Yoga for Osteoporosis The Complete Guide
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Yoga
for Osteoporosis
The Complete Guide
Loren Fishman, MD
Ellen Saltonstall
W. W. Norton & Company
New York • London
To our teachers,
and all teachers and therapists using
HEALTHFUL means to improve health.
Contents
List of Illustrations
Acknowledgments
Authors’ Note
Introduction
Chapter One The Facts
Chapter Two Bones
Chapter Three Factors That Affect Bones
Chapter Four Medications for Osteoporosis
Chapter Five Exercise
Chapter Six A Wollf in Yoga Clothing
Chapter Seven Yoga Stands Apart
Chapter Eight Before You Start
Chapter Nine Poses That Focus on Bone Strength
Chapter Ten Poses That Focus on Muscle Strength
Chapter Eleven Poses That Focus on Balance
Afterword
Alphabetical List of Poses
Poses by Chapter
Glossary
Notes
Resources
List of Illustrations
1. The wedge fracture
2. Normal distribution
3. High versus low variance
4. Osteoporosis and osteopenia in a normal distribution curve
5. DEXA scores and the risk of fracture
6. Normal bone
7. The chemical structure of hydroxyapatite
8. Compact and spongy bone
9. Euler’s law and a ladder
10. Comparison of two types of bone structure
11. Bone strengthening and weakening
12. Osteoblasts, osteocytes and osteoclasts
13. How osteocytes communicate in bone
14. Close-up of an osteoclast
15. MRI of the spine of a yogi
16. Wollf’s law and the femur
17. The leverage of the supraspinatus muscle
18. MRI: muscles and their antagonists
19. Spicule production: an osteoblast’s response to exercise
20. MRI of the cervical muscles
21. Results of osteoporosis study
22. Three categories of therapy
23. Compression, tension, and the fate of stem cells
24. MRI of three different people doing Paschimottanasana
25. MRI showing how excessive extension affects the neck
26. The four corners of the foot
27. Manually widening the pelvis
28. Parallel feet
29. Safe and unsafe forward bends
30. Tadasana
31. Muscle action on lumbar vertebrae in back bends
32. MRI of Paschimottanasana
33. MRI of Ardha Matsyendrasana
34. MRI of Vasisthasana: effect on spondylolisthesis
35. MRI of Vasisthasana: effect on spinal stenosis
36. Why retrolisthesis prohibits headstand
Acknowledgments
The authors would like to thank B. K. S. Iyengar and John Friend for their
wisdom, astute precepts, and examples, and Krishnamacharya for the
tradition in which so many of our teachers stand. We are extremely grateful
to Tommy Moorman for his fine hand and patience in creating numerous
illustrations and their numberless reincarnations in this book and in Yoga
for Arthritis. We also thank Donal Holway and Julio Torres for excellent
photography, Susan Genis and David Fink for remarkable guidance during
the photo shoots, and Sally Hess and Rachel Fishman for their expert
modeling and support. We thank our editors at W. W. Norton—Jill Bialosky,
Evan Carver, Paul Whitlatch, Adrienne Davich, Alison Liss, and Kristin
Sperber—both for making the manuscript more intelligible and for
understanding us. Once again we thank Carol Stratten, Dr. David Palmieri,
and Norman Brettler of Dynamic Imaging in Tilton, New Jersey, for their
generous donation of time and facilities that made dynamic MRI studies of
yoga possible.
Thanks to our students and patients for the many elucidating exchanges
that have occurred in the process of yoga therapy; for their personal
improvement they must thank themselves. Last and most overdue, we
acknowledge a debt to our families for their willing sacrifices during the
periods of writing and revision.
Authors’ Note
Scientists and healers enjoy certain “rights of access”: We can enter our
patients’ personal space, ask intimate questions, and give advice that,
subject to the sacred sieve of scientific skepticism, is generally taken
seriously. Our rights are earned through a combination of aptitude, study,
and personal trust.
But scientists and healers only exist within the complex matrix of their
society, and along with their rights come certain responsibilities. Among
those responsibilities are impartial seeking and sharing of the truth,
articulately and intelligibly responding to problems, questioning what is
seen as unwise practice or false belief, and selfless giving of help when and
where it is needed. Yet national security and commercial confidentiality
often require that scientists not share all information. Healers also have
legally delimited confidentiality and may choose not to vitiate their gift by
disseminating what is, by necessity, only part of the story. This censorship,
self-imposed or otherwise, is consistent with the society-wide duty to share
what one knows only if the sharing and use of the knowledge are equally
discreet. Please use the information herein with humble awareness of the
vast present and future human experience of which it forms a very small
part.
In the healing arts a commitment to open communication must be
tempered by caution. On the societal level, just as with individuals,
scientists and healers have a responsibility to “do no harm.” Here yoga
therapy leads the way. The flow and structure of what is known about yoga
survives only through mutual trust, as much among those who want to
know as those who know already. Being passed on from individual to
individual, it nevertheless has societal aims: peace and thoughtfulness. The
morality is part of the message.
There is another general problem that yoga therapy resolves rather
gracefully: All the healing arts must synthesize abstract and anonymous
laws of biology to accommodate individuals’ needs and vulnerabilities. If
we just adhere to the general laws of science, individual uniqueness falls
out of the equation. But if we only attend to an individual’s circumstances,
treatment is merely anecdotal, and the vast legacy of scientific fact is
ignored. Healers are able to heal when patients trust them to adjust and
apply objective laws to the advantage of the individual’s particular case.
This trust is what makes medical science practical and most healing
possible. Yogis have been earning this trust for thousands of years.
We hope that yoga will appeal to people of all ages; we know that
osteoporosis is most effectively countered in the teens and early twenties!
But we expect that many people reading these words will be older, and then
another consideration is relevant: the fragility of the bones, joints, and
sinews. As you get beyond age 50, some experts look at the facts about
mechanoreception and urge “impact” exercise to “stave off bone loss.”
Unfortunately, another group of experts, with just as much empirical
support, caution that impact exercise, such as jogging, can lead rather
directly to osteoarthritis.
This puts older people in an impossible position: If they exercise with
impact, the bones may stay strong, but the joints at either end will become
painful and difficult to move. On the other hand, if they stay away from
impact, they will save their joints, but the bones themselves may
deteriorate. It’s both ends against the middle.
We believe yoga is the answer for older people who want to stay strong,
flexible, and pain-free: In yoga the joints are moved to an ever-expanding
range, circulating their fluid and stimulating renewal of cartilage, tendons,
and ligaments.1 Simultaneously, the bones are isometrically subjected to
forces many times those of gravity, exactly the same forces involved in
impact exercise. But in yoga, the forces are applied without any impact—
yoga provides an excellent solution to the twin perils of osteoarthritis and
osteoporosis.
Introduction
Don’t want to end your days in a nursing home’s wheelchair? Averse to
pain? Have little relish for osteonecrosis of the jaw brought on by years of
ingesting stomach-upsetting medicines? May we suggest another way?
Yoga. Paradoxical as it may seem, yoga—which appears to the uninitiated
to be the cessation of outward movement, with its ultimately introspective
focus—has in its repertoire the remedy for osteoporosis. We are about to
prove this in fine detail.
It would be hard to find a more direct medical application of yoga than to
osteoporosis. Bones are strengthened by good diet and sunlight, of course,
but that is true of tree trunks too. Force applied to bones stimulates them to
grow stronger. The greater the forces applied to a bone, the greater the
boney build-up at the point of stress. Wollf’s law, which we will come to
again in chapters 5 and 6, states that the architectonic of bone, its structure,
follows the lines of force to which that bone is exposed. Since Wollf’s time
a persuasive number of studies have shown that, within a bone, levels of
different enzymes and biochemical markers of bone synthesis increase
abruptly within 10 seconds of adding stress to it. Yoga is a simple, silent,
inexpensive, and impact-free way of applying that force exactly as one
intends.
Although much research during the past 100 years supports the
application of Wollf’s law in yoga, this book contains a summary of the first
pilot study that actually demonstrates yoga’s bone-strengthening benefits.
The study also describes an additional advantage for the older person with
osteoporosis (as well as osteopenia, the precursor to osteoporosis).1 The
usual prescription for osteoporosis is “weight-bearing and impact
exercises.” However, most people over 55 have osteoarthritis, and impact
exercise is exactly what the rheumatologist did not order.
Yoga safely stresses bones without impact, a solution to this dilemma.
With many poses that avoid moving joints altogether, yoga has been shown
to strengthen bones without any evidence that it weakens joints. On the
contrary, several studies find that yoga ameliorates osteoarthritis. Many
poses do stretch joint capsules, ligaments, and sinews, moving selected
joints through wider ranges of motion. Yoga actually exerts a positive
influence on arthritic joints, internally irrigating and moving cartilage-
making tissue both within the fluids of the joint and inside the cartilage
itself. (For more detail, please see Yoga for Arthritis.)
But yoga’s advantages do not end there. Almost everyone who practices
yoga—including the thousands we have encountered, taught, and treated—
reflect a calm sense of well-being, a willingness to accept the differences of
others, and an orientation toward peace that makes for a stronger, more
flexible, and healthier world.
Chapter 1
The Facts
Definition
Osteoporosis, or porous bone, is a disease characterized by low bone mass
and structural deterioration of bone tissue, leading to bone fragility and an
increased susceptibility to fractures, especially of the hip, spine, and wrist,
although any bone can be affected.1
Epidemiology
In the hippie days of the 1960s, two fellows crossed Michigan Avenue to
Chicago’s Oak Street Beach. “Man, look at the water,” one said. “Like, that
lake is big.” The other observed. “And that’s only the top.” So it is with
osteoporosis. The extent of the problem is much greater than first meets the
eye.
The statistics are hard to ignore: Forty-four million Americans are known
to have low bone mass. That amounts to 55 percent of everyone over age
50.2 One in two women and one in four men over age 50 will have an
osteoporosis-related fracture in his or her lifetime. Osteoporosis is
responsible for more than 1.5 million fractures annually, including roughly
• 300,000 hip fractures,
• 700,000 vertebral fractures,
• 250,000 wrist fractures, and
• 300,000 fractures at other sites.3
In 2001 more than 315,000 people were admitted to American hospitals
with hip fractures, most of them due to osteoporosis.
In the year 2000 it was estimated that osteoporosis caused 37,500 deaths
in the United States alone.
Men over 50 are more likely to suffer from a hip fracture than prostate
cancer.4 A woman’s risk of hip fracture is equal to the combined risk of
breast, uterine, and ovarian cancer.5
Women are as likely to die after a hip fracture as they are from breast
cancer.6
Thirty-two percent of women will fracture a hip before reaching the age
of 80. After reaching 50, the mortality rate in the first year following a hip
fracture is 25 percent.7
Twenty percent of those who could walk before a hip fracture were
relegated to long-term care afterward. The cost of hip fractures to the
United States in 2002 was $18 billion.8
Osteoporosis is in fact a global problem, excluding no ethnic group or
gender. More than 200 million people worldwide are faced with the
progressive weakening of already thinned bones and the prospect of often-
fatal, always painful, and disabling fractures.9 In most cases, the medical
support and financial means necessary to diagnose the condition are
lacking, as are medications for its amelioration, or treatment for the
fractures that will otherwise occur.
Researchers in many countries have investigated osteoporosis and
contributed to its understanding. The pressure is on to effectively prevent
and treat this threatening condition, which increases in incidence as life
expectancy improves.
Why Is Osteoporosis Dangerous?
What osteoporosis does is impressively simple: It breaks bones. Spine and
hip fractures grimly result in painful nights awake, invalidism, and
demise.10
