried some of the western treatment options, such as medications, physical therapy, and braces, and such and are looking for alternative ways to work with the knees to avoid worsening of your situation and surgery.

Yoga is both helpful in addressing the acute problems of swelling and pain, and the longer-term issues of improving mobility, strength and stability of the knee joints. 

In acute situations, restorative practices or reclining sequences can allow for you to maintain some gentle movement of the knee while reducing the effects of gravity on the knee that occurs when you stand. A regular favorite when the knee is swollen is any reclining posture that elevates the leg higher than the chest. My personal favorite is Legs Up the Wall pose (Vipariti Karani). Another is the door jam version of Reclined Leg Stretch (Supta Padangustasana_, where you lie down on the floor on your back at a doorway, your hips lined up with the doorway, and take the affected leg up in the air and rest the heel on the door jam. This allows for a more passive approach to this pose that we usually do with a strap on the foot of the lifted leg.

In addition, a whole slew of other reclining poses can be performed that are safe for the knee and allow you to get some of the stress-reducing benefits of a regular home practice (see Timothy’s post from yesterday Home Practice: The Best Way to Improve Your Health and Well-Being). On top of helping to quiet down an inflamed knee, you can use your practice to strengthen the muscular/tendonous support around the knee. Engaging the muscles that surround the knees simultaneously has been shown to benefit the joints, as Shari noted in a post a while back on hips. So I recommend starting with poses in which the knees are extended or straight, as this reduces sheering actions on the cartilage. This includes Mountain pose (Tadasana), Triangle pose (Utthita Trikonasana), Pyramid pose (Parsvottanasana), Wide-Spread Standing Forward Bend (Prasarita Padottanasana), and such. If these are done successfully, without aggravating your knees, and are hopefully bringing some gradual improvement in your symptoms, you can add in standing poses with knees bent. This will require that you pay special attention to the trajectory of the knee as you flex it. Ideally, you will want to bend the knee directly in line with your mid-foot, so the knee is tracking in the most anatomically correct way. You may want to have your local yoga teacher help you to figure this out, as it is a bit difficult to sense on your own at first.

Another potential way to modify seated poses to allow you to do them pain free is to use some sort of a spacer tucked into the back of your knees before you deeply flex (bend) the knees. You can use a rolled up washcloth, or a thinly folded yoga blanket. Once you place the spacer in the fold of the back of the knee, mindfully bend the knee and see how it feels. There should be no pain. If you have a history of ACL repair (anterior cruciate ligament), then never use a spacer, as it could loosen this precious repaired tear.

Since every arthritic knee is going to be a bit different, these suggestions are offered to get you thinking about ways yoga could be helpful for you. As I always say, it would be a good idea to do some one-on-one work with an experienced teacher to guide you safely on your way.

And skip the Flying Twist Dropping Pigeon from your repertoire until next lifetime!

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Yoga and Arthritis of the Hands

by Baxter

Every time I get a call from a student or patient about arthritis of the hands, it brings to mind an image of my beloved Grandma Lopresto, at her towering height of 4’11”, who lived to be 93 with the clearest mind you can imagine. She had arthritis in her hands. Yet I never recall her complaining about it. In fact, I never heard her complain about her body at all, even though she also suffered from post-herpetic neuralgia, a chronic painful condition that is an aftermath of getting shingles. 

But back to Grandma’s hands—when you looked at her hands, she had obvious swelling around the knuckles of almost every finger on both hands. And although I would see her working the fingers by rubbing and bending them, it did not seem to slow her down, as she lived on her own for 29 years after her husband died when she was 64. I can recall her even doing some simple sewing projects to replace a button and such.

Ah, if this were the case for others with arthritis of the hands! For many, there is chronic pain that is disruptive to daily activities, sometimes requiring pain medication, anti-inflammatories, injections and more invasive measures to deal with it. Grandma certainly had classic osteoarthritis of the fingers, which affects the last joint of the finger, the DIP joint, and involves small nodular swelling around the joint known as Heberden’s nodes, and the closer knuckle, the PIP joint, with Bouchard's nodes. The most common site affected by arthritis in the hands, however, is the thumb. It is usually a form of osteoarthritis, the common wear and tear arthritis that affects millions of Americans annually. It affects the joint between the carpal (wrist bones) bones and the metacarpal of the thumb (which resides in the palm of the hand). On its worst days, basal joint arthritis (its other name) can cause pain, swelling, stiffness, weakness or immobility. In addition to what I have mentioned already, treatment by your family doc or rheumatologist can also include self-care recommendations and splints. These splints can help decrease pain, re-align the bones, and permit the joint to rest. Obviously, if you have to wear a splint, you’ll need to modify your hand use in yoga.

One thing to keep in mind is that osteoarthritis often results from trauma or injury to the thumb at some point in the past, and that over time the protective coating of cartilage on the ends of the bones wears away, exposing sensitive bone to bone.  One way to address this via yoga or visualization is to lengthen the thumbs or fingers, depending on which joints are affected, from palm to fingertips, specifically focusing on the affected joint. The encouragement you get from your teacher to spread and lengthen the fingers in poses like Downward-Facing Dog pose is pretty good advice. Although, as you might imagine, you may need to avoid putting full body weight onto your hands if you are experiencing a full-blown joint flare.  In such situations, non-weight bearing asana would be more appropriate, of which there are many.  Ones in which the arms are overhead, such as Warrior 1 and Tree pose, can be particularly helpful to enlist the aid of gravity in pulling swelling away from the hands and back toward the heart. 

Often the pain and stiffness of osteoarthritis in the hands is most noticeable in the morning when you first get up. Warming your joints in the shower and gentle movements of your hands and fingers for 15 to 20 minutes can result in less stiffness and decrease in pain.  If you have not seen a physical therapist for specific range of motion exercises, consider asking to do so. In the meantime, you can use your yoga sessions to put your hands and thumbs through their paces, maximizing the range of motions in the most pain free way you can. 

Other patterns of finger arthritis include the less common condition of rheumatoid arthritis, which affects the hands at the wrist joint and at the joint between the palm bone and the finger bone, the metacarpal-phalageal joint.  Often, more than one joint is involved. Rheumatoid arthritis is an autoimmune illness, and it can cause much worse and more persistent symptoms than osteoarthritis so even gentler approach may be needed.

If you are at risk for developing arthritis in the hands, via age (over 40), sex (female), family history of osteoarthritis or rheumatoid arthritis, or history of trauma to your hands, a balanced yoga practice, with a careful, stepwise approach to yoga poses that involve bearing weight on the hands (such Cat/Cow pose, Downward-Facing Dog pose, Upward-Facing Dog pose, and all arm balances), may be helpful in maintaining a good range of motion in your hand joints over time. Adding a variety of hasta mudras, or hand seals, could exercise and strengthen your fingers in a non-weight bearing fashion.

And for those who have already developed arthritis, less weight-bearing asana is likely the way to go. There are also a number of props coming out that could assist in more pain-free exploration of the asana in which your hands are on the floor.  Specialized gloves with a rubber cushion for the heel of the hand, as well as wedges, rounded blocks, and weird circular cushions called Yoga Jellies are all possible aids to permit careful inclusion of weight-bearing asana in your practice.  And surely, as you must know by now if you are a frequent reader, enlist the help of an experienced teacher who has worked with others who have arthritis!

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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!

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Featured Pose: Wrist Circles

by Baxter and Nina

Another very simple pose in our office yoga series, wrist circles move your wrists through their full range of motion Most of us use our hands in similar and limited movements over and over during the day. Moving your wrists through their full range of motion helps relieve fatigue in your hands and keeps your joints healthy, flexible and mobile. And we can all use some of that. Plus, you'll get to hum The Supremes (see “Instructions” below).

This pose works more than your wrists. As you rotate your wrists, you use the muscles of your forearms all the way up to your elbows. So these movements not only reduce tension in your forearms, but are also beneficial for your elbow joint. Baxter actually prescribes wrist circles for those of you with elbow issues, like tennis or golfer’s elbow.

This pose is super convenient—you don’t even have to leave your desk to do it. And you can do it several times a day if it feels good, even once every hour. For other wrist exercise, see Wrist Flossing for Wrist Care.

Baxter prescribes this pose for:

• carpal tunnel syndrome
• elbow issues like tennis or golfer's elbow
• arthritis of fingers, hands, wrists or arms
• fatigue in your hands or arms due to keyboard work, driving or any repetitive movements

Instructions:  Start by sitting with your knees parallel to each other, and your feet firmly on the floor, hips-distance apart. Stretch your arms out in front of you or rest your elbows on your knees. Next, draw your hands back with your palms facing forward in to a “Stop in the Name of Love!” position. From there, choose a direction and circle your wrists around into three to ten circles, drawing your fingers wide and back, which brings more stretch across the palm of your hand.

Repeat on the other side by circling in the opposite directions, for the same number of rounds.

Cautions: Generally this pose very safe. However, if you experience any pain in your hands or wrists, modify the circle to avoid the painful areas.

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Arthritis of the Spine, Part 2

by Nina

With Baxter’s blessing, I’d like to add my two cents to his post yesterday on Arthritis of the Spine. You see, he forgot to mention hanging upside down! Yes, there is a whole group of poses that can provide great relief to those of you with arthritis of the spine (as well as other types of back pain), where you hang upside down and allow gravity to lengthen your spinal muscles and create space between your vertebral discs. You can use these poses at any time for relief from back pain and to help maintain the health of your spine. You can also use them to lengthen your spine at the beginning of a yoga practice.

Caution: If you are experiencing acute pain and your muscles are contracting, before hanging in an inverted pose, it is a good idea to start by relaxing and releasing your muscles in supine or prone poses.

If you’ve ever been in an Iyengar studio that has wall ropes, you may have seen people hanging upside down on the ropes with their legs in Cobbler’s pose. If you don’t know what I’m talking about, you can take a look at this the first pose in this video:

Other yoga studios have a yoga horse that you can hang from. Most of us can tell intuitively, just by looking at these hanging poses, just how good our backs would feel in them (kind of like looking at a recipe and being able to tell how good the dish would taste). And both these hanging poses, along with other variations, are excellent options for you if you have access to the appropriate props. So definitely try them out sometime in your local yoga studio. But what if you do yoga somewhere that doesn’t have these special props? And what can you do when you’re on your own at home? 

One good possibility is doing Downward-Facing Dog pose with a strap and a doornob, as shown in the photo below (taken from Back Care Basics by Mary Pullig Schatz, M.D.). Having the strap support you in the pose takes the weight off your arms and shoulders so you can just relax in the pose and let gravity do its magic.

 

Here's how to do it:

1. Find a door with a knob that is sturdy enough to support your weight.
2. Take a rope or yoga strap and make it into a loop.
3. Open the door half way, and hook the loop over both sides of the doorknob.
4. Step inside the loop and place the strap or rope at the tops of your thighs, at the point where your hips bend when you bend forward.
5. Lean forward into the rope until it supports your weight, bend forward and place your hands on the floor.
6. Using your hands to stabilize yourself, walk your feet back into Downward-Facing Dog position, with one foot on each side of the door.

Stay in the pose for several minutes, keeping your arms extended and your legs active. To come out of the pose, walk your feet forward out of Dog pose, then bend your knees and slowly roll up to standing.

Another possibility is lying on a table, with your legs on the table and your torso hanging off the edge, as shown in this photo (also taken from Back Care Basics by Mary Pullig Schatz, M.D.). For this one, you’ll need help from a partner. You will also need to do some experimenting to see whether the table is high enough for you to hang from without your arms touching the floor. If it isn’t, place a folded blanket or a stack of folded blankets on the surface of the table, as shown in the photo.

Here's how to do it:

1. Place a chair about one foot from the table, with the seat facing the table.
2. If you are not using blankets on the table, fold a sticky mat and place it over the edge of the table, to create a softer surface over which to bend.
3. Sit on the table and then use your arms to bring yourself to a side-lying position.
4. From your side-lying position, roll onto your belly and scoot yourself to the edge of the table.
5. Have your partner hold your thighs or calves as you hold onto the chair seat and gradually move your torso off the table until the tops of your thighs are supported by the edge of the table.
6. When you are in the full position, fold your arms overhead so you can hang comfortably (your head and arms should not be touching the floor). Stay in the pose for several minutes, as long as you are comfortable.

To come out of the pose, bring your hands to the floor to support you as your partner releases your legs and comes around to support the chair for you. Then, place your hands on the chair for support. Slide your legs toward the side edge of the table. Then slowly put one foot down on the floor, then the other. Use your hands on the table to help you come up.

Do let us know if you try any of these poses! We'd love to know if they provide you with any relief.

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Arthritis of the Spine

by Baxter

Whale Bone by Michele Macartney-Filgate

Be it lower back, middle back, upper back or neck pain, not a day goes by when at least one student offers up his or her particular version of back pain. Due to the effects of time, age and stress on the spine, one of the underlying causes of back pain is arthritis of the spine. To be more specific, we usually refer to it as “osteoarthritis of the spine” to differentiate it from other types of arthritis that may be due to autoimmune conditions.  Sounds specific, maybe even helpful to have a label to attach to one’s problem, but what does “arthritis” refer to? Well, it is an “itis,” so there’s a clue. "Itis" usually implies some inflammatory process, you know, like tendonitis, where the tendon is inflamed.

In arthritis, it is the boney structures and their coverings, usually cartilage, that are involved. In a healthy joint, anywhere in the body, the ends of two bones that make up a joint are covered with a protective coating of connective tissue known as cartilage, which acts as both a cushion between the two bones, and as a smooth, slippery surface that can slide and glide as the bones move over one another during motion. Here’s where time, age, stress and other factors ruin a perfectly good system.  Over time, with the aging process (which can dry out and thin the cartilage independent of the other factors), and with certain movement patterns (especially unusual, misaligned ones) and repetitive use, especially with additional stress from gravity or carrying loads, the cartilage can fray and thin and outright wear away. This exposes bare bone, which is not that smooth and slippery, and leads to the “itis” or inflammatory process we feel as “arthritis” via the symptoms of stiffness, immobility and pain.

When talking about the spine specifically, the places where two spinal bones, or vertebrae, meet include the donut-like intervertebral discs (which I will refer to as discs from now on), which sit between two adjacent “bodies” of the vertebral bones, in vertical relationship, and the two posterior facet joints, right and left, whose smaller surfaces are covered by a thin coating of cartilage. The most common area for arthritis in the spine is in the lowest part of the lower back, or lumbar region, due to extra effects from gravity of holding up the belly, torso, head and arms. The next most common area is the neck area or cervical spine, likely due to its incredible mobility and relatively short intervertebral discs. The thoracic area or rib cage region of the spine is often affected when two other complicating factors are present: scoliosis, or curvature of the spine, and osteoporosis, or thinning of the bones. I’m sure there will be more on those topics at another time.

Coming back to the discs for a minute, all the cumulative factors mentioned above can cause these guys to lose their normal integrity, resulting in the discs losing water and drying out, which increases the risk of them breaking open or rupturing their tougher outer ring known as the annulus fibrosis (even sounds tough!) and extruding or pushing out their inner contents, which is the gel-like inner part, the nucleus pulposa, often compared to the jelly in a jelly-filled donut. The discs also lose some of their height, which normally helps to keep a healthy distance between two vertebrae. This can then result in the facets rubbing more closely together, the opening for nerves narrowing enough to start pinching on nerves, and other such difficulties! When that nucleus pulposus material is released into the spinal canal, which sits just back of the discs and where your spinal cord descends down from the brain to the tail bone, it causes a local flare of inflammation that can last a while. When the disc is losing height but does not rupture, we call that degenerative disc disease (a bit of a misnomer, as it may not be a disease per se, but more like a natural aging process of the disc). This alone can result in pain for some, and it can be found in adults starting in their thirties!

How’s yoga supposed to improve this arthritis situation of the spine? Well, those of you who have been in class with me lately have heard me use the phrase “the prime directive.”  Sounds a bit Star Trek-y doesn’t it?  But in this setting, it refers to the inner action of creating an even lift from the base of the body, either the tailbone or the sitting bones, up through the whole length of the spine to the crown of the head. This is technically known as axial extension, and, according to Leslie Kaminoff, it does create a longer spine, even as it slightly diminishes the amount of natural arch in each region of the spine. That is, it straightens the spine a bit, but not entirely.  And it requires some muscular effort, especially if you have not been practicing it. You can do this anywhere, anytime, and if you are doing it and paying attention to how it feels as well as, perhaps, how it affects your breath, and you remain connected to the action for a bit, you have a mini yoga practice under way. 

And then from there, you can take the spine through some gentle range of motions, via some easy, basic yoga poses, such as Cat/Cow pose, Child’s pose to low Cobra pose, Standing Side Bend (sometimes called New Moon pose), and gentle reclining or seated twists. As you do this, you are always assessing the effect on the area of your spine that is sensitive, modifying the intensity, range of motion or number of repetitions or length of holding to make it appropriate for you situation. I believe that a while back Shari mentioned that movement actually hydrates, nourishes and revitalizes the discs of the spine, so inactivity is not a great option, is it? (See Yoga for Osteoarthritis for an interview with Shari about arthritis.).  So let’s get moving, yogis!  Great to be back from spring break. More good stuff tomorrow! See Arthritis of the Spine, Part 2 for more poses you can do to find relief from back pain and to lengthen your spine.

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Yoga for Osteoarthritis: Interview with Shar Ser

By Nina

Last Saturday, I took a wonderful workshop at the  Berkeley Yoga Room on Yoga for Bone Health, with Bonnie Maeda and Shari Ser. We covered yoga for osteoporosis, osteoarthritis, and joint replacements. Because I know that many of you are concerned about osteoarthritis (and I have it myself), I asked Shari if I could do another interview with her, this time about yoga for osteoarthritis.

Nina: Why is yoga so beneficial for people with osteoarthritis?

Shari: Yoga is beneficial for people with osteoarthritis because it is something proactive that they can do for themselves to cope this chronic disease. Arthritis is due to imbalances on the ends of bones in the joints with uneven wearing down of the cartilage that covers the bone ends, which allows the bones to move smoothly on one and other. Arthritis is a wear and tear syndrome, an alignment syndrome, or a result of inactivity as well as obesity.

People stop moving with arthritis because it hurts, but when you stop the joint motion you decrease the nutrition to the joint structures. The body tries to repair the area by laying down more bone to protect the area and the result is spurring, which then cause more irritation from the “bones rubbing.”

When the cartilage has deteriorated and there is no movement, the synovial fluid that bathes the inside of all synovial joints decreases, which then decreases nutrition to the joint and the cycle reinforces itself with pain=no movement=more pain with swelling and inflammation=even less movement.

Yoga is so perfect for arthritis because it can stop that cycle by providing infinite variations in joint mobility and ways to maintain the joint alignment to improve joint weight bearing. You need to keep the joint moving in its full range of motion to keep the joint healthy, and yoga allows you to do that.

Nina: Should you do yoga if it hurts?

Shari: Judicious usage of pain meds to allow movement but not to obliterate the feedback mechanisms that pain provides us with is important. Medication that decreases inflammatory response will allow people to move more, but pain medications that mask pain so people overdo activities are dangerous. Pain keeps our expectations and engagement focused. You don't want to be stoned and do something dangerous!! So a healthy respect for pain is important. You can start out with a small movement and then as fluid in the joint increases you can increase the range of motion slowly till you are at your limit. Deep knee flexion (bending) is very difficult with knee arthritis so modifications to the yoga poses are important are important for people with knee arthritis.

Nina: Is there anything that people with osteoarthritis should watch out for?

Shari: You need to study with a teacher who can observe your alignment when you are doing poses to help you correct your imbalances. Co-contraction of muscles is extremely important. I would not do a lot of jumping into poses but stepping into them instead. Playing with joint position is really key because you may need to change things considerable to minimize your pain. Also being gentle with yourself is important because it took years for the arthritis to develop and will take years to manage and prevent it from progressing. It is true that you CAN remodel cartilage but how long it takes is unknown (at least I haven’t seen any studies).

Nina: What are some of your favorite poses for osteoarthritis and why?

Shari: Favorite poses—hmm, this is a hard one because you have to think about what joint you are focusing on. If I am dealing with osteoarthritis in the spine, I would focus on accessible twists and gentle back bends. If it was hips, balance is the key of co-contracting to keep the joint in good congruency and neutral alignment—maybe Ardha Chandrasana (Half Moon pose) would fit. For knees Warrior 2, but not too deep and starting with a chair if it is problematic bear weight in a knee flexed position. Warm-ups are very important to try to get the fluid circulating first, and then adding non weight-bearing isometrics before starting weight bearing activities. Also cool down poses shouldn’t be missed!

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 (see here.)

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Featured Pose: Locust (Dynamic Version)

by Baxter and Nina

Locust pose (Salabasana) is a simple backbend that strengthens the entire backside of your body, from the nape of your neck to the backs of your heels. Baxter loves this pose because it’s helpful for such a wide range of problems, including lower back pain, postural problems, and weakness anywhere along the chain of your back body, including your , including hips and hamstrings. And because the backbend is shallow and doesn’t put pressure on the wrists, it is accessible to almost everyone.

We’re recommending two versions of this pose: one with your hands on the floor and the other with your arms parallel to floor and hands lifted. The version with your hands on the floor provides more support, making the pose less demanding. The version with arms raised increases the amount of strengthening in your arms and shoulders.

Baxter prescribes this pose for:

• lower back pain (it strengthens the muscles along the sides of your lower back)
• hamstring injuries
• arthritis of the knees (it strengthens the leg muscles)
• postural problems (such as excessive rounding and head-forward syndrome)
• arm strength (in the version where you lift your arms)
• depression (accessible even when your energy is low)
• general weakness

Instructions: Lie on your belly, with your head resting on the floor, your arms resting at your sides, hands palm down, and your legs stretched evenly back behind you, toes gently pointed. If your lower back feels vulnerable, press your hips gently down to the floor.

Think about your right leg being a bit longer then your left, and on an inhale, lift your right leg up a few inches off the floor without bending your knee knee, while also lifting your head and chest up a few inches. As you lift your chest and head, be careful not to overextend your neck (throwing it back) because this could cause neck strain. If you wish, raise your arms and hands so your arms are parallel to the floor and your palms are facing the floor.

Exhale and release back to the starting position. Repeat the process with your left leg.

Alternate right and left with every round of breath. Do about six times, side to side. Then rest.

Cautions: As with any pose, Locust might aggravate an existing problem or condition. In particular, if you have a pronounced lumbar curve, your back problems could be aggravated. Consult your favorite teacher for an alternative is you have any trouble. If you have asthma or any other breathing difficulties, this pose might make you short of breath. If this happens, come out of the pose and rest.

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Arthritis, Exercise and Yoga

by Nina

Hey, I heard this really nice little piece on arthritis and exercise on NPR that I wanted to share with you. Fortunately, NPR has both the audio and a transcript of the piece on their web site (see here). What I liked so much about this particular piece was how simple and clear it was about why it is important to continue to exercise when you have arthritis (even though most people don't) because exercising, while it cannot reverse arthritis, is the only way to prevent the arthritis from getting worse. Here's why:

1. Arthritis breaks down your cartilage, the natural shock absorbers in your joints. As a result, blood doesn't circulate as freely and doesn't deliver adequate nutrition to your cartilage. Exercise massages the joints, improving the blood supply to the joints, providing your cartilage with more nutrition.

2. The stronger the muscles are around the joint, the more protection your body can provide for the joint. Your muscles take up the weight and pressure, instead of the joint itself.

The end of the piece even mentions yoga as a good way to improve the strength of the muscles around your joints! (That's refreshing because most people are under the misconception that yoga is only about stretching.) But yoga is also a good way to massage your joints to get the blood flowing because in a well-rounded practice you move your joints in every direction. Just think of all the directions in which your hip joints move in the various standing poses. And your knee joints are bent or straight, turning out to the side or even turning in slightly (such as in Eagle pose). Your shoulder joints really get a workout, too, as you hold your arms overhead, out to the side, behind your back, or across your body (again, as in Eagle pose).

For strength building, it's easy to think of standing poses (especially those with bent knees) and balancing poses that strengthen the muscles around the knees and hips. But what about your shoulder joints? Downward-Facing Dog and Plank pose spring immediately to mind because you are bearing weight on your arms as they extend forward. But there are also other poses that you can use to strengthen your shoulder joints in which you bear weight on your arms reaching sideways (such as Vashistasana, sometimes called Sideways Plan pose) or behind you (such as the backbend Purvottanasana, sometimes called Upward Plank pose). Here's Esther doing Purvottanasana:

That looks like it does a good job strengthening the hip joints, too! Yeah, it can definitely be a challenge to practice with pain in your joints or to practice modified versions of poses you used to be able to do without props (I know because I have mild arthritis in one of my hip joints), but enjoying more mobility in your daily life and possibly avoiding joint replacement surgery, well, that's a pretty big payoff.

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