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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Yoga and Shoulder Joint Replacements

by Shari

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

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

Healthy Shoulder Joint

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

Shoulder With Joint Replacement

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

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

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

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

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

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

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

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Arthritis of the Shoulder and Yoga

by Baxter

If you have been following our blog for any amount of time, you’ve become familiar with the wide variety of joints and areas of our boney spine that can be affected by osteoarthritis. From your hands to your toes, any movable joint is subject to this condition of wear and tear on the end surfaces of the bones and their slick, cushiony covering, the cartilage. The older we get, the more likely we are to develop osteoarthritis somewhere in our bodies, including the shoulder area. Seems the magic age is sometime after 50, but if you have sustained a traumatic injury to your shoulder or have the rarer form of arthritis, rheumatoid arthritis (RA), you could develop the tell-tail symptoms of arthritis-pain, swelling and reduced movement at the shoulder.

I’ve worked with many students and patients over the years with arthritis, and I will mention that the shoulder area is less commonly affected than say the knees, hips or spine. But it does show up now and again. Turns out there are actually two joints in the lateral shoulder area that can develop arthritis.

The first one is where a finger-like projection of the shoulder blade or scapula meets the far end of your collarbone or clavicle at what is technically referred to as the acromioclavicular joint (the AC joint). You can actually feel to the top connection of this joint if you trace your collarbone from your breastbone toward your shoulder area. You’ll note a sudden drop off as you move laterally. That’s where the two bones meet. Arthritis in this joint usually refers pain to the front of the shoulder area.

Shoulder Joint

The second joint affected is where your arm bone, the humerus, meets the side of the scapula at something called the glenoid fossa (a shallow, cup-like area that is concave to fit the round end of the arm bone), forming the glenohumeral joint. Arthritis pain in this joint is usually referred to the back of the shoulder area. And like other forms of arthritis, a diagnosis is usually reached after a history and physical exam by your doc, possibly including X-rays to look for narrowing of the joint space or the development of bone spurs around the joint and, on rarer occasions, blood tests to rule out RA or drawing fluid from the joint to look for crystals or infection. Once diagnosed, usually with osteoarthritis, you’re likely to have rest, ice, anti-inflammatory meds and physical rherapy prescribed to help decrease swelling and pain, and increase your range of motion in the shoulder joints. On more rare occasions when these treatments are ineffective, injections or surgery may be recommended. Like the hip and knee joint, the surgeon may replace part of the joint with an artificial joint.

Humerous and Scapula

Where does yoga fit in? Well, since shoulder arthritis can result from chronic wear and tear action on the joints, it is possible that a yoga practice heavy on weight-bearing asana, such as Downward-Facing Dog pose, Push-Up pose, and arm balances, such as Crow or Heron, as well as vigorous repetitive practices that don’t vary much in their routine, could lead to this kind of shoulder problem. However, on average, yoga is more likely to be helpful as a tool for healing than the underlying cause of the problem. And if you suffer from shoulder arthritis, this is yet another setting in which working one-on-one with an experienced teacher could save you time in getting on the right course of practice to improving your symptoms.

Just as we discussed in arthritis of the hip, even with the abnormal changes to the joint that accompany arthritis, it is still essential to keep mobility in the affected joints. In the situation where symptoms are already present, you will want to proceed slowly and mindfully as you begin to experiment with yoga postures that are exclusively non-weight bearing (at least at first). Many of the standing poses, such as Triangle, Extended Side Angle (being cautious not to bear too much weight with the bottom arm for both of those), Warrior 1, 2 and 3 would all be reasonable choices.

Poses that involve more pressure around the shoulder joint, in which there are additional rotational forces, such as Prayer position behind the back, or Eagle arms, may not be appropriate, as they could more likely aggravate the joint than help it. However, working with a teacher, you may gradually be able to add in more complex arm movements if your symptoms stay quiet. Versions of poses you would be likely to encounter in class, such as the ubiquitous Downward-Facing Dog, may be added later if you are progressing, with wall versions, such as Half Downward-Facing Dog at the Wall (see here).  And since it is not unusual for the muscles around the affected joint to be atrophied from lack of use when the joint is initially inflamed, holding the arm positions, like Warrior 2 arms, for 30-60 seconds can add strengthening of the muscles to the goal of maintaining mobility in the joint.

In addition, the pain-diminishing effects of pranayama and meditation practices could be very helpful along with your physical poses, and could be substituted for asana during times when your shoulder symptoms flare up and resting your body makes more sense for a while.  And, as always, we welcome your comments and experiences with the topics we share with you. So if you have some yoga insights on arthritis of the shoulders, we are all ears (and shoulders, of course!).  

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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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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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