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TherapeuticYoga for SeniorsSafely adapting the practice to older bodies, minds and spirits.

Almost 20% of America's nearly 16 mil-lion yoga practitioners are over age 55(Yoga journal 2008), which presents bothan extraordinary opportunity and a seri-ous challenge for yoga instructors.

While some older adults are extremelyhealthy and fit-able to do headstandsand other difficult postures-more com-mon are those who fit the profile of an "av-erage" senior in America, 80% of whomhave at least one chronic health conditionand 50% of whom have at least two (CDC2003). Many face a broad array of healthchallenges that may impact participationin a yoga class, ranging from joint re-placement and arthritis to taking medica-tions that can affectbalance. Health issuesoften mount with age. For example, theaverage 75-year-old has three chronicconditions and uses five prescriptiondrugs (Merck Institute & CDC 2004).

While there is a potential for harm ifyoga instructors do not appropriatelyadapt the practice to this vulnerable agegroup, yoga also holds the promise ofgreat benefit for older adults. An emerg-ing body of evidence suggests that yogamay relieve numerous ailments of partic-ular concern to seniors; for example, itmay lower blood pressure, ease back pain,enhance sleep and boost mood (Wang2009). In fact, many activities currentlybeing promoted for older adults-such asbalance training and flexibility exercise-are integral parts of most yoga classes.With seniors aged 65 and older repre-senting the fastest -growing sector of thepopulation-expected to more than dou-

ble to over 80 million by the year 2050(He et al. 2005)-it is essential for yogainstructors to learn how to adapt thepractice safely and effectively to olderbodies, minds and spirits.

Reducing RiskOne of the greatest risks of compromisethat can occur if yoga classes are not ap-propriately modified for seniors involvesthe potential for broken bones amongpeople with osteoporosis, a disorder ofimpaired bone strength that re-sults in skeletal fragility andincreased fracture risk. Anestimated 35% of post-menopausal white women r

have osteoporosis of the hip,spine or distal forearm (HHS2004),which is particularly alarming sinceosteoporosis is considered a "silent dis-ease:' This means people with the condi-tion are often undiagnosed and unawareof their risk, so they will not, of course, beable to inform their yoga instructor thatthey need a modified program.

Although many yoga postures are ex-tremely beneficial for people with osteo-porosis, two kinds of movement that arecommon in yoga classes can potentiallycause significant harm: spinal flexion(forward bending) and end-range rota-tion (twisting). For this reason, theNational Osteoporosis Foundation(NOF) warns that "many exercises andactivities such as yoga, Pilates, tennis andgolf may need to be avoided or adjustedbecause they often involve twisting and

bending motions" (NOF 2010). The NOFrecommends that people with osteoporo-sis avoid bending forward from the waist

such as lying on the back with knees bentand feet on the floor and rocking theknees from side to side. Another option

While there is a potential for harm if yogainstructors do not appropriately adapt thepractice to this vulnerable age group,yoga also holds the promise of greatbenefit for older adults.(flexion) and twisting the spine (rotation)to the point of strain.

These recommendations can come asa shock to yoga instructors, many ofwhom consider postures such as ut-tanasana (standing forward bend) andardha matsyendrasana (seated spinaltwist) essential components of the prac-tice. At first, it may seem that teaching ayoga class without spinal flexion or end-range rotation is impossible. In addition,numerous older adults have been warnedby their physicians to avoid yoga becauseit typically involves too many risky move-ments. Clearly, there is a need to educateyoga instructors, physicians and olderadults themselves that yoga can be bothsafe and effective for people with osteo-porosis-when the practice is appropri-ately modified.

ModificationsA key element to consider in appropriatelymodifying postures to reduce fracture riskis the concept of a loaded spine, whichrefers to the amount of pressure on thespine and represents a combination of theweight of the head and upper body as wellas the pull and tug of muscles and liga-ments on the vertebral bodies. When thevertebral bodies are under high load,adding flexion or rotation significantly in-creases the risk of vertebral fracture.

Understanding the biomechanics ofspinal loading is central to the basic rulefor safely adapting postures for peoplewith osteoporosis: "take a load off" thespine by offering forward bends and/ortwists in an unloaded or less loaded posi-tion. For example, instead of a standing orseated forward bend, both of which in-volve greater spinal load and higher frac-ture risk, substitute a safer variation withthe spine in an unloaded position, such asa supine knees-to-chest pose. Instead of aseated end-range twist (with the elbowpressed against the outside of the oppo-site knee), substitute a gentle supine twist,

would be a gentle twist done standing-aposition with less load on the spine-be-ing sure to keep the rotation movementwithin midrange.

In addition, the quality of movementis important in reducing fracture risk.Avoid jerky or ballistic motions and en-courage participants to move mindfullyand slowly, synchronizing their move-ments with the breath. Props can enhancesafety.Since most older adults who beginyoga for the first time in later life find itdifficult or impossible to sit comfortablyon the floor without rounding the back,avoid floor-sitting and encourage the useof chairs, both for seated postures (e.g.,seated mountain pose) and as props to of-fer support for standing poses.

Having a chair back to hold onto dur-ing standing postures can make theseposes more available, even to seniors whouse a cane for walking. In caseswhere stu-dents are too tall to hold onto a chair backwithout bending over and compromisingposture, a wall can provide support andserve as a useful prop. In a standing pos-ture such as warrior 1, where one foot isforward and the other back, pressing theheel of the back foot into a wall can helpwith stability. Having a chair or wall sup-port available for all students in a class is

recommended, as it takes the stigma outof using props and makes it clear they arenot only for "unsteady" students.

Along with greater risk of osteoporoticfractures, older adults are also at in-creased risk for numerous other poten-tially life-threatening ailments, includingheart attack and stroke. Some emergingevidence suggests that yoga may help re-duce risk of adverse cardiac events, sincecertain brain-heart signals can be influ-enced by intangible factors that are typi-cally part of the yoga practice, such asrelaxation, mindfulness, prayerfulness,meditation and group support (Krucoff etal. 2010). Yoga instructors should havecurrent CPR/AED certification and alsoare advised to take a simple medical his-tory form for all students-asking abouthealth risks such as heart disease and sur-geries. If necessary, ask permission topartner with a client's physician to seekguidance in designing a safe and effectiveyoga practice.

Principles of PracticeWhile creating a safe environment forolder-adult students is essential, it isequally important that this imperative forsafety does not translate into setting afearful or limiting tone. Instead, welcomeolder-adult students as they are, honoringall abilities and limitations, and create anenvironment that celebrates what partic-ipants can do. You will get a laugh andhelp prospective students (who are oftenconcerned that they're not flexible or fitenough to take yoga) if you say that ther-apeutic yoga classes are open to anyonewho can breathe. While it's fine to offerdifferent levelsof practice for older adults

Principles of Practice

Howyoga is taught to seniors is as important as what is taught. Practice principlesinclude the following:

Encourage Yogic Balance. The ancient text on yoga, Patanjali's Yoga Sutras,states Sthira sukham asanam, which means that a yoga pose should be "steady andcomfortable" or, by some definitions, "stable and sweet." If practitioners are pushingthemselves to achieve a posture suitable for a magazine cover, that's gymnastics orcalisthenics, but not yoga. Yoga teachers should invite students to challenge themselvesbut avoid strain.

Emphasize Feeling Over Form. Let go of ideas about how a pose should look.Focus instead on how a pose feels. Teach students to discriminate between discomfort,which may be welcomed as an inherent part of the growth process, and pain, whichis to be avoided.Source: Krucoff et al. 2010.

Spinal loading

Different body positions result in differ-ing amounts of load on the spine. Hereis a list of positions and their relativeload on the spine, beginning with theleast amount of load:• lying supine• standing erect• walking• sitting• standing, lifting a 20-kilogram (kg)

(44-pound) weight with backstraight and knees bent

• sitting in slouched position• standing, flexed forward from waist• sitting, flexed forward and rotated

while lifting 20 kgSource: Nachemson 1975.

of varied abilities- for example, a chair-based practice for those unable to getdown to and up from the floor and a morechallenging class for those who can-of-fering a gentle yoga option appropriate foranyone who can breathe is also a usefulway to enhance participation.

It's important to recognize that the yo-gic approach is quite different from thewestern exercise mentality that says theharder you work, the better the results. Inyoga, the way to go deeper is often not bydoing more, but by "undOing"-by culti-vating the ability to relax, release and letgo. Yoga encourages participants to bal-ance effort and surrender; courage andcaution. Yogais noncompetitive, and stu-dents should not compare themselveswith anyone else, or even with themselveson a different day.

Along with the challenges posed byteaching yoga to seniors come extraor-dinary rewards. Unlike younger practi-tioners who often focus on the benefitsthat yoga can have for physical appear-ance, older adults are typically quite re-ceptive to the profound benefits offeredon all levels-physical, emotional, men-tal and spiritual. It is a privilege to offerelders the experience of ease and unionthat is at the heart of a yoga practice .•

Carol Krucofj, E-RYT, and KimberlyCarson, MPH, E-RYT, are co-directors ofthe Yoga for Seniors teacher-training pro-gram. Krucoff is a yoga therapist at DukeIntegrative Medicine in Durham, NorthCarolina, author of Healing Yogafor Neckand Shoulder Pain, and creator of thehome practice CD,Healing Moves Yoga.

Carson is a yoga therapist and yoga re-searcher at Oregon Health & ScienceUniversity, whose Yoga of Awareness pro-gram has been shown in clinical studies torelievepain in people with fibromyalgia andenhance quality of life in cancer patients.

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He, W., et al. 2005. U.S. Census Bureau, CurrentPopulation Reports. 65+ in the United States: 2005.Washington, DC: U.S. Government Printing Office.

HHS (U.S.Department of Health and Human Services). 2004.Bone Health and Osteoporosis: A Report of the SurgeonGeneral. Rockville, MD: Office of the Surgeon General.

Krucoff, C, et a1.2010. Teaching yoga to seniors: Essentialconsiderations to enhance safety and reduce risk in auniquely vulnerable age group. The fournal ofAlternative and Complementary Medicine, 16 (8), 1-7.

Merck Institute & CDC 2004. The state of aging andhealth in America. http://cdc.gov/Aging/pdflState_ oLAging.and.Heal th.in.America.2004. pdf; re-trieved jan.10, 2011.

Nachemson, A. 1975. Towards a better understanding oflow-back pain: A review of the mechanics of the lumbardisc. Rheumatology and Rehabilitation, 14 (3),129-43.

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