Friday Q&A: Back 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

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.

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).