Yin Yoga and Osteoporosis
This comment is in response to the first post in this thread and a request to comment on a video blog posted by Margret Martin, a physiotherapist who recently attended her first Yin Yoga class and was horrified to find that the teacher allowed students to do a forward fold with a rounded spine: her fear was that one of the other students might have osteoporosis and allowing her spine to round would be very dangerous for her.
There are several possible topics that can come out of watching Margret’s vBlog: is Osteoporosis a big deal? If it is a big deal, should we address it in every yoga class? If we should address it in every yoga class, should we not allow anyone to flex their spine? If we should allow some students to flex their spine, should we not allow those with osteopenia or osteoporosis to flex their spines? I could also comment on the attitude that Margret expresses while making her comments; she was definitely implying that the teacher of the Yin Yoga class was grossly incompetent and that there are many other such terrible teachers out there and you as a student should be very very afraid and careful not to submit yourself to their teaching. Also implied is that Yin Yoga is a dangerous form of yoga.
Whew! Where to begin? I will make an opening assumption that osteoporosis is a problem for many people (although there is a considerable body of opinion that osteopenia is not a problem and that our current fascination with bone density is an affectation of the drug industry who created this “disease” where one doesn’t really exist: see this article
for more on this discussion.)
First several statistics: 50% of North American women and 25% of men will get osteoporosis; 50% of these cases will be in the lumbar spine, 20% in the hips and 10% in the wrists. (See The Complete Guide to Yin Yoga
page 213 for details.) So, yes – osteoporosis is a big problem, and as Margret says, the chances are – if you have students in your class over 50 years old, you probably have students who have osteoporosis to some degree, (but rarely, I would comment, in the upper spine.) Prior to the development of drugs to treat osteoporosis the common suggested treatments were to increase Vitamin D and calcium intake and increase weight-bearing exercise. There are many studies that show exercise is the key: we need to stress bones but not all exercise is equally useful – some are beneficial: others harmful.
In Loren Fishman’s book Yoga for Osteoporosis
he cites a 1984 study
done by researchers at the Mayo Clinic that show flexion of the spine is very bad and extension is very good. This study is cited many times in the literature as proof that spinal flexion should be avoided for women with spinal osteoporosis. There are two big points to be made about this study however that we, as yoga teachers and students should be aware of:
1) The flexion exercises in this study were yang exercises: they were basically sit-ups. From this an extrapolation was made that any flexion of the spine was harmful, but this was not what the study claimed.
2) Like all studies, the results were averaged: for most people the exercises were harmful, but for some the exercise may have been neutral or slightly beneficial. Be careful of averages: no one person is average!
It is great that the study showed extension of the spine (basically Locust poses and seated scapular retractions, the kind we do in Eagle Arms) helps reduce the risk of fracture. This shows that we should keep doing extensions of the spine and build spine health. [In the Yin Yoga repertoire, keep offering Sphinx, Seal and Saddle pose.] But are all flexions contra-indicated? I have found no studies that have investigated long held, gentle stress of the spine in flexion and its impact on spinal health. At best we can say we don’t know but maybe to avoid any risk we should avoid all flexions: but is this really appropriate?
There used to be a medical philosophy that bed rest was essential for women who had just given birth, as well as for many people recovering from illness. Today we “know” that for best health we need to mobilize patients as soon as possible. What used to be considered “best” or “safest” turned out to be exactly the opposite. Now we have some physiotherapists telling yoga teachers that the best way to help a student with osteoporosis is to never allow any flexion of the spine: is this really the best we can do?
All tissues need stress to become or stay healthy. Too much stress can be harmful but so can too little. The study cited above showed that yang stresses on the spine are not good for women with osteoporosis but they did not study women with osteopenia nor the effect of yin stresses. We have known since the time of Wolff that bones need some stress to remain strong: if we say to never allow any stress of the bones, they will decay.
A muscular stress on the bone generates several times more stress than the body’s own weight can generate (Again I recommend Fishman’s book Yoga for Osteoporosis for a good overview of the cellular effects of exercise on our bone cells.) Yang yoga will generate a large amount of transient stress, but Yin Yoga, where we simply use gravity to generate a stress, a much smaller stress, time is the magic ingredient, not intensity.
To never stress the spine is to invite problems: to overstress the spine is to invite problems. We need a Goldilocks’ amount of stress – not too much and not too little. Where is the Goldilocks’ position is never easy to determine. A student needs to work this out for herself, but of course she can use her yoga teacher and her doctor to help her decide.
To come back to Margret’s vBlog: to say “never flex the spine” is not helpful. The body needs stress to stay healthy; the question is how much? Margret admits to ignorance about Yin Yoga (this was her first class) and I have to wonder if she even knows the basic principles behind it and the benefits: she seems to have come from a pre-judged view that any flexion is bad: the studies do not conclude that! Margret also is critical of the teacher who seems to not be considering the possible dangers of each pose for the students from a perspective of osteoporosis. It is not obvious that Margret is really in a position to make that conclusion: did she talk to the teacher? Maybe the teacher already knew each student’s condition? We can only speculate because so few details were offered in her 2-minute video.
The main question for us in the Yin Yoga community is not Margret’s condescending attitude towards yoga teachers in general and Yin Yoga in particular but rather whether she is correct in saying that we should not teach flexion of the spine in a Yin Yoga class. We should also try to answer Frank’s questions about which poses would be safe in a Yin Yoga class and how to teach someone who does have osteoporosis. Let’s consider some poses:
Loren Fishman recommends reclining twist unless the student has “colostomy, inguinal or abdominal hernia, larger herniated disc, spondylolisthesis.” Note: this is a book for people with osteoporosis! This is a yang version: he suggests squeezing a block between the calves and lifting and lowering the legs from side to side. From this, I would predict that a passive reclining twist would be okay for students because a passive reclining twist will put a lot less stress on the vertebrae than the active version of this pose. He also offers several versions of seated twists, so we can assume that twists per se are not a big concern unless there are other conditions applying.
Here almost all yang-yoga teachers agree, and the 1984 study showed, active flexions of the spine are not helpful. It is easy to say, “to be safe – avoid Yin Yoga flexions” but again that may be going too far. The bones still need some stress in order to avoid further deterioration. We don’t know how much is too much or too little, and it varies by student anyway. You may want to “play it safe” and not allow any spinal flexion, but you may also want to offer some flexion to also “play it safe.” My recommendation: if a student tells you that she has osteoporosis, give her the options, explain why you are suggesting these options, ask her to discuss these options with her doctor and let her decide.
Frank asked whether this pose would be safer reasoning that the spine is more or less straight. In my experience the spine is not straight in Snail and that this pose has the maximum stress along the vertebrae. This is not a pose I would recommend for anyone with osteoporosis.
I assume that Frank was asking about this, not due to worries about the spine, but worries about too much stress in the hips (which, after all, are the second most commonly affected area for osteoporosis.) Full Swan could be another nice backbend (extension) which could help the spine, but it also has the greatest stress on the hips sockets. Sleeping Swan has a neutral spine and less stress on the hip socket so may be okay. Loren Fishman has two variations: the first for students with osteoporosis is Swan using a chair and the second, for students with osteopenia is Swan with a bolster under the front hip. In my Yin Yoga classes, I don’t use chairs so, to be safe, if a student told me that she has osteoporosis, I would suggest she skip Swan and do reclining Butterfly or just sit cross-legged: those poses give some stress to the hip sockets but are gentler compared to Swan. Another option is the Wall Eye-of-the-needle
Every student is different. It is difficult in a class setting to accommodate everyone’s uniquenesses. Osteoporosis is a big concern and one that grows with age. Make sure if a student tells you that she has osteoporosis that she also let’s her doctor know what she is planning to do in yoga. Explain the philosophy that too much stress can make matters worse, but no stress at all is also problematic. Depending upon where the problem is, some poses can be very therapeutic. It has to be up to the student to decide how to proceed: you are not a doctor and can not offer medical advice. At best you are a consultant offering suggestions, but do offer what you know. Above all else, be humble; what we know today may turn out to be totally wrong tomorrow.