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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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: Kyphosis (Dowager's Hump)

Q: I teach chair yoga for older people. Several of my students have pretty bad kyphosis, a rounded curve in the upper back. They are not yet into a dowager's hump but they are on the way. When we do down dog with a chair, their upper backs are very humped. If I have them try to do cat/cow stretches with hands on the chair seat, their upper backs barely move. I have suggested that they try to lie on their backs with a small blanket roll under the bottom tips of the shoulder blades. Do you have any suggestions for how they might try to reverse this curve or at least stop it from getting worse?

A: This is an interesting question: what to do with the student who has kyphosis of the thoracic spine, the part of the spine in the area of the rib cage? What can we do as yoga practitioners to prevent the progression of the spinal changes we are seeing, and is it possible to reverse the excessive posterior curve in the upper back?  And should we be more attentive to this area when we are younger and possibly avoid this kind of change in the upper back (yes!)?

As we have discussed in the past, the normal anatomy of the spine involves a gentle, undulating set of curves from head to tail. From the backward curve of the back of the skull, as we move into the cervical (neck) spine, the spine curves forward toward the front of the body.  As we travel down into the thoracic (rib cage area) spine, there can be a natural backward curve, although in indigenous peoples and from ancient sculpture there is evidence that minimal curve in this area might be a healthier variation (see the work of Esther Gohkale). As we proceed further south and enter the lumbar (lower back) spine, the spine curves toward the front of the body once again. Finally, the sacrum curves backwards to complete the serpentine trail of the spine.

According to the Mayo Clinic website (I love these folks!):

“Kyphosis is a forward rounding of your upper back. Some rounding is normal, but the term "kyphosis" usually refers to an exaggerated rounding — sometimes called round back or hunchback. While kyphosis can occur at any age, it's most common in older women where the deformity is known as a dowager's hump.” 

Today, I am interested in kyphosis that occurs in older adults. In my experience, I have encountered this pronounced curve in both older men and women. The Mayo clinic notes that it occurs more often in women, likely due to the earlier onset of osteoporosis (OP) in women. What’s the OP connection?

The most common site of fracture in people with osteoporosis is the spine, and more specifically the thoracic spine. The typical fracture in the area is called a wedge fracture, in which the body of the vertebrae, that kidney bean-shaped biggest part becomes so thin that the front part collapses, and when seen from the side, it looks like a wedge. If you get several of the vertebrae in a row doing that, then the whole upper spine begins to bow forward like the Kokopelli image.

In some instances this will result in stiffness and difficulty maintaining an upright posture, and for some pain will also arise. Along with pain, in more severe cases of kyphosis, the change in spinal curve can affect your lungs, nerves, and other tissues and organs. So we need to do at least one important thing before we start moving these students of our reader around a lot: have them see their family doctor for an X-ray of the thoracic spine to see if fractures have already happened and get a DEXA scan to rule out OP if this has not been done. Once you know their OP status, you can make better decisions around yoga poses and practices.

Two other important factors that can contribute to kyphosis in older adults are disc degeneration (we have written about this, too) and cancer and cancer treatments (which can weaken the vertebrae and contribute to fractures as well).

Your western doctor may recommend certain treatments:

• If there is OP present, medications to treat osteoporosis might be prescribed.
• If pain is present, pain relieving meds could be recommended. 
• If the person’s condition is compressing a nerve or causing some other significant problem, surgery to fuse bones could be suggested, but the risk of complications is high and tends to minimize this option.
• Physical therapy exercises are prescribed to improve flexibility in the spine, as well as ones to strengthen the abdominal muscles to help support better posture.

Obviously, this last area, improving flexibility of the spine and strengthening abdominal muscles, is where yoga practice could be helpful.

If you don’t yet have a copy of Loren Fishman’s book Yoga for Osteoporosis and you are working with older adults, perhaps today’s the day to order it! It is a good resource of suggested poses and ways of doing them that you will likely find invaluable. A valuable piece of advice from the book regarding patience with these students is:

“Although yoga can be slow, requiring months or even years to achieve major effects, the trip is pleasant…”

So, with patience in mind, in regards to the reader’s observations, I’d suggest that for Downward-Facing Dog with the chair, if they are putting the hands on the seat of the chair, bring them up to the back rung, and if already on the back rung, do a higher version of Half Dog Pose at the Wall.

Half Dog Pose at the Wall

Let them bend their knees a bit and focus on lengthening their spines to whatever degree they can pain free. Even if not much seems to be happening in Cat/Cow pose, keep doing it anyway. I like the effect of dynamic movements like that for loosening tightness up gently. Along those lines, have them stand in Mountain pose with their backs to the wall, perhaps with the kyphosis lightly touching the wall. Then have them inhale one arm forward and up overhead and exhale it back down. Repeat with the other arm. Do several sets of these. The mere act of taking the arm overhead will begin the encourage extension of the upper back, exactly what you are looking for here, and strengthen the upper back muscles that assist in this goal. You could obviously do this sitting as well. 

If they can easily get down to the floor for Savasana, I find that no lift is needed under the thoracic spine, but a lift is definitely needed under the head so it stays level with the chest. Over-extending the neck has its own set of worries you don’t want to cause! In that reclining position, you can again have them work the arms as we did in Mountain pose.

To strengthen the abdominals, you could create a variation of Boat pose (Navasana) done sitting at the front edge of a chair, lifting one bent leg up a few inches and holding it in position for a few breaths, then lowering that foot to floor and repeating with the second leg. Again, if they can get to the floor and you can teach them Locust pose (Salabasana) or even one-legged Locust (which takes the spine into extension), you can have them do that at home or even in bed if they have a firm mattress.

One-Legged Locust Pose

I’ve already gone on a bit too long today, but I do believe that by intervening now and getting these people to practice at home as well as in class, you have a good chance of stopping the progression of the kyphosis and in some cases, where no wedge fractures have altered the anatomy, maybe even helping to reverse it! Please let us know how things go.

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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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Osteoporosis, Balance and Yoga

by Brad

A couple weeks ago, I attended a very interesting seminar on “Bone Marrow Adiposity:  An Age-Associated Phenotype; What's between bone and fat?  New insights into age-related osteoporosis” by Dr. Clifford Rosen, MD.  Dr. Rosen is the Director of the Center for Clinical and Translational Research at the Maine Medical Center Research Institute in Scarborough.  His talk was fairly technical and had to do with the regulation of fat in bone and how it increases slowly with age, as well as being affected by other environmental and genetic factors. His data showed that as fat accumulates in bone with age, it appeared to be related to a decrease in bone density, and therefore could be a driver of osteoporosis in both men and woman. He also stated that the clinical manifestation of osteoporosis is bone breakage, and therefore as your bone density decreases, it is the fall and inevitable bone fracture that typically turns people into patients. Avoiding a fall in the first place is possibly the best and for some the only way to avoid the adverse effects of this age-related decline in bone density.

After his seminar, I had a chance to talk with him after his research and asked him whether yoga might help by decreasing the risk of falling. He immediately said yes, and added that the yoga and tai chi were the two things that he knew that had been shown to have the greatest benefits in reducing this falling and bone fractures (see, for example, the Mayo Clinic web site's Exercising with osteoporosis: Stay active the safe way by choosing the right form of exercise and the New York Times article Ancient Moves for Orthopedic Problems). He implied that this was primarily through an increase in balance as opposed to strength. Indeed, while there is plenty of evidence that strength training is important, an increase in balance and flexibility can make all the difference between a stumble or misstep and a full-fledged fall.

As I sit on my flight to Seattle, I am reminded of how much variation exists in flexibility and balance among adults. Squeezing out of an aisle seat to make your way to the restroom or retrieving a suitcase from the overhead bin can easily become an awkward and precarious—and at times dangerous—act. And it is often not the oldest passengers, but the middle-aged and muscle-bound adults who induce serious cringing from neighboring passengers. Imagine how much more agile they would be if they all practiced yoga!

And for those of us who already do yoga, this is yet another compelling argument that working on balance is critical as we age. So if you haven't done so already, check out Shari's post last week about how to create a yoga practice to improve your balance (see Planning a Practice for Improving Balance).

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Friday Q&A: Is Loren Fishman's Osteoporosis Sequence Safe?

Q: You say that people should not do the same poses all the time. What about programs like Dr. Fishman's osteoporosis study, which has participants doing the same sequence of poses every single day?

A: Thanks for this question. Indeed, if a person does the same sequence day in and day out, you could run the risk of a repetitive strain injury. The fact that Dr. Fishman's sequence is only supposed to take 10 minutes a day to do means that the practitioners are not holding the poses terribly long, which would reduce this risk considerably. However, a review of the poses taught (see here) reveals several poses that I feel could be potentially injurious to the wrists, neck and lower back, these being Upward Bow pose and the deep seated forward bends. I would consider other poses if I were to design such a practice, but Dr. Fishman does mention tailoring the sequence to students individual needs. I would suspect that this had to be done quite a bit.

Recall that the number of patients that started the study was much larger than those that completed the study. (117 vs 11). Interestingly, there is no discussion as to what caused so many to drop out  and why they were unable to do a 10 minute practice everyday. One factor could have been boredom, which is why I often suggest that students alternate practices from day to day to help maintain better focus and follow through. And it is possible that some found the sequence too advanced, despite the individual adjustments offered. The bottom line, in real life, when you can vary your practice, I highly recommend you do so.

—Baxter

A: With Baxter's blessing I'm going to tell you why I wouldn't want to do this sequence on a daily basis. I'll start by telling you that the three yoga injuries I've sustained have all been repetitive strain injuries. I was a pretty enthusiastic practitioner for a number of years, and did a lot of standing poses and sun salutations. And the injuries I had were: sacroiliac joint injury (common among dancers and yoga practitioners, but not the general public), tennis elbow (possibly from sun salutations), and housemaid's knee (from kneeling too much on the bare floor).

Now let's look at the sequence:

1. Triangle Pose (Trikonasana)
2. Downward-Facing Dog Pose (Adho Mukha Svanasana)
3. Upward-Facing Dog Pose (Urdva Mukha Svanasana)
4. Bridge Pose (Setu Bandhasana)
5. Upward Bow Pose/Rainbow Pose (Urdva Dhanurasana), without or with a chair
6. One-Legged Forward Bend (Janu Sirsasana)
7. Two-Legged Forward Bend (Paschimottansana)
8. Boat Pose (Navasana)
9. Reclined Leg Stretch (Supta Padangusthasana)
10. Marichyasana 1 twist
11. Lord of Fishes twist (Matsyendrasana)
12. Reclined Twist (Jathara Parivarthasana)

After I got over the shock of trying to imagine doing all those poses in 10 minutes, without any warm-ups, I examined the poses in detail. First, two of the poses in the sequence are known for causing sacroiliac joint injuries, Triangle pose (Trikonasana) and One-Legged Forward Bend (Janu Sirsasana), with One-Legged Forward Bend a particularly guilty party. For me, personally, I've concluded it's just not good to do either of those poses every single day. Then, as Baxter mentioned, there is a very deep backbend in the sequence, Upward Bow, and doing this every day could put a lot of strain on the wrists and elbows, but of just as much concern to me is that it is followed immediately by a deep forward bend, taking the lower back into such extreme movements with no rest between. In particular, the Two-Legged Forward Bend is known for causing lower back strain. The combination of the deep backbend followed by the deep forward bend could cause a lot of back strain (personally, I would have moved the forward bends to the end of the sequence). The sequence ends with three twists, asymmetrical poses that are also hard on the sacroiliac joint, with no symmetrical counter pose to finish the sequence. (On the bright side, no danger of housemaid's knee here.)

I understand some of the thinking behind this sequence, which tries to engage all the different muscles of the body to strengthen as many bones as possible, within a short sequence, and uses the twists to "release" the back after the strain of the backbends and forward bends. However, if I were to design an osteoporosis practice, for safety's sake, I would develop five or more different sequences that the practitioner could alternate between on different days, rather than trying to cram everything into one single practice. There are so many wonderful poses in the yoga tradition, why would you limit yourself to just 12?

—Nina

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Featured Pose: Warrior 2 (Virbrdrasana 2)

by Baxter and Nina

This week’s featured pose is one of Baxter’s favorite poses for osteoporosis (see here). In addition to building bone strength, Warrior 2 strengthens your arm and leg muscles. This pose also improves your balance and stretches your inner thighs. The variations we describe below make it accessible to almost everyone (it can even be done on a chair).

Baxter prescribes Warrior 2 for:

• osteoporosis
• balance problems
• anxiety (it burns off excess energy and is “grounding”)

Warrior 2 Pose (from Moving Toward Balance)

General Instructions:Step your feet wide apart (about the length of your legs). Turn your right foot out about 90 degrees and your left foot in slightly, so the toes of your back foot line up with the long edge of your yoga mat. Inhale and extend your arms out to your sides. Then exhale and bend your right knee toward 90 degrees (but not further), making sure your right knee is aligned with your middle right toe. If it’s comfortable for you, turn your head to gaze over your right hand. Repeat the pose on your left side.

Recommended Timing:30 seconds (8 breaths) for beginners, working up to 1 minute (12 to 16 breaths)

Some helpful variations:

1. To build arm strength, leave your arms up while changing from the right side to the left.

2. If you have balance problems, practice with your back to a wall, with the hip of your front leg touching the wall. If balance is a serious concern, you can touch your hands to the wall as you bend your knee and while you stay in the pose.

3. If you are generally weak or tight in the hips, practice the pose with your back heel touching the wall. This is also useful to get a clear sense of the straightness of your back leg.

Cautions: If you have knee problems, don’t bend your front knee quite as deeply. Make sure it stops just shy of being over the front ankle. In addition, standing with your feet a bit closer than the 4 to 4 1/2 feet apart that is usually recommended can also help. And if your knee is acutely painful, you could sit on a chair with your front thigh supported by the chair seat to take all weight off your front knee.

Warrior 2, with feet closer, knee less bent (from Moving Toward Balance)

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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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Active Engagement: Yoga and Osteoporosis

by Baxter

Roots and Water by Brad Gibson

Earlier this summer, some good news was reported in the New York Times about recent study on the benefits of yoga asana for osteoporosis. Physiatrist Loren Fishman, MD (a physiatrist is an MD who works mostly with helping to rehabilitate those with chronic illnesses and injuries without the use of surgery) released the results of a study on the potential benefits of yoga on the progression, or course, of osteoporosis. Originally enlisting over 180 subjects, the study had participants attend a series of classes to learn a short 10-minute home yoga practice that they were then asked to do daily for two years. Knowing human nature, it is perhaps not surprising that only 11 participants were able to complete the study as required. But those who did had some very encouraging results: an increase in the bone density of hips and spine, while the seven controls with osteoporosis continued to lose bone mass. That’s right, the bones of the yoga practitioners actually got stronger. The downside to this result, of course, is the small number of folks who stuck to it, which means that additional larger studies will be required to confirm these initial encouraging results.

Sadly, we live in a culture that often is looking for the quick fix, the one-pill solution, or the single visit to the doc for the cure. The yoga tradition is pretty clear on how positive change occurs, and how goals are met through regular practice done over the long haul. And this ongoing active engagement concept seems supported by the results from this study. Got 10 minutes a day?

For more about this study and what it might mean for you, check out the New York Times article here. You can get complete information on the study (and see the poses included in the osteoporosis yoga practice) here.

Next week, my Rx for osteoporosis in your home practice. If you can’t wait till then, know that all of your yoga poses are “weight bearing,” so keep on doing some poses you love for now, and I will add in my favorite picks next time!

And remember to ask us questions for our Friday Q&A. Leave questions in a comment or email us at the address in the Contact Us page. 

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