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OSTEOPOROSIS

Structural Yoga Therapy Research Paper




Sally Champa
yogaforhealing@cox.net


May 6, 2005




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1. Case Study - Initial intake, review of symptoms, subjective pain level


Marilyn

Marilyn is 57 years old and is married. Her husband just recently retired so he is home
most of the time which is stressful for Marilyn. Marilyn loves to garden and read. She
likes to travel and every year her and her husband go to Europe for 3 months. She is a
very busy person she always has to be doing something. She has a hard time sitting
down to relax. She says There are too many things that need to be done and I feel like I
am wasting time if I sit down. Her parents passed away 8 years ago and she still carries
a great deal of grief from this. She started *perimenopause at 49 years old. She has
been a vegetarian for 14 years. She likes her black tea which is caffeinated and drinks 4-
6 cups a day.

She was told in October 2003 she had Osteoporosis in the spine. She could not
remember where in the spine it had started to affect her. She was complaining of acute
pain in her right hip accompanied by low back pain, joints are very stiff, pain inside left
elbow, pain in left knee, acute pain in neck on the left side. She has continual flair-ups of
pneumonia. In the year 2000 she had pneumonia 7 times. And she has asthma.

On my initial intake I observed a high right shoulder with the head tilted toward the right.
She had a small thoracic curve of 4 degrees (with the scoliometer) to the right with the
Apex around T8. Her sacroiliac joint does not move on the right and the left. In standing
and using the scoliometer her left leg was longer.

Yoga Sutra of Patanjali by Mukunda Stiles chapter 1 sutra 30-31 (p. 9 & 10) says Lack
of concentration leads to suffering, frustration, restlessness and disturbed inhalation and
exhalation. I observed Marilyn with these qualities due to her lack of concentration.

*Definitions:
Premenopause are women with signs of menopause about to begin.
Perimopause are women who are having irregular periods which happens in their late
40s to early 50s.

. In April 2005 she decided to go to Europe for 3 months herself to heal.
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1b. Examination Records


Dates 8/23/04 10/24/04
Range of Motion Left Right Left Right
Supine Position
Hips
Leg length longer 1/8 longer
Internal Rotators Felt tight both sides Felt more movement
External Rotators Tighter on left Felt more equal
Internal Rotation 30 30 35 34
External Rotation 40 35 45 40
Hip Flexion 125 135 129 135
IT Band check Tight Tight Dropped further both
sides
Neck
Neck Lateral Flexion Very limited due to pain 35 30
Neck Rotation Very limited due to
pain
60 52
Prone Position
Hips
Internal Rotators 30 30 35 35
External Rotators 43 40 45 42
Muscle Testing
Supine position
Hips
Hip flexion 3 3 4 4
Psoas 2.5 2.5 3.75 3
Sartorius 4.5 2 4.75 3
Prone Position
Hips
Internal Rotators 3.5 3.5 4 4
External Rotators 3 3 4 4
Hip Extension 4.5 3 4.5 3.75
Gluteus Maximus 2.5 2.5 4 4
Knee Flexion 3 3 4 4
Shoulders
Shoulder Extension 3 3 4.5 4.5
Lower Spinal Erectors 4 4 5 5
Upper Spinal Erectors 3.75 3.75 4.5 4.5
Middle Trapezius 3 3 3.75 3.75


With Marilyns neck pain I evaluated her ROM and muscle testing on her shoulders. She
had normal ROM.
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1c. SUMMARY OF FINDINGS

Muscles to be Released (V) Stretched (P) Strengthened (K)

Left/Right hip internal rotators-TFL Left hamstrings Left/Right Psoas
Left/Right external Left/Right internal -
Rotators rotators more on right
Left/Right external rotators
Left/Right hip flexors psoas
Left/Right gluteus maximus
Left/Right triceps
Left/Right hamstrings &
Left/Right gracilis
Middle and Lower trapezius


1d. RECOMMENDATIONS

Marilyn was in a lot of pain in the neck and hips. She is an extremely uptight person with tremendous amount
of anxiety. I found she has been a chest breather for a long time. I first taught her the wave breath to help her
calm down and to teach her how to breath correctly. I then gave her the SI Joint Exercises to stabilize the
sacroiliac joint. I had her do 12 times on each side. The poses to strengthen the gluteus maximus and the deep
6 external rotators were lifting one leg at a time straight leg and then with bent knee 6 times on each side. I told
her to work up to 12 repetitions each. Then camel with little pulses while squeezing the external rotators 6
times each. I recommended the Joint Freeing Series to help with the stiffness in her joints and also to work on
calming her down. I had her do 6 times on each pose incorporating the wave breath. When she came to the
neck exercises I told her to do them slowly and to focus on breath and movements. I did not want to overwhelm
her at first because she is a very stressed person.

The painful neck could be a pinched nerve so I recommended her to a massage therapist to start to release the
pain in the neck.

On our next session she felt that the SI exercises were freeing up her hips a little bit. She was continuing with
the wave breath but her mind was all over the place. I had her continue with the above exercises and I added
Cat Bows (6 times) to strengthen her triceps and middle/lower trapezius, Stick with the leg lifted and then out to
the side (6 times) to strengthen her psoas and Rolling Bridge (3 times) to continue to strengthen her external
rotators, her whole back side and front abdominals. I had her lie in Savasana for as long as she could after the
asanas. Then I taught her Alternate Nostril Breathing and had her do this for as long as she could and then to
meditate for as long as she could. Although sometimes this type of breathing was difficult because of her
sinuses so I had her do it without the fingers. I also told her that she could split these up and alternate the poses
on different days.



1e. Summarize the Recommendations

To summarize my recommendations is as follows:

1. SI Exercises to stabilize the sacroiliac joint 12 times each
2. Locust with straight leg and bent leg to strengthen the gluteus maximus, piriformis, gemellus superior,
obturator internus, gemellus inferior, quadratus femoris, obturator externus.
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3. Camel with pulses to continue to strengthen the gluteus maximus and the deep 6 external rotators.
4. Joint Freeing Exercises to free up the stiffness in her joints.
5. Cat Bows to strengthen her triceps and middle and lower trapezius
6. Stick with leg lifts to strengthen her psoas
7. Rolling Bridge to strengthen her whole back side and the front of the abdominals
8. Alternate nostril to bring calmness into her body and mind.
9. Meditation to start to feel her mind and body quieting down.




2a. Name and description of the condition

NAME OF DISEASE: Osteoporosis
Osteoporosis is a generalized disorder of the skeleton in which the amount of bone tissue is reduced and the
microscopic structure or architecture of bone is abnormal. The word osteoporosis means porous bones.
Bone is a living tissue that has cells. Both the abnormal quantity and quality of the bone make it weak and
susceptible to breaking given even minimal amounts of trauma. The result of osteoporosis can be viewed as
skeletal failure. There is no documented evidence that bone loss or reduced bone tissue itself, in absence of a
fracture, is associated with pain or any other symptoms. This means that there are no symptoms of osteoporosis
per se, only consequences: fractures and associated chronic pain, deformity, and disability. This is why it is
called the silent disease.

You can think of your skeleton as a bone bank. Just as your financial health benefits from funds that you put
aside and can draw on in time of need, your bone health benefits from a fund of calcium and other minerals that
you store in your skeleton. Good bone health depends on keeping your bone bank account solvent, fully
supplied with minerals and able to meet all of your bodys needs. Throughout your life, new bone is constantly
being formed and deposited. Old or worn-out bone is constantly being broken down and withdrawn. This
process is how your skeleton refurbishes and maintains itself. For adults, the ideal situation is to have about as
many deposits as withdrawals.

Some key terms when talking about the bone bank are: bone mass is the total amount of bone tissue you have
in your skeleton-the total assets in your account at any time; bone density refers to how tightly that tissue is
packed-that is, how mineral-rich you bones are; bone strength refers to the ability of bone to withstand stress
which depends on bone density, mass and quality. The more bone you have and the denser it is, the stronger
your skeleton and the stronger and deeper your bone bank account.

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Generally, after about age
30, our bone bank account
begins to shrink.
Withdrawals from your
account are exceeding
deposits. You gradually
begin to lose bone mass
and bone density. This is
normal. Whats not normal
is when the withdrawals
exceed deposits at such a
rate that portions of your
skeleton become weak and
brittle. Bone loss doesnt
mean you actually lose
whole bones. It is the
mineral content of the
bones that is depleted. The
outer shell of a bone
becomes thinner, and the
interior becomes more
porous. This action
bankrupts your skeleton of
its strength.

Your risk of osteoporosis doesnt depend only on your current rate of bone loss. It also depends on how much
bone you banked in your account when you were young and growing. That makes osteoporosis a young
persons concern as much as an older adults concern according to the Mayo Clinic (p. 7).

A certain amount of bone loss can be expected as you age. How much calcium and other minerals that have
been deposited in your bone bank during the years of peak bone formation is critical. A high peak bone mass
can counteract or cushion the impact of bone loss in your later years and may lower your lifetime risk of
fracture. Recommended by the Mayo Clinic (p. 26) to maximize your peak bone mass:

Consume a balanced diet with adequate calories, vitamins and minerals, especially calcium and vitamin D.

Get regular exercise because physical activity contributes to higher bone mass.

Avoid smoking and excessive alcohol and caffeine.

For teenage females just starting to menstruate, avoid excessive dieting and other behaviors that can interfere
with the timing of menstrual periods.

Even if youre past the age of peak bone mass, these actions can still help keep your bones strong and healthy.

The Wisdom of Menopause (p. 369) reports: Osteoporosis begins in earnest at perimenopause, but its effects
may not appear until twenty or more years later, often when it is too late to do much about it. When it comes to
bone health, prevention is absolutely essential. And that prevention must begin in perimenopause.

The Wisdom of Menopause (p. 371) states: We are designed to live on this planet well supported by sturdy
bones from youth to old age. Like other degenerative diseases so common in Western civilization, such as
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coronary artery disease, hypertension, and obesity, osteoporosis is either unknown or very rare among
indigenous peoples living time-honored lifestyles characterized by a strong connection with the wisdom of the
earth. A deep sense of connection to the earth shores up the health of our first emotional center the part of our
emotional anatomy that is associated with a sense of belonging, and with our basic sense of safety and security
in the world. This sense of safety affects our bones, blood, and immune systems. This information points to
the first chakra Muladhara and second chakra - Swadhisthana.

Before a diagnosis of Osteoporosis the patient might get diagnosed with Osteopenia. Osteopenia refers to
decreased calcification or density of bone. Having osteopenia places a person at risk for developing
osteoporosis. Bone density is described in relationship to what it should be in young women; it is expressed as
a standard deviation from the mean (average) bone density in a 35-year-old. Within 1 standard deviation of the
mean in either direction is considered normal. A bone density within the range of 1 to 2.5 standard deviations
below the mean is defined as osteopenia, and greater than 2.5 standard deviations below the mean is
osteoporosis. Osteopenia is a warning -- time to sit up (actually, time to walk around the block and lift some
weights!) and take measures to prevent developing osteoporosis.

It is important to make the distinction between osteoporosis and osteoarthritis. Osteoporosis is a disorder in
which the bones become weak and susceptible to fracturing. Osteoarthritis affects the spaces between the
bones, or joint spaces, which contain cartilage, other connective tissue, and shock-absorbing fluid. The joint
becomes swollen, inflamed, and deformed, the cartilage is eroded, and bone spurs (small pieces of bone tissue
outside the normal confines of the bone) may grow. The causes and treatments of osteoarthritis are very
different from those of osteoporosis.

Osteoporosis occurs most frequently in postmenopausal women, sedentary or immobilized individuals, and
patients on long-term steroid therapy. Almost one in every two Caucasian women will suffer an osteoporosis-
related fracture at some point in her lifetime. The corresponding number of Caucasian men is one in four. The
greater risk in women versus men is related to smaller body size, smaller bone size, lower bone mass at its peak
and greater loss of bone in midlife due to the menopause. Cosman (p.8) recommends: getting a bone density
check when menopause begins or by age sixty or sixty-five. I do not recommend getting tested in the
premenopausal years because there is no drug to take to get rid of the disease. She feels it is unnecessary and
even unhealthy. Some people argue that getting a test at an early age may help younger women stick with good
preventative measures, but there is little evidence to support this argument, and it is hard to justify the cost of
these tests in a medical system already overburdened with expenditures. This disease is a psychological
challenge at any age.

The medications that are currently on the market help to slow down the bone loss process and not to actively
build up the bone tissue. In general, premenopausal women manifest little total skeletal bone loss until they
reach perimenopausal phase of life.

Few studies suggest that women who took the pill had a higher bone mass than women who did not. However,
oral contraceptives have a risk of breast cancer.

The early postmenopausal years are associated with a specific increased risk for the occurrence of wrist and
vertebral fractures. While wrist fracture frequency does not increase further as women get older, almost all
other osteoporosis-related fractures continue to increase in occurrence with advancing age.

The key of osteoporosis is to prevent the disease before it happens. The keys to success are building a strong
skeleton when youre young and slowing the rate of bone loss as you age according to Mayo Clinic (p. 3). It is
never too late to do something about your bone health.


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2b. Common Symptoms

Osteoporosis is called a silent disease because it is common that it causes no pain initially, and there are no
outward symptoms. It is a symptomless condition for many years or even decades. However, the consequences
of this disease are pain, especially in the lower back, pathologic fractures, loss of stature, and various
deformities. Osteoporosis may be without a known cause or secondary to other disorders, such as
thyrotoxicosis, or the bone demineralization caused by hyperpthyroidism. The American Medical Association
defines thyrotoxicosis as: Severe hyperthyroidism (overactivity of the thyroid gland). Hyperthyroidism is a
condition produced by excess thyroid hormone in the bloodstream, which leads to overactivity of the
metabolism of the body.

2c. Related Challenges

The biggest challenge with osteoporosis is bone fractures. The fear of a bone fracture could limit their
activities. Typically these fractures occur in the spine, hip or wrist. Mayo Clinic (p. 27) reports: Each year
osteoporosis leads to 1.5 million fractures in the United States, including about 700,000 spinal fractures and
300,000 hip fractures. The fractures can occur completely spontaneously with absolutely no precipitating
movements, or with activities so minor that people often cannot remember what they were doing. People with
osteoporosis may develop compression fractures after a coughing or sneezing fit.



Most of the time (about two-thirds of
compression fractures), these fractures
occur initially without any notice or
symptoms. A compression fracture of the
spine causes your vertebrae to collapse
and may lead to lost inches and height and
possibly a stooped posture. Often chronic
back pain eventually sets in, the person
then becomes very hunched over and
develops the so-called dowagers hump, or
they lose height. Ultimately, even those
compressions that were initially clinically
silent do produce problems and reduce
quality of life.





The classic dowagers hump deformity, or exaggerated kyphosis, is due to an uneven compression of the
vertebral bone where the front part of the bone, closest to the abdomen, crushes down more than the back of the
bone therefore assumes a wedge-type shape. This thrusts the spine forward over itself. A wedge-type
compression in the middle or lower thoracic spine (between the neck and lower back or lumbar spine) is
associated with the greatest likelihood of producing significant deformity. When this deformity occurs, the
patients head is often forced downward and chronic neck pain can result from the constant struggle to keep the
head upright. Walking is difficult and the center of gravity is off, making falls more likely.

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An important manifestation of the loss of
height in the thorax is restricted breathing,
with an inability to fully expand the chest
cavity, resulting in shortness of breath
upon limited activity. This is probably
one of the reasons why multiple vertebral
fractures are associated with an increased
risk of premature death, often due to
pneumonias and other lung problems. It is
difficult to expand the chest fully and to
clear secretions normally.

In addition, with loss of height in the
abdominal cavity, the abdomen is often
distended. The contents of the abdominal
cavity (all the organs, including the liver,
stomach, and intestines) need a certain
volume of space, and if the height dimension is reduced they push outward, thereby increasing the depth or girth
around the middle. Due to the cramped space, there is often an inability to eat a full meal, abdominal
discomfort, and constipation and excess gas. With all these chronic symptoms, patients can become depressed
and socially isolated.

By far, the fracture that causes the most misery in osteoporosis is the hip fracture. Only one-third of the people
who break a hip ever return to being as active as they were before the fracture. These fractures occur at the top
of the thigh bone or femur. They increase dramatically in frequency in women after age sixty-five and in men
after age seventy, with progressive increases in risk with advancing age. Hip fractures are accompanied by
severe pain in the groin,
buttock, or hip, and almost
always render the victim
unable to stand or walk.

Because the hip fracture
requires surgical repair, there
are surgical complications.
Infections, bleeding, and
blood clots are all possible.
The risk of dying in the year
following the fracture is 15 to
20 percent higher than in a
group of individuals of the
same age with no hip
fracture. Many patients will
need rehabilitation to make
any reasonable recovery. Hip
fractures are frequently on of
the ways in which healthy older people begin to suffer major disability.

Diet related challenges are not having enough vitamin D, magnesium, potassium, iron, and other minerals in the
diet, all of which are critical cofactors for moving calcium into the bone, which your body cannot absorb
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calcium efficiently. And if the body cannot absorb something, it cannot use it. Some of the unabsorbed
calcium will stay in the body where it can show up in the joints (arthritis and fibromyalgia), in your arteries
(heart disease), and in your kidneys (kidney stones). The American diet is full of a lot of calcium-wasting foods
high levels of protein and phosphoric acid which is in soda pop.

It has been found that caffeine reduces the absorption of calcium from the bone. The Wisdom of Menopause (p.
379) states: Caffeine results in increased urinary excretion of calcium; the more you consume, the more
calcium you lose. If your calcium intake is relatively low to begin with, regular caffeine consumption could
result in significant loss of bone over time. If, on the other hand, your calcium and mineral intake is high, a
couple of cups of coffee a day probably wont matter much. Note: Even though tea contains caffeine, both
green and black tea have been shown to build bone mass-probably because of their phytoestrogen content.
Also, excessive amounts of salt and protein may increase the amount of calcium excreted in the urine. The low
carbohydrate diets are creating risks for the younger and older women on these diets.

Changes to be made in the diet are: eat less animal-derived protein, eat an alkaline diet which consists of fruits
and vegetables especially dark green leafy vegetables, carrots, almonds, tofu, miso and other soy products,
seaweed, and salmon. Include calcium rich herbs such as nettles, horsetail, sage, oatstraw, borage, raspberry
leaf, and alfalfa. Current studies show that calcium citrate malate may be the most easily absorbed. However,
dont try to get the calcium from antacids that contain aluminum, which causes the calcium to be excreted.

Other diet related changes include cutting down on alcohol and stop smoking. An occasional cocktail or a
single glass of wine in the evenings may actually slow bone loss in postmenopausal women (but not in those
who are pre or perimenopausal). Chronic drinking can also elevate parathyroid hormone levels in the body,
which signals the bones to release too much calcium into the bloodstream. According to The Osteoporsis
Solution: An Australian study has shown that smoking one pack of cigarettes daily throughout adulthood
would have a deficit of 5-10% in bone density by the time they reached menopause. Plus smokers have a more
difficult time absorbing nutrients from the foods they eat. Malabsorption of calcium, magnesium, vitamin D,
and other vitamins and minerals from foods can cause the body to search for other suppliers, such as the bones.

3. Ayurvedic Assessment of the Condition

Osteoporosis is an increase in Vata and a decrease in Kapha. It disturbs the flow in the body including
assimilation of nutrients and their delivery to bone tissue. Ama is the buildup of toxins and impurities that
block the flow of nutrients to the bone and disturb the natural biochemistry of the bone structure. Osteoporosis
is a disturbance in asthi (bone tissue) and requires tissue specific recommendations to help reverse the
imbalance. Susan Brown from Better Bones, Better Body says: Osteoporosis is really our magical bodys
intelligent response to long-term imbalances and stressors. Vasant Lad states: According to Ayurveda, a
woman should take natural herbal estrogen that is present in shatavari and other herbal remedies. Shatavari is
effective in preventing osteoporosis during menopausal age. However, if you give a woman synthetic estrogen,
her menstruation can return, or she may develop pitta symptoms, because estrogen is pitta provoking. Natural
estrogen is present in shatavari, guduchi, and aloe vera as these all decrease pitta. Every tissue requires ojas
(the essence of properly nourished bodily tissues, it maintains immunity, strength, and vitality of the body.) to
help its proper formation. Lack of ojas leads to wasting conditions and contributes to osteoporosis. Health
problems at menopause such as osteoporosis represent an imbalance in the body that were already growing in
the body and are unmasked by the stress of shifting hormones.

First to balance Vata the Joint Freeing Series, the wave breath and a pranayama practice. To work on Kapha
they want to incorporate a yoga program to build strong bones so a weight bearing program to build strength
and stamina.

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Ayurveda can also offer nutritional guidelines and herbs to balance Vata and build up Kapha. This can be
worked on by a trained Ayurvedic practitioner.


I could see a lot of increased Vata with Marilyn. Her skin was dry and she looked dehydrated. She had a lot of
worry and anxiety and I sensed some deep fear that may had to do with the loss of her parents and her health
issues. The signs of decrease Kapha were stiff joints and things had to be done her way.

4. Common Body Reading

Poor posture in the early years heightens the risk of developing hyperkyphosis later in life. Common body
signs are shrinking in height, the vertebrae in your spine will compress or even collapse, forward head position,
collarbones move forward, collapsed chest which then the lungs will lack adequate space to function and press
against the diaphragm and move it downward against the abdominal wall. The abdominal muscles weaken,
which causes more problems in the lumbar spine. Due to these imbalances in the spine ROM will be limited
and can be the cause of lower back pain.


5. Contraindicated Yoga Practices and General Activities to Modify or Eliminate

With Yoga, backbends would need to be modified to make sure there was no compression in the spine. It is
important that the person be very aware of lengthening the spine before going into a backbend. Doing spinal
flexion may compress the spine. When doing lateral poses work on elongating the waist and watch that there is
no compression while doing side bends. And of course headstand and shoulderstand would put too much
pressure on an already weakened vertebrae and should be avoided.

If the person has already begun to lose bone mass and may therefore be susceptible to vertebral stress
fractures running can put too much stress on your knees, ankles, and lumbar spine. The other problem with
confining weight-bearing exercise to walking or running is that these activities only benefit your lower limbs
and do nothing to strengthen your wrists, shoulders, upper back, or elbows.

Poor body mechanics, such as slumping while in a seated chair or standing should be avoided. Always work to
stand straight and keep working to align the posture.


6. Generalized Recommendations

6a. Therapeutic/Free of Pain

A course of action to follow for preventing osteoporosis or someone who has osteopenia would be to follow the
first yoga sequence in appendix A. Also, please refer to Exercises for Osteoporosis by Dianne Daniels for more
sequences to follow for someone who has osteopenia or osteoporosis.

If the person is in pain get them out of pain. The Joint Freeing Series will help with lubricating the joints and
increasing range of motion and decreasing Vata. If they have Khyphosis it is important to stretch the rectus
abdominis, pectorals and upper trapezius and strengthen the thoracic erector spinae, middle and lower trapezius.

Patricia Waldon for recommends for people who have osteoporosis forward bends to help quiet the adrenal
glands, mitigating the effects of the fight-or-flight response, and backbends to energize them. However, I have
seen other books say that forward bend may compress the spine. Regarding flexion vs. non flexion Mukunda
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recommends: keeping anatomical curves in all asanas. Have the client come two-thirds into a hip flexion pose
and make sure they dont lose the lumbar curve. Keep the spine elongated in every pose. Twists are equally
effective for regulating the adrenals, which provide adequate amounts of estrogen and androgen for healthy
bones. The wave breath would be helpful here. Always end with Savasana.

6b. Stabilize the situation and lifestyle change recommendations

Continue to monitor the progress and work on weight bearing poses to increase Kapha. Keep the joints mobile
and flexible, move in and out of standing poses several times before holding the position. Do not hold a pose
too long or lock your joints, but focus on creating freedom in the joints. Starting with standing poses and Sun
Salutations done rhythmically with the breath will balance Vata. And as they become stronger incorporate
supported shoulderstand and plough pose. However, if they already have osteoporosis fractures, avoid sudden
or jerking movements. Do not do headstand or other unsupported inversions that could bring weight to bear on
the spine.

Patricia Waldon recommends when working with osteoporosis, it is important incorporating inversions
(supported so as not to compress the spine) and weight-bearing asanas in their daily practice. Downward-facing
dog pose especially down dog with the use of ropes, headstand, handstand and upward-facing bow pose are all
beneficial. If they are an advanced practitioner, standing on the hands or doing an elbow balance such as
Pincha Mayurasana works well too. These poses, as well as upward-facing bow pose, enables them to lift their
own weight, which is very important for building bone mass. Again, all of these poses would be beneficial for
the advanced practitioner. Someone in their 60s would benefit more from supported inversions such as
supported bridge.

If working with deficient lungs, asthma, or depression introduce intercostals breathing and a pranayama practice
of Kapalabhati. Continuing the wave breath and once they are comfortable with this incorporate alternate
nostril breathing.

Maintain good posture, with your head over your shoulders and your shoulders in line with your hips, to prevent
pressure on your spine. Practice sitting, standing, and walking with the same posture you use in Tadasana.

Incorporate restorative poses that allow your body and your muscles to relax completely. Also starting a mantra
practice can be very beneficial for uplifting the persons spirits and honoring where they are at in life.

Change the diet to eating less animal protein. Research has shown that eating less animal derived protein will
loose less bone mass. Supplement the diet with calcium by taking Juice Plus+ which is 17 fruits and vegetables
in a capsule. Absorbing the calcium from a supplement is very important. According to the Journal of Current
Therapeutic Research 1996: Test subjects on Juice Plus+ showed significant increases in blood plasma levels
of key antioxidants after only 28 days on Juice Plus+. For more information on the different tests done see the
website given under references.

Spending twenty-five to thirty minutes three or four times a week in the sun will give you the vitamin D the
body needs to absorb calcium effectively. Taking additional supplements like vitamin K, magnesium may help
the bones stay less breakable, according to researchers at Tufts University, Boston.

It is helpful to look at the environment. Make sure there is not clutter around for the person to fall and create a
fracture.

6c. Maintenance of underlying issues at the root of the situation

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Maintenance of the breathing practices, weight bearing poses and Joint Freeing Series as a daily practice is
important in stopping bone loss and building new, stronger bones. Incorporating the machines at the gym,
walking, and low impact aerobics could be other alternatives for a change of pace and to keep the patients
mood elevated.

The following recommendations could be used at any point in the therapy:

Herbs: Use of herbs that improve the absorption of calcium into the bones. Herbs that will help digestion to
increase absorption of calcium.

Meditation: To quiet the adrenal glands and produce calmness in the body.

Breath: Continuing with the wave breath and the alternate nostril breathing. Also, incorporating the agnisar
kriya to improve the digestive fire.

Foods: Eating alkaline foods such as fruits and vegetables and foods high in calcium. Possibly adding Triphala
to improve the digestion.


7. Questions and Answers from Yoga Forums

Questioner
August 5, 2004

Ive checked your forum and Structural Yoga Therapy book in search of an answer to the question of whether standing balancing
poses like tree and eagle are good weight-bearing exercises to help prevent osteoporosis. I know the standing poses and inversions are
good for this, but dont find any evidence that the balancing poses like Tree Pose, Eagle, Warrior III, etc are good weight-bearing
poses for preventing osteoporosis. I have a friend with osteopenia who has asked me if balancing poses are good weight-bearing
poses. I have told her the standing poses (Triangle, Warrior II, Parsvakonasana, etc.) are good poses, but dont know about tree and
eagle. Thank you for your help. I enjoy getting your electronic newsletter and have greatly enjoyed and used your book, Structural
Yoga Therapy.

Answer
In theory any poses that put stress on the bone tissues will help prevent osteoporosis. Balance poses will certainly tone abductors and
adductors, which in turn may stress the femur and hip joint. though i suspect this theory is quite limited in its understanding of the
condition. Not being well trained in medical information, i cannot answer this. instead i would recommend you check with the yoga
research and education center, the experts on what has been tested. www.yrec.org and ask there. You can also go to esutra group at
esutra-owner@lists.esutra.com and ask to be put on the list then you can ask the group of over 1000, many are medically trained yoga
professionals receiving those messages, perhaps they can answer this query. namaste mukunda

Questioner
July 15, 2003

I am looking for asanas that are beneficial for osteoporosis. My mum has this, and has been practicing yoga since the early '60s. The
teacher training that I am following is not too keen on yoga therapy, arguing that you do yoga for you whole being, and not for
therapeutic purposes -- well, I'm sure you know that sort of comments. Could you perhaps recommend a few asanas? I could imagine
that backbends are good, but perhaps not so much for a 74-year old spine. If it doesn't bother you too much, I'd be very happy to hear
from you. Thanks. Best wishes, L


Answer
Yes doing a committed yoga practice is good for whole person. But each whole person has unique challenges and so it is best to listen
to the motto "Modify the practice to the individual needs." In general to work with this situation you want to hold the poses longer
while doing full breathing, a kapha approach to strengthening not only bones but also immune system. So the ideal is fewer poses but
held longer. Standing poses (but not balancing poses) are best as they strengthen the hips and lower body. Also poses that emphasize
strength of spinal column -- locust and cobra -- are good second choices.
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Questioner
May 10, 2002
I have a prospective student with severe osteoporosis. (51 yr. old female -- spine cracked during hysterectomy 18 months ago.
Sedentary since then. 25 pounds overweight.) Any recommendations would be appreciated.

Thanks! M

Answer
To build up the bones I would recommend that you look to Ayurvedic principles for increasing Kapha and its subtler component Ojas.
See Prakruti by Robert Svododa for recommendations here. On the Asana level focus her on doing my Joint Freeing series as
described in Structural Yoga Therapy book for strength (chap. 18 - pg. 171). She will benefit greatly by identifying the specific
muscles that she is strengthening as described in the chapter 16 on anatomy. The objective is not necessarily for her to learn anatomy
as it is to feel her anatomy responding with contraction forces in the specific places that are ideal for each motion. Learning to feel the
feelings of strength as distinguished from stretch is often a surprisingly confusing experience for many students. Often what is
perceived as a stretch is really strength and tone. When this is clarified the student makes progress in toning the muscles, bone strength
is necessarily built on this foundation over time. I would keep this woman to only doing this series with mild modifications to
compensate for the tendency to be bored. I would not recommend asanas except those done lying on the floor to strengthen the spinal
column (erector spinae muscles not latissimus - in other words do not use arm strength), until she is feeling emotionally and physically
stronger.

Questioner
July 1, 2002
Pertaining to the question about osteoporosis...Ayurveda does not promote the increase of ANY DOSHA. The goal is to reduce the
Vata dosha that is causing dryness, emaciation, weakness, constipation, dry skin, dry hair, inability to go to sleep easily at night and
stay asleep, and all the other signs of Vata provocation. The increasing of any dosha is very, very different from DECREASING THE
AFFECTED DOSHA through proper diet, lifestyle, Asana and pranayama practices, even proper mediation for specific dosha...vikruti
and Prakriti. To increase Kapha dosha will only created congestion in the nadis...the individual needs to be assessed with a
consultation and pulse diagnosis for proper protocol to be determined.

As much as we would like these steps to be a simple answer, osteoporosis is usually do to a Vata type Prakriti, leading a very typical
Vata provoking lifestyle and diet and even Yoga practice for years which has lead to osteoporosis. Eliminating deep seated Vata
AMA and then going through Rasayana (rejuvenation) practices like Abhangas (sesame oil massage...must make sure the dhatu AGNI
is strong enough to support the obligation therapy) is one practice that could be helpful. The most important step is to stop provoking
Vata.

Love, blessings and health to all. P

Answer
P is on the staff at Rocky Mountain Institute of Yoga and Ayurveda (www.earthlink.net/rmiya) with me. I highly respect her advice.
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8. References

Books
YOGA FOR HEALTHY BONES, by Linda Sparrowe & Patricia Walden

MAYO CLINIC ON OSTEOPOROSIS, KEEPING BONES HEALTHY AND STRONG AND REDUCING THE RISK OF FRACTURE, by
The Mayo Clinic This book is very clear and understandable about the disease and how the bone grows.

THE WISDOM OF MENOPAUSE, by Christiane Northrup I highly recommend this book.

THE WOMANS BOOK OF YOGA AND HEALTH, by Linda Sparrowe & Patricia Walden

MOSBYS MEDICAL DICTIONARY, 6
TH
EDITION

WHAT YOUR DOCTOR MAY NOT TELL YOU ABOUT OSTEOPOROSIS, by Felicia Cosman, M.D. I highly recommend this
book.

MENOPAUSAL YEARS: THE WISE WOMAN WAY, by Susun Weed

THE OSTEOPOROSIS SOLUTION; NEW THERAPIES FOR PREVENTION AND TREATMENT, by Garl Germano, RD, CNS,
LDN & William Cabot, MD

EXERCISES FOR OSTEOPOROSIS, by Dianne Daniels, MA I like this book a lot as well. It has a great deal of
beneficial exercises for osteopenia and osteoporosis

AYURVEDA FOR WOMEN, by Robert Svoboda


General Information about Osteoporosis
National Osteoporosis Foundation: www.nof.org
Osteoporosis and Womens Health: www.osteoporosis_and_womens_health.com
Osteoporosis Education Project: www.betterbones.com
Womens Health Initiative (WHI): www.hhlbi.nig.gov/whi.com


Dietary Supplement Information
Juice Plus+: www.juiceplus.com/+sc13461



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9. APPENDIX A

YOGA AND RELATED EXERCISES FOR BONE STRENGTH AND PREVENTATION

The type of exercise that most experts agree is exercise that involves either weight or resistance is
the most bone-beneficial. Weight-bearing activity is a term used to describe work performed
against the force of gravity, like walking, jogging, hiking, tennis, climbing stairs, yoga.
Resistance training, on the other hand, involves the use of weights, such as barbells or Nautilus
equipment.

Weight-bearing exercise may be more likely to increase skeletal mass because of its role in
stressing the bones through both gravitational force and muscular contraction. This dual action
places the bone at an above-average stress level and stimulates it to adapt. Resistance training
puts only muscular stress on the bones, and its benefits may not be as great as when implementing
weight-bearing exercises.

A Yoga Sequence for Preventing/Reversing Bone Loss

CAUTION Do not do this sequence if you already have osteoporosis or have suffered fractures
in the past.

1. Wide-Angel Seated Pose (Upavistha Konasana)
2. Bound Angle Pose (Baddha Konasana)
3. Reclining Big Toe Pose (sputa Padangusthasana)
4. Tadasana with various arm positions
5. Standing Forward Bend (Uttanasana)
6. Downward-Facing Dog (Adho Mukha Svanasana)
7. Extended Triangle Pose (Utthita Trikonasana)
8. Warrior II Pose (Virabhadrasana II)
9. Extended Side-Angle Pose (Utthita Parsvakonasana)
10. Warrior I Pose (Virabhadrasana I)
11. Intense Side Stretch Pose (Parsvottanasana)
12. Revolved Triangle Pose (Parivrtta Trikonasana)
13. Wide-Angle Standing Forward Bend (Prasarita Padottanasana)
14. Four-Limbed Stick Pose (Chaturanga Dandasana)
15. Upward-Facing Dog Pose (Urdhva Mukha Svanasana)
16. Camel Pose (Ustrasana)
17. Upward-Facing Bow Pose (Urdhva Dhanurasana)
18. Childs Pose (Adho Mukha Virasana)
19. Bridge Pose (Setu Bandha Sarvangasana)
20. Legs-up-the-Wall Pose (Viparita Karani)
21. Corpse Pose (Savasana)


A Sequence for Osteoporosis or Kyphosis

For women who have osteoporosis or kyphosis, this gentle, safe yoga sequence will relax tension,
encourage deeper breathing, open the chest, and build strength in the upper back. When lying on
the back pad the head with one or more folded blankets so that the chin is not pointing toward the
ceiling and youre not compressing the back of the neck.
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1. Corpse Pose (Savasana) with the wave breath
2. Corpse Pose with Arms Overhead (Urdhva Hastasana in Savasana)
3. Shoulder Girdle Press lye on the floor, knees bent. Inhale into the chest and as you exhale
press your shoulders and the backs of your arms into the floor. Repeat 5 times.
4. Pelvic Tilt (Setu Bandha Sarvangasana)
5. Locust Pose (Salabasana) with different arm positions
6. Twisted Stomach Pose (Jatara Parivartanasana)
7. Corpse Pose (Savasana)

A Chair Sequence for Hyperkyphosis

This is designed for people who can do the above floor sequence comfortably. Make sure you
can stand up from a seated position and then sit back down with relative ease. Use the chair as a
prop in the standing poses to help you balance; go slowly and mindfully, using your breath to
gauge your progress. This series of poses will strengthen the spinal erector muscles, improve
your posture, which will take pressure off of the spine, create better balance and more self-
confidence. This combination of gentle weight-bearing poses and isometric movements will
serve to build muscle and bone mass slowly and safely.

1. Staff Pose in a chair (Dandasana) with Ujjayi Pranayama
2. Staff Pose in a chair with Arms Overhead (Urdhva Hastasana in Dandasana)
3. Staff Pose in chair with Arms in Prayer Position and then out to side (Namaskar in Dandasana)
4. Leg Raises while sitting in chair (Utkatasana prep)
5. Tadasana while holding onto chair
6. Tadasana with Arms Overhead while holding onto chair (Urdhva Hastasana in Tadasana)
7. Fierce Pose while holding onto chair (Utkatasana)
8. Warrior I Pose while holding onto chair (Virabhadrasana I)
9. Half Downward-Facin Dog Pose with hands on the wall (Ardha Adho Mukha Svanasana)
10. Simple Seated Twist Pose (Bharadvajasana)
11. Corpse Pose with legs up on a chair (Savasana)

Osteoporosis Exercise Program

This program works on the neck, upper and mid back, lower back, hips, wrist, chest-arms,
abdominals, balance, breathing and skeletal alignment.

1. Resisted Neck Place a hand on the back of the skull and resist with the hand. Place the hand
on the front of the skull and resist with the hand. Place the hand on the side of the skull and
resist.
2. Retraction Squeeze the shoulder blades together.
3. Bent Arm Retraction Arms at a 90 degree angle and bring shoulder blades together.
4. Spinal Press Lie on the back with the head into a pillow. Press the head into the pillow and
feel the chest begin to lift off the floor.
5. Knee to chest Bring one knee to the chest and repeat on other side.
6. Modified Trunk Lift Lie on your stomach, head resting comfortably. Place your forearms on
the floor, elvows close to your sides. Engage your abdominals and press the hip bones into the
floor.
7. Bridge
8. Buttock squeezes While on the back, knees bent squeeze the buttocks without lifting the
back off the floor.
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9. Inner thigh squeeze On the back place a pillow between the knees and squeeze using the
inner thigh muscles.
10. Hip flexion On the back place the hands on your hip bones and engage the abdominals.
Bring the right knee up 6-12 inches off the floor, then lower slowly, all while keeping the hip
bones level (do not allow the left hip bone to sink down as you lift the right leg).
11. Hip Rotation Lie on the right side, place your head on a pillow and bend both hips and
knees to about 90 degrees. Lift up your left knee and feel the work deep in your buttocks.
12. Towel wrings hold a towel with your elbows bent and next to your side. Try to wring out a
towel so that one wrist extends as the other wrist flexes.
13. Angel Arms Lie on the back with the arms by the side, palms up. Bring the arms off the
floor 1, keep the elbows straight which bringing the arms in an arc until they are overhead.
14. Chest stretch starting in the fetal position bring the top arm to the other side until you feel a
stretch.
15. Breathing In and up With the hands on either side of your stomach around the belly button,
narrow the waist as you contract your abdominal muscles. Feel the hands moving slightly closer
together as you exhale.
16. Knee Twist lie on the back with knees bent and feet together and slowly lower both knees
towards the right side, but do not let them touch the floor. Then slowly lower both knees to the
left side.
17. Ankle Circles
18. Toe Taps While keeping heal on the floor lift your toe up toward your shin.
19. Breathing into the chest place one hand on the chest just below the collar bone. Inhale as
deeply as you can into your hand.
20. Breathing into the ribcage place both hands on the back of your lower ribcage and inhale as
deeply as you can into your hands.
21. Diaphragm Breathing place one hand over your stomach at the level of your belly button.
Inhale as deeply as you can and direct your breath into your hand.


Staying Active

Ideally, exercise should become an intrinsic part of the patients daily life. It is best to
incorporate at least half an hour a day to half an hour a few days a week. Even during regular
exercise times, they can still incorporate ways to add more activity to their daily life:

Look for more opportunities to walk: stroll to the store and take a walk in the park with a friend
after lunch.

If you drive to work, park your car farther away from the office and walk the extra distance.

Take the stairs instead of the elevator.

Do light calisthenics while watching television.

If youre doing chores around the house, set a pace and time yourself, then try to break the old
record the next time you do that chore again.