Latest Info on Muscle and Bone Strength!

by Baxter and Nina

Strong Dream by Paul Klee

Just as the natural aging process affects all organs, structures, and systems of your body, aging also affects the strength of both your muscles and bones. Because both your muscles and bones contribute to your overall strength, loss in one is typically associated with loss in the other, so it’s equally important to actively maintain the strength of both. Fortunately, using yoga to maintain your muscle strength will help with bone strength and vice versa.

For our long-time readers, it’s true we’ve written about how aging affects strength a few times before. But recently, due to Nina’s fortuitous meeting with an expert in sarcopenia and age-related muscle loss, Dr. Christopher Adams (see Age-Related Muscle Loss: An Interview with Dr. Chris Adams), we realized that most of what we’ve written in the past wasn’t quite accurate. So this is our official redo! We hope this information clarifies things for you. What hasn’t changed, however, is our understanding of how effective yoga can be for maintaining both muscle and bone strength as we age. And Chris told Nina he had recently become convinced that he should start practicing himself!

Muscles

We have over 640 muscles in our body, and starting as early as our thirties, these muscles gradually lose strength. This natural aging process, called “skeletal muscle atrophy,” causes your muscle cells and fibers to become smaller and weaker, leading to a loss of muscle mass, quality, and strength. The rate at which we lose muscle strength varies from person to person, and is also influenced by:

• Behavioral factors. Working at a sedentary desk job or not exercising are the most obvious behaviors that contribute to loss of strength over time, although these can be counteracted by becoming more active.
• Genetic factors. Your body type can influence how weak you become with age, due to the natural size of your muscles when you are younger. If you tend to have larger muscles as a young adult, you simply have more muscle mass to lose as you age before you become weak. On the other hand, if you’re someone who tends not to bulk up easily, without intervention, you may become weaker more quickly as you age. Although you cannot change your body type, if you have not already started to do so, you can begin building up your muscles now as a preventative measure. Yoga’s strength building poses and techniques provide an excellent way to do this (see Techniques for Strength Building with Yoga). All things being equal, men and women likely have a similar rate of loss of muscle strength as they age, that is until women reach menopause, at which time the more rapid loss of bone they experience (see below) contributes to greater loss of muscle strength as well. So at that phase of life and even leading up to it, women need to be particularly focused on maintaining muscle strength.
• Environmental factors. Scarcity of healthy food (malnutrition, for example, worsens skeletal muscle atrophy) and environmental toxins are the most obvious environmental factors that can contribute to loss of strength, so if possible, try to keep yourself protected.

Although skeletal muscle atrophy is caused by aging itself, other factors, such as muscle disuse (sedentary lifestyle, joint injuries, arthritis, strokes), certain illnesses that affect nerve and blood supply to muscles or have other negative effects on muscles (diabetes, cancer, and chronic infections like HIV/AIDS, to name just a few), and medications that can weaken or damage muscles (such as prednisone and chemotherapy agents) can accelerate this process. So if you have any of these conditions, using yoga to address them—whether that means by simply start to move again or by actively improving your health, such as improving diabetes control through stress management and exercise—could slow down loss of strength over time. 

Sarcopenia. For some people—whether due to illness, long-time inactivity or just very advanced age—loss of muscle mass can become a serious problem if it falls well below the average muscle mass of the general population. This advanced stage of skeletal muscle atrophy is sarcopenia. Sarcopenia is the disease stage of skeletal muscle atrophy, just as osteopenia and osteoporosis are two disease stages of aging-related bone loss. 

Naturally, this serious loss of muscle mass—which is accompanied by significant muscle weakness—is something we want to avoid if at all possible because serious muscle weakness is of the main factors that can lead to loss of independence, not to mention of enjoyment of activities that you love. Fortunately, gentle forms of yoga can help even very elderly and weak people regain strength.

Bones

We have 204 bones in our skeletons and, like our muscles, those bones undergo changes as we age. Bones slowly and gradually become thinner and weaker as we age, though it is only when they reach a certain degree of thinness that a you are at greater risk of a fracture from a fall or prolonged poor postural habits (for example, wedge fractures in the thoracic spine). The rate at which we lose bone strength varies person to person, and is influenced by:

• Behavioral factors. The same behavioral factors that have a negative effect on muscle strength—such as working at a sedentary desk job or not exercising —contribute to bone loss over time, although these too can be counteracted by becoming more active.
• Genetic factors. Your body type can influence how weak your bones become with age. Some people just naturally have thinner bones, so they have less bone mass to lose before bones become weak and brittle. And for women hormonal changes during menopause accelerate the rate of bone loss, which is why more women develop osteoporosis after their fifties. Although you cannot change your body type or gender, if you have not already started to do so, you can begin strengthening your bones now as a preventative measure. Yoga’s strength building poses and techniques provide an excellent way to do this (see Techniques for Strength Building with Yoga).
• Environmental factors. The same environmental factors that have a negative effect on muscle strength—such as scarcity of healthy food and environmental toxins—can contribute to bone loss, so for both muscle and bone strength, try to keep yourself protected.

Osteoporosis. While everyone’s bones thin somewhat as they age, for many people, due to advanced age, illness or medications, or menopause for women, bone thinning can reach a critical point, called osteoporosis. At this stage, the bones are more vulnerable to fractures, which can then be slower to heal due to the bone’s thinness. (Osteopenia is the stage of bone loss just before full osteoporosis, when you are already starting to be at risk for fractures from falls, but not to the same degree as with osteoporosis.)

Because body type and gender influence how weak bones become with age, smaller-boned people and women in general are at greater risk of developing osteoporosis at younger ages than those with thicker, bigger bones or men. However, for people over 65, developing osteoporosis is very common, with up to 50% of women and 25 percent of men developing it. 

For those with osteoporosis, the bones of the thoracic spine (your mid-spine) are at greatest risk for fracture, followed by the wrist bones and the femur bone (thigh bone) in the hip joint. These fractures can lead to ongoing chronic pain, physical disability, and, particularly with hip fractures, premature death. Naturally this is something we’d all like to avoid. Fortunately, yoga strength building poses and techniques can actually reverse bone loss (see Techniques for Strength Building with Yoga) , and practicing yoga balance poses is helpful for preventing falls (see Techniques for Improving Balance).

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Yoga for the People (and Healthy Bones)!

by Shari

With the recent passing of BKS Iyengar (the teacher of my teacher, Donald Moyer) and the exponential growth of yoga inspired by Mr. Iyengar, I have been thinking a lot about health outcomes and why yoga is such a powerful self-help tool. You see, in my day job as a home health physical therapist, health outcome is measured very differently than it is in a complementary alternative health care model that yoga falls within.

My patients too often don't get better. My job in aiding their recovery often feels like I am trying to put a small Band-Aid on a gaping wound. I can’t change the situations that lead to their poor health. They suffer from the chronic life challenges of poverty. Years of poor health management, from an uncaring overworked, depersonalized, underfunded health care delivery system, and the chronic stress from living marginalized lives lead to chronic health issues. To often these patients are living in polluted urban environments, where walking is not done by choice because it is unsafe. They also are victims of poor health from years of eating processed, nutritionally void meals. The places where they live are commonly food deserts, where fresh food is unavailable without having to take public transportation via circuitous routes. Many of my patients don’t have cars. My care often feels inadequate because I can’t change their life circumstances even when they are doing all they can do to regain their health.

For example, J was in her early 80's when I met her. She was a homemaker, a long-time smoker who had remained physically inactive though very slim. She had been diagnosed with osteoporosis in her 60's and her family started a walking program with her. They also enrolled her in a senior exercise class at the near by senior center. She was pretty stabile for about 15 years and maintained independent living in her own home. But then her husband became ill, and she couldn't care for him any longer, so he was institutionalized. He died approximately one year later. After that she had a bout with pneumonia and her long history of smoking finally caught up with her; she was diagnosed with chronic obstructive pulmonary disorder and became oxygen- and steroid-dependent for respiratory management. She was also placed in an assisted living facility by her family because of frequent falls due to leg weakness. I was her home health PT. She was compliant with her exercises but wasn't really walking more than a couple of steps because of extreme fatigue. Also, she suffered from several osteoporotic fractures from "hugs" from her family. She was really upset by this because she felt like she was crumbling from the inside out. The pain from the osteoporotic fractures and the immobility from not walking and being pushed in her wheelchair by staff further eroded her overall health. She died in her sleep—with no major medical cause—several weeks after I discharged her. 

So you might be wondering, could yoga have helped J? I believe that if it had been a part of her activity regimen when she started her walking and exercise class that it would have. Yoga could have helped J with her sense of physical and emotional loss as she lost her independence and her home. Guided strength training for specific bone strengthening positions might have slowed her progressive osteoporosis. Unfortunately I will never know for certain because her care was limited by her HMO insurance company and I was only given four visits and told to "get her back onto her feet." 

In my more cynical moments I am disgusted by the public degree of privilege that American yoga seems to support. The visual images of perfect woman and occasionally men shine from the glossy covers of popular mainstream yoga magazines, with headlines urging pursuit of the “perfect yoga body” and touting delicious organic recipes, not to mention hyping over-the-counter supplements for “health” or lovely yoga fashions to enhance your practice of yoga.

So when the accolades of the wonders of yoga are constantly cited sometimes I can’t take it. But then I remember B.K.S. Iyengar and how he really did bring yoga to the people and how he did make it accessible to everyone. I also remember that yoga is more than asana—that it truly is a credo on how to live your life for the greater good.

So in this spirit of inclusivity and my own belief that the best way to deal with health challenges is through personal empowerment, I am starting a new beginner-level yoga class focusing on bone health called Yoga for Healthy Bones, both to honor J and to support my general yoga students who, as they are aging, are being diagnosed with bone loss from either osteopenia or osteoporosis. This class will provide camaraderie, creating a community of mutual support as well sharing, which the class members can engage in if they so desire. There is nothing better in self care than learning what worked or didn't for individuals with similar diagnosis. And, most importantly, this will be a venue where people can practice yoga without fear of hurting themselves.  

I am personally very impressed with the work and level of dedication that Dr. Loren Fishman has provided for his patients through his ongoing medical study on the efficacy of yoga in building bone density. This class will incorporate some of his basic principles of bone stimulation as well as focusing on many of the safe beginner level standing and seated poses for osteoporotic individuals. If you live in or are visiting the San Francisco Bay Area, come and join us on Sunday afternoons from 4:00-5:30pm at the Yoga Room in Berkeley, California (see yogaroomberkeley.com).

Namaste.

Shari

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Friday Q&A: Forward Bends and Osteoporosis

Standing Forward Bend (Uttanasana)

One of our readers left the following comment on our post Featured Sequence: Mini Sun Salutation:

I am surprised you are including a deep forward bend. Research supports avoiding forward bends in osteoporosis and osteopenia and considering there are over 54 million people with osteoporosis and many don't know they are osteoporotic it seems safer not to teach forward bends for healthy aging. I think we have a higher percentage of yoga practitioners who fit the risk profile....slight, female, white, especially if they had a restricted diet in their younger years. 

This reader is concerned about practitioners who may have osteoporosis doing deep forward bends as we showed in our Mini Sun Salutation. And, indeed, for those with OP or even undiagnosed OP (they have it but don’t know it yet) forward folds hold the potential of increasing the risk of the most common fracture in those with OP: a wedge fracture of the thoracic spine. So, if you fall into this camp, I’d recommend modifying your standing forward bends by allowing your knees to bend as much as you need to help release your pelvis over the thigh bones as you bend, and maintain a more neutral alignment of your spine as you go down. That means avoiding rounding your upper back in the area of your thoracic spine.

I have a student in one of my class in her late 60s with recently diagnosed OP, and we discussed her modifying her forward bends in just this way for poses such as Standing Forward Bend (Uttanasana) and Widespread Standing Forward Bend (Prasarita Padottansana), and she has been diligent about doing so.

Having said all that, I’d like you to keep in mind that our blog is not just for older adults who might have or be at risk for OP—or any condition for that matter. So, the Mini Sun Salutation post was really just an opportunity for us to share with you a basic common modern yoga practice that you can refer to as needed. We will try to add in a few more cautions to these sequences in the future, but you should always read our posts on yoga poses and sequences through the lens of your own personal situation, and take good care of yourself by making any modifications to the poses to better serve your needs. And if you are uncertain as to the safety or appropriateness of any YFHA recommendations, check things out with your local teachers. 

—Baxter

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Cautions for Bone Strength Practice

by Nina

On Tuesday we posted a sequence designed by Baxter Featured Sequence: Bone Strength Practice. Since then we've had a couple of questions from people about whether the sequence is safe for people who have osteoporosis or osteopenia. We've added a warning to the original post, but for those of you who have already read that post, we're posting the warning here as well. 

Cautions: The Bone Strength Sequence was designed for those with no evidence of osteoporosis or osteopenia. If you have either of those conditions, be mindful to avoid the forward folding action of Cat/Cow pose (the Cat position), although the hands and knees position will lessen the potentially negative force on your thoracic vertebrae quite a bit. Otherwise, the sequence should be safe.

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Featured Sequence: Bone Strength Practice

by Baxter

As part of my continuing series of special sequences, I’d like to offer a sequence for building stronger bones. To start, please see one of my previous post on osteoporosis Healthy Bones for Men and Women Alike. When practicing the poses I have chosen for the sequence today, remember some of the suggestions I made in that previous post: 

“The research data that shows that we can stimulate new bone growth along lines of stress by holding poses for between 8-72 seconds is, for me, the pivotal nuance to add to the yoga practice you are already doing. Because of this, I have been working recently with holding postures for 30-60 seconds, depending on the physical demands of a given pose (for example, holding Downward-Facing Dog for 60 seconds, while holding Hand to Foot pose (Hasta Padangustasana), a much more demanding pose on many levels, for 30 seconds.” 

So, you will want to experiment with holding your poses in that 30-60 second range. The other key concept to keep in mind relates to the following: 

“Remember that engaging opposing muscle groups while doing the pose increases the stimulation of the underlying bone cells that make new bone (this is essentially an isometric contraction around a joint). So, in Downward-Facing Dog I consciously engage the muscles around all the joints I can think of.” 

In standing poses, I am not only taking advantage of the weight bearing part of the pose, the feet and legs, but using this isometric muscle contraction around the shoulder joints, for example, and in the contraction of the muscles of the back spine to assist in keeping the posture actively upright. So, if you want to add more poses to the sequence, you can include any of your favorite standing poses and apply these two principles for bone strengthening.

Cautions: The Bone Strength Sequence was designed for those with no evidence of osteoporosis or osteopenia. If you have either of those conditions, be mindful to avoid the forward folding action of Cat/Cow pose (the Cat position), although the hands and knees position will lessen the potentially negative force on your thoracic vertebrae quite a bit. Otherwise, the sequence should be safe.

Warm-Up

Cat/Cow: This pose warms up your spine and its joints, as you are also bearing weight on your wrists, the second most commonly fractured area in people with OP. Start on your hands knees, with a blanket or other padding under your knees. On your inhale arch into a gentle backbend, and then on your exhale round your spine towards the ceiling. Repeat for about six rounds. 

Hunting Dog: This pose a great one for building strength in the wrists and spine. See Hunting Dog Pose for basic instructions. Be mindful to keep your chest lifting towards your shoulder blades, especially on the side where your hand is on the ground. And strongly reach your lifted arm and shoulder blade forward, as you reach the lifted leg backward. After you come out, be sure to shake out the wrist of your supporting arm.

Downward Facing Dog: Because you are bearing weight on hands and feet and really working around the hip joints, the third most commonly fractured joint in the body, this is a great pose for building bone strength. From hands and knees position, come up into Downward-Facing Dog pose. See Downward-Facing Dog Pose Variations  for variations that might work best for you. 

Downward Dog Variation

High Plank Pose: This is another great pose for your wrists as well as your arm bones, and also for your spine as it engages the muscles attached to your spine. Start in Downward-Facing Dog pose, and then shift your shoulders forward until your shoulder joints are directly over your wrist joints. Keep your ribcage lifting up towards your shoulder blades and your elbows strong and straight. The rest of your body should be in a Mountain pose-like shape, so you need to keep your core and legs engaged, while maintaining a natural curve in your lower back. To come out of the pose, swing back to Downward-Facing Dog, then to hands and knees. Afterward, give your wrists a good shake out and brief rest. 

Active Poses

Extended Side Angle Pose: This is a great pose for your legs and hip joints, your bottom wrist joint, and your spine. You could substitute Triangle or Warrior 2 pose here, if you prefer those standing poses. From Mountain pose, step your feet wide apart, turn your right foot and leg out 90 degrees and kick out your back heel an inch or so. Bring your arms up parallel with the floor and bend your front knee. Then side-bend your hips and torso over your front leg and put your right hand on a block on its highest height, placed snug up against the outside of your front shin. Swing your top arm up and overhead, completing the side angle from your back leg through your torso and into your top arm. Push down firmly into the block with your bottom hand and feel your right shoulder blade firm into your chest and slightly down toward your waist. Reach your top arm and shoulder blade strongly forward towards your fingers. Be sure to actively engage the muscles around your mid-spine to strengthen your mid spine area. Come out of the pose on an inhalation, relax your arms at your sides, and repeat on the other side. 

Warrior 1: This a good pose to strengthen the spine, as it contracts the back muscles that pull on the vertebrae of the entire spine. See Warrior 1 Pose for instructions. You will use this pose to transition into your next pose.

Warrior 3: This pose adds in a balance challenge to weight bearing on the standing leg and isometric work on the lifted hip and along the spine. See Warrior 3 Pose for instructions and easier variations. Since the  pose can be quite challenging, start with shorter holds and gradually work up to 30 seconds or more. 

Forearm Dog Pose to Forearm Plank Pose: See Downward-Facing Dog Pose Variations for instructions on Downward-Facing Dog pose with Headstand Arms for instructions. From that pose, move into Forearm Plank by swinging your shoulders directly over your elbows and bringing your body parallel with the floor. When you come out of the pose, release down onto your belly in a prone position.

Locust: See Locust Pose for instructions. Even though those instructions are for dynamic Locust, practicing this pose dynamically will give you a good way to ease into full, static Locust pose, in which you lift both legs, your chest and your head and hold the pose for 10 seconds to start. Gradually add more time until you can do a 30 second hold. Rest for a few breaths before moving on. 

Simple Seated Twist: It is theorized that twisting helps nourish the spine—movement of the spine helps maintain the health of the discs—and also strengthens the bones themselves as your back muscles pull on the bony insertions of the spine. If you already have osteoporosis, you may need to be a bit more cautious, so I recommend that you twist to a bit less than your potential maximum. Start by sitting in a comfortable crossed-legs position, on a prop such as a folded blanket if needed. Sit tall and on an exhalation, rotate your chest and upper belly to the right, placing your left hand on your right knee and your right hand on the floor behind you. Stay for 30-60 seconds before releasing and changing the cross of your legs and twisting to other side. 

Bridge Pose: This pose will engage your back body muscles, so it's a good one for strengthening your spinal vertebrae as well as your legs. Starting on your back, bend your knees to come into Constructive Rest pose, with your feet about four inches from your hips. Warm up by lifting your hips up as you inhale and lowering them down when you exhale, up to six times. Then inhale and stay in the pose for 30-60 seconds, breathing gently in and out the entire time. Press down evenly into your feet, and lift both from your hips and the lower tip of your breastbone. Optionally, you can turn your upper arm bones under the pose, being mindful not to put strain on your neck. On an exhalation, release your arms and come out of the pose.

Before moving on to Relaxation pose (Savasana), take a moment to do bring your knees to your chest or rock your knees and hips side to side to release your back muscles. 

Cool-Down

Savasana: If time permits, take a generous 10-minute rest before heading into your day. Bring attention to your bones and imagine them heavy, dense and strong. 

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Friday Q&A: Ostepenia of the Spine and Headstand

Q: I am 63 years old and have osteopenia of the spine. What are your thoughts of headstand for those of us with osteopenia of the spine? I have taken yoga for several years. My teachers are wonderful and all are Iyengar certified as senior teachers. I have not yet shared with them my recent diagnosis. I appreciate your thoughts on this question.

A: As a general rule, I’d say don’t do it. As we have written about before, the spine is the number one sight for fractures secondary to osteoporosis and osteopenia means your spinal bones are already thinning. And although the thoracic spine is the most common area for wedge fractures to show up in OP, lumbar and cervical fractures happen, too. The human cervical spine—as you probably already realize—is not structured to bear weight on the head, no matter how much you might love Headstands and Shoulderstands (also not a good idea if you have osteopenia of the spine) or what your teachers might like to believe. The cervical region of the spine has the shortest vertebrae and the thinnest discs of anywhere in the spine, because it is evolved only to have to bear the weight of your head, not your body resting down on your head.

I also recommend sharing your diagnosis with your teacher. Now. If your teachers are not particularly concerned about the possible negative effects of Headstand on your spine, you might seek out a new teacher. This does not mean that you cannot do certain inverted postures. Legs Up the Wall is generally safe as an alternative, and if you can get up and down by pivoting mostly at the hip joints to use a “Headstander” (a special prop that allows a variation of Headstand where the head dangles toward the floor but does not rest on the floor) to go upside down, you could give that a try. But do remember that you need be careful about forward folding and it’s potential negative impact on the thoracic and lumbar spine with OP. 

As senior Iyengar teacher Ramadan Patel once said during a workshop on Shoulderstand when someone was bemoaning the fact they might not be able to do the pose again, “Nobody ever attained enlightenment doing Shoulderstand! It is not big deal. Let it go.” It was helpful to actually hear that back when I was able to do Shoulderstand and Headstand without a second thought. These days, I myself skip Headstand to keep my delicate cervical spine happier.

—Baxter

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Friday Q&A: Back Stretches and Inversions for Chair Yoga

This week, we have a follow-up question to our Friday Q&A on chair yoga (see Friday Q&A: Chair Yoga) from one of our readers who actually teaches a chair yoga class

Q: I teach a chair yoga class which cannot go to the floor for healthy aging. How can I do a safe inversion or back stretch that does not stress the osteopenic back?

A: If you teach chair yoga, many students are older or infirm and not able to transfer from standing or sitting in a chair to the floor, where you might have them do any number of reclining poses that could stretch the back or approach an inversion, like Legs Up the Wall pose (Viparita Karani). 

If by “back stretch” you mean a forward bending action of the spine, like in Standing Forward Bend (Uttanasana), in light of possible osteopenic or osteoporotic spine, you need to be careful with most forward folding positions (see What is Ostepenia and How Can Yoga Help?).  It is not hard to do a seated version, however, if that is what you are looking for. One of my favorites that is fairly shallow and would not create too much force on the vertebrae of the spine would involve placing a second chair in front of the first, facing it away from you. Then ask your students to tip as much as possible from the hips and place their crossed forearms on the top seat back of the chair in front of them. This is similar to seated forward fold we showed for our Office Yoga series (see Featured Pose: Chair Forward Bend).

If, however, by “back stretch” you are referring to a back-bending action, then there is a bit less concern of hurting the spines of students with OP.  In seated Cat/Cow pose, the Cow variation is a nice, easy backbend shape that most could do in the chair. (See Featured Pose: Chair Cat Pose.)

Or, have the students stand behind the chair, use the top back rung for their hands for balance purposes and do a gentle standing backbend from Mountain pose (Tadasana).

As for inversions, this may be a bit tougher. You could have them put their chairs against the wall, and if they still have good hip mobility of rolling the pelvis over the femur bones, you could do a Downward-Facing Dog version with the hands on the seat of the chair, walking the hips and feet back into this higher version of regular Downward-Facing Dog, but with a slight downward slant from hips to hands. Make sure they bend their knees as they walk forward towards the chair at the end of the pose, and rise up slowly monitoring for any lightheadedness or dizziness. (See Featured Pose: Downward-Facing Dog (Chair Version)).

And you could show the class how to do Legs Up the Wall pose on the ground, demonstrating it for them, and suggesting they try this at home in their beds, swinging the legs up the headboard side of the bed if the bed is up against a wall. I’d have them only stay for 2 minutes or so at first, as you will not be there to monitor them. Of course give them all the usual precautions regarding inversions and high blood pressure and glaucoma, as the older your crowd, these conditions are more common. I hope these suggestions give you things to consider. And armed with the information from our posts on OP, you can be creative in your approach to working with your chair yoga classes.

—Baxter

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What is Osteopenia? And How Can Yoga Help?

by Shari

Last Friday Baxter answered a reader’s question about osteopenia (see Friday Q&A: Yoga and Osteopenia), regarding whether or not yoga practice on its own is sufficient to maintain and/or increase bone strength. By chance, we recently received a request for an article addressing “dangerous” poses for osteopenia. Since most of you probably don’t know much about osteopenia—and its relationship to osteoporosis— we decided it was about time to provide some background information about the condition. I promise I’ll get around to answering the reader’s question eventually! Look for it this coming Friday.

Let’s start by discussing osteoporosis, which is a disease in which bones become fragile and are more likely to break or fracture due to loss of density (not bone strength). It is not painful and many people (both men and women) don’t even know they have it or are at risk for developing it until they take a DEXA scan. The DEXA scan (dual energy X-ray absorptiometry scan) measures bone mineral mass, because medical researchers have discovered that there is a correlation between bone breaking and bone density loss. But the DEXA scan can also cause lot of confusion because it doesn’t take into consideration the different way bones are constructed. Some bones are short and fat, and some are long and thin, and differently shaped bones can have different density readings. Bone mass is affected by both how densely a bone is constructed and by its corresponding physical dimensions.

Femur Bone

The World Health Organization has defined the statistical measurements of bone density through a system of comparing your numbers to women of the same age, height and weight, and then comparing them to the average measurements of women age 25-30 that are at the peak of bone strength. Three areas are measured in the DEXA scan: lumbar spine, total hip, and surgical neck of the femur (thigh bone). Two scores are given:

• T score, which is the measurement of bone mineral density and how your score compares to healthy 25-30 year old women.
• Z score, which is the comparison to women your age, height and weight.

Osteopenia is defined as a T score of 1 to 2.5 standard deviations below the mean (negative numbers), and means that you are at risk for developing osteoporosis. Osteoporosis is defined as a T score of 2.5 standard deviations below the mean (negative numbers). The higher the T score (or the more negative the numbers), the higher the fracture risk.

The correlation between a low bone mineral-density reading in a DEXA scan and a higher fracture risk is stronger than the relationship between high blood pressure and a stroke. But even though the test detects 9 out of 10 people with osteoporosis, the test is not perfect and it wrongly diagnoses healthy bones between 5-7% of the time. Also, readings will differ in different test sites, so for consistency the same test facility needs to be used for repeated scans.

So how does yoga fit into this picture? Bone has two main components: outer bone and inner bone. Bone is a living matrix of living cells and canals that are interrelated. Outer bone, which surrounds inner bone, is called the cortex and it forms a hard outer ring and is a large part of bone strength. Its construction is fairly uniform in individuals. Inner bone is spongy and is called cancellus or trabecular bone. It varies greatly in individuals. For us to improve our bone health we want to not only build outer bone but also inner bone.

Wolff’s law describes bone strength as follows:

1. The architectural strength of a bone develops along the lines of force that the bone is subjected to.
2. If a bone is loaded, the bone will remodel itself over time to become stronger and resist that sort of loading.

In conjunction with Wolff’s law there are some other important forces that act on the bones to improve bone strength and density:

1. Gravity increases bone loading. 
2. Muscle contraction increases bone loading. Dynamic tension occurring between muscle agonist and antagonist affects the bones by applying opposite pressures, and the forces are doubled on the bone.
3. Muscle activity stimulates bones to strengthen themselves more vigorously than weight bearing alone.

In our yoga asana practice, we not only take weight-bearing positions, such as standing poses, but all the active poses involve muscle contraction in some form. And the great variety of poses and movements means that all your bones are involved! In addition, Dr. Loren Fishman cites from his extensive research on osteoporosis that bone stimulation (growth) occurs after 12 seconds of static (isometric) hold but not more after 72 seconds of hold. 20-30 second holds are recommended for bone stimulation. And 20-30 second holds are quite typical for many of the poses we practice.

Now you can see why yoga is recommended for people with osteopenia as a way to prevent the development of osteoporosis and is also considered beneficial for people who already have osteoporosis. And for those of us who don’t have either condition, yoga is a very versatile and adaptable way for maintaining our bone strength. However, because osteopenia means more fragile bones, certain yoga poses are considered risky for people with the condition. Tune in Friday for my answer to the reader’s question about those poses.

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Friday Q&A: Yoga and Osteopenia

Q: I have been going to a yoga class 3x a week for about three months. It's at my gym, and my teacher trained with one of Erich Schiffmann’s students.  I used to weight train, for about ten years, but found my motivation ebbing, but loved having muscle definition. I love doing yoga! My body feels so much better, I walk better, my shoulders feel more open, and I have a wonderful sense of peace. My questions are, is yoga enough to maintain my bone mass? (I am small, with slender bones, have osteopenia). Also, are cardio and walking ok? Not strenuous enough? I want to incorporate a daily yoga practice in addition to my classes. I can tell my energy and strength are different now, how to stay healthy now that I'm almost 61?

A: Thanks for your interesting question. I am so excited to hear how the yoga practices are feeling for your body and your life! A balanced yoga asana practice may indeed provide enough stimulation to your bones to stabilize or improve your condition of osteopenia, the precursor state to osteoporosis. We know that yoga asana can increase the density or mass of bones, and we think it also may add the added benefit of changing the structure of the bone to be stronger and more pliable. In addition, as Loren Fishman, MD points out in a recent interview on this topic:

“There are numerous other important ways in which yoga benefits people with osteoporosis, such as improving balance, muscular strength, range of motion and coordination, while lessening anxiety.” 

 In fact, I recommend that you read this interview on YogaU Yoga for Osteoporosis - An Interview with Loren Fishman, M.D. and Ellen Saltonstall, as it is quite informative.

Cardio workouts and walking are certainly good additions for your overall health, and walking is beneficial for your osteopenia as well. You do need to be mindful of any forward bending in your regular yoga classes, as these are usually contra-indicated for osteopenia, and go easy on any side-bending poses, as they are also a potential problem. We’ll have more on osteopenia from Shari next week, including information about how to modify your yoga practice, so stay tuned!

I love Erich Schiffmann’s style of yoga and have studied with him over the years, but for your condition I would recommend adding in a more alignment-based style of yoga (such as Iyengar or Anusara) with a well-trained, experienced teacher. As you become more familiar with the poses that are likely to benefit your bones, you can start doing some of these each day at home as the foundation for your home practice. Another good resource for your home practice is Dr. Fishman’s book Yoga for Osteoporosis: The Complete Guide. It sounds like with all that, you’ll being doing a lot for your health each week. Please let us know how things go for you!

—Baxter

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Poses for Osteoporosis

by Baxter 

As promised, today’s post will address a few of my recommendations for yoga for osteoporosis. As many of you know, OP is a very common condition that increases in incidence as we age. And before you fellas tune this out with the common misconception that OP is just a woman’s condition, it might surprise you to learn the following statistic from the Mayo Clinic: 1 in 8 men over the age of 50 will suffer an osteopenic fracture! And what are the most common fractures in men and women? The hips, spine and wrists are the areas most commonly affected. 

The easiest lifestyle recommendation to have a positive impact on the progression of the condition is weight-bearing exercise. And although there are other forms of physical activity and exercise that fall in that category, all of yoga’s poses or asana fit the bill, and unlike walking, yoga actually requires that we bear weight on not just the feet, but the wrists and the spine as well, so in my estimation yoga is far superior to walking alone.

Three classic modern poses that are well known to most yogis are good examples of poses that are good for OP:

Warrior 2: I like this one because you are balancing on both feet, which is easier than on one foot, yet it is still a challenge for your balance receptors. And not only are you bearing weight, but if you do the pose for 1-2 minutes, you notice that you are also building strength and endurance in your legs and arms. (Later this week, we’ll talk about this Warrior 2 in detail. See here.)

Warrior 2 Pose from Moving Toward Balance

Downward-Facing Dog: Since all four of your limbs are in contact with the floor, balance is not much of an issue, but you are now bearing weight on your hands, wrists and arms as well as your legs. This will stimulate the bones of the upper extremities and could lead to increase density in these areas. 

Downward-Facing Dog Pose from Moving Toward Balance

Tree Pose: For immediately obvious reasons, Tree pose will challenge your ability to remain balanced on one leg. The supporting leg must really work and be strong and stable to keep you upright, and the other leg’s hip gets a bit of opening from its position. And although this or any yoga pose will not eliminate the chance of a fall at some time in your future, more than one of my students has reported that after taking an unexpected spill, they felt their yoga practice prepared them to fall more gracefully and minimize the injury they sustained.

 Tree Pose from Moving Toward Balance

Keep in mind that if you are young and/or without evidence of OP at this time, a regular practice could be preventative. If you have been diagnosed with osteopenia, the precursor to OP, it is possible that your regular practice could stabilize or even reverse the trend of thinning of the bones, at least according to a recent pilot study by Loren Fishman, MD. The same is true if you already have OP, but have not suffered fracture; but you will need to be a bit more cautious as you practice, and I’d recommend that you take class with an experienced teacher familiar with modifying the poses to fit your individual needs.

Even 10 minutes a day may be enough yoga asana to impact OP, so why not start today with these three poses?

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