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Evidence-Based Yoga Therapy for Older Adults (3 CE Hours)

This course is approved for 3 hours of Continuing Education for Yoga Teachers and Yoga Therapists by the Yoga Alliance.

Learning Objectives: After reading this course, you will...

  1. be able to describe the types of physical and mental morbidities facing older adults.
  2. be able to identify the conventional treatment of these disorders.
  3. be able to explain the way yoga can help with these disorders.
  4. be able to identify research studies that have proven the efficacy of yoga.

Introduction

Between the years 2000 and 2050, the world wide proportion of persons over 65 years of age is expected to more than double, from the current 6.9% to 16.4%. This growing older adult population represents a group of people coming to yoga with special needs related to the aging process.

Physical Health Considerations in Older Adults

Osteoarthritis
Literally “joint inflammation” there are more than 100 types of arthritis, including rheumatism, lupus, gout, fibromyalgia and the most common form, osteoarthritis.  Osteoarthritis (OA) develops as your body progressively loses articular cartilage inside the joints, especially weight-bearing joints, spinal joints and hands.  Healthy hyaline cartilage is spongy (filled with synovial fluid) to provide cushion and slippery so the bones glide easily. When OA starts, the cartilage becomes inflamed, begins to dry out and wears away. This leads to swelling, heat, pain, stiffness, weakness and even bone damage.  Osteoarthritis, also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, which can include articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion (swelling). A variety of causes—hereditary, developmental, metabolic, and mechanical—may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax. Once considered a disease of aging, OA is now seen as a complex disorder that can be complicated by family history, mental stress, inactivity, obesity, repetitive stress and trauma.  Arthritis affects 28% of Americans between the ages of 45 and 64 and 50% of those over 65 years old, which is 20 million people. 

Conventional Treatment for Arthritis
Since there is no cure for OA, treatment is focused on relieving symptoms. Treatment generally involves a combination of exercise, lifestyle modification, and analgesics (pain relievers). If pain becomes debilitating, joint replacement surgery may be used to improve quality of life. OA is the most common form of arthritis and it is the leading cause of chronic disability in the United States. The 3 main medications that doctors recommend are over-the-counter drugs like acetaminophen (Tylenol), non-steroidal anti-inflammatory drugs like ibuprofen and Naproxen, and COX-2 inhibitors like Celebrex.  Doctors also recommend physical therapy focused on stretching, strengthening and aerobic exercise. PT’s may also use hot packs, ultrasound and massage to relieve symptoms.

Non-conventional Treatments for Arthritis
In ayurvedic medicine, arthritis is amavata, which is the accumulation of toxins in the joints. Practitioners may use massage techniques using special oils like mahanarayan (which has a sesame oil base to reduce vata imbalance) to alleviate toxins and bring circulation and prana into the joint.
Dietary recommendations include avoiding heavy, hard to digest mucous-forming foods. Avoid calcium inhibitors like red meat, refined sugar, nightshades, intoxicants, and excess salt. Do eat whole grains, steamed vegetables, legumes, sprouts, seaweeds, chlorophyll-rich foods, foods rich in omega-3 (flax oil) and omega-6 (CLA-rich oils) fatty acids. Natural anti-inflammatory agents like ginger and turmeric can be added to food. Some research suggests that taking 150 mg of Vitamin C daily, 400 IU of Vitamin E, 9000 IU of beta carotene, 400 IU of Vitamin D, 1200 mg of Glucosamine with MSM and SAM-e can help reduce symptoms and improve function.  Drink plenty of water to keep your tissues hydrated.

Yoga for Arthritis
Yoga asana movement is the best natural medicine for OA.  Gentle range of motion encourages the production of synovial fluid, stretching eases tension around joints and strengthening promotes stability of the joints. Exercise leads to the release of endorphins, your body’s natural pain relievers. One research study showed a significant decrease in hand pain in subjects who practiced a series of yoga hand exercises. (1) Patients with OA of the hands were randomly assigned to receive either the yoga program or no therapy. Yoga techniques were supervised by one instructor once/week for 8 weeks. Variables assessed were pain, strength, motion, joint circumference, tenderness, and hand function using the Stanford Hand Assessment questionnaire.  The researchers found that the yoga treated group improved significantly more than the control group in decreased pain during activity, tenderness and finger range of motion. Other trends also favored the yoga program. In conclusion, this yoga program was effective in providing relief in hand osteoarthritis. (1) Isometric strengthening is also considered an important part of treatment for OA.  In one study, 64 patients with osteoarthritis of the knee joints were studied to observe the effects of isometric quadriceps muscle strengthening exercise plus non-steroidal anti-inflammatory drugs (NSAIDs). (2) Another 75 patients were treated with NSAIDs as control. They were assessed by visual analogue pain scale, OMAC scale and range of motion of the knee joints and followed-up weekly for six weeks. Improvement was found in both groups (p = 0.001) after treatment. In comparison, more improvement was found in the exercise group after four weeks (p = 009). Then improvement was gradually increased day by day and finally there was highly significant improvement (p = 0.001). This study suggests that isometric quadriceps muscle strengthening exercise has its beneficial role to reduce symptoms in osteoarthritis of the knee. In yoga, we can activate the muscles around the knee to create an isometric contraction of the quadriceps muscle.  We can accomplish this in any position and in a variety of postures. A pilot study by Kolasinski and colleagues concluded that Iyengar yoga may reduce pain and disability caused by knee OA. (3) In this trial, 11 subjects meeting American College of Rheumatology criteria for knee OA were enrolled. Subjects were instructed in a modified Iyengar yoga sequence during one 90-minute class weekly for eight weeks. No home exercise program was required. Nine people completed at least one session, the average number of sessions completed was five, and seven (six of whom were obese) had data from pre- and post-course time points available for analysis. At the end of the study, researchers saw statistically significant reductions in WOMAC Pain, WOMAC Physical Function, and Arthritis Impact Measurement Scale 2 (AIMS 2) scores compared to their pre-intervention status. Physician Global Assessment (MDGA) and Patient Global Assessment (PGA) also showed trends in improvement. Subjects in the study reported no adverse effects from the treatment.
A study by Bukowski and colleagues also looked at the effect of an Iyengar yoga program and strengthening exercises in subjects with knee OA. (4) Fifteen participants were assigned to a traditional stretching and strengthening regimen, Iyengar yoga, or no exercise. Low back and hamstring flexibility and quadriceps strength and function were monitored before and after the program. The WOMAC Osteoarthritis Index and a global assessment questionnaire were also used to assess improvement. After the six-week intervention period, functional changes and improvement in quality of life were noted in the traditional exercise and yoga groups compared to the controls. Those with the greatest improvements in flexibility and quadriceps strength had the greatest improvement in WOMAC scores.
Two subsequent studies have suggested that at least part of the effect of yoga on subjects with knee OA involves alteration of gait. Evangelisto and colleagues looked at the biomechanical changes following an eight-week yoga intervention in the knee as assessed by a formal gait laboratory analysis.(5) WOMAC pain, stiffness, and disability and visual analog scale (VAS) scores were used to assess the subjects’ improvement. All subjects met ACR criteria for knee OA. They participated in eight weekly 90-minute Iyengar yoga classes. Three-D motion analysis revealed a statistically significant reduction in ankle dorsiflexion, an increase in plantar flexion, and an increase in the total range of motion for pelvic tilt between baseline and follow-up evaluations. Analysis of footfall parameters from baseline to follow-up revealed significant increases in walking speed as well as maximum moments during hip rotation, hip flexion/extension, and knee varus. Three of four subjects who completed seven of eight yoga classes had reductions in WOMAC pain, stiffness, and disability. The increased walking speed and modified ankle motion during gait may underlie the improvements in WOMAC scores. Thus, improved biomechanics may lead to a reduction in knee OA symptoms.
A second study used gait analysis to elucidate the potential role of Iyengar yoga in treating elderly patients with impairments in ambulation. (6) Participants were non-obese, yoga-naive subjects older than age 62 who did not require assistive devices. Nineteen individuals completed the eight-week study, which included two 90-minute Iyengar yoga classes each week, as well as a minimum of 20 minutes of home yoga practice five times a week. Relative to baseline values, both peak hip extension and stride length at comfortable walking speed demonstrated significant increases after the intervention. The researchers also observed a trend toward a decline in average pelvic tilt from baseline to eight weeks. Change in peak hip extension was strongly and positively related to change in ankle plantar flexion and ankle joint power. Stride length was strongly and positively related to all three secondary outcome measures, including walking speed.  Importantly, the frequency of yoga practice at home (measured in total days and mean days per week) and the duration of practice (measured as mean minutes per day) showed a strong linear dose-response relationship to change in hip extension and average pelvic tilt. The authors noted that loss of hip extension and the compensatory increase in pelvic tilt and reduction in stride length is associated with aging, the risk of recurrent falls, and increased morbidity and mortality. Both of the studies using gait analysis to evaluate patients with knee OA who did yoga suggest that altering gait biomechanics is not only possible via yoga but that it can be associated with improvements in pain and other outcomes as well.


Osteoporosis
Osteoporsis is the demineralization of the bones. Osteoporosis ("porous bones") is a disease of bones that leads to an increased risk of fracture.  In osteoporosis the bone mineral density (BMD) is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered. Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density that is 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by DXA; the term "established osteoporosis" includes the presence of a fragility fracture.  The disease may be classified as primary type 1, primary type 2, or secondary. The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis, or senile osteoporosis, occurs after age 75 and is seen in both females and males at a ratio of 2:1. Finally, secondary osteoporosis may arise at any age and affects men and women equally. This form of osteoporosis results from chronic predisposing medical problems or disease, or prolonged use of medications such as glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP). Osteoporosis is a component of the frailty syndrome and especially at risk are the femur (thigh bone), vertebrae (spine) and wrists. Every year, forty-four million Americans suffer from low bone density, and osteoporosis is the culprit behind over 1.5 million fractures annually. Osteoporosis affects 10% of population (8 million women; 2 million men) and 18 million people have osteopenia (low bone density that has not reached a critical stage).  People that have osteoporosis will often have no symptoms, except loss of height and kyphosis (rounded back). Sometimes they will experience joint and muscle aches. As the population of the world grows older, it is critical to find something for the continued activity and health of an increasing number of people. Present estimates are that 200,000,000 suffer from osteoporosis or osteopenia.

Conventional Treatment for Osteoporosis
Osteoporosis risks can be reduced with lifestyle changes and sometimes medication; in people with osteoporosis, treatment may involve both. Lifestyle change includes diet and exercise, and preventing falls. Medication includes calcium, vitamin D, bisphosphonates and several others. Fall-prevention advice includes exercise to tone deambulatory muscles, proprioception-improvement exercises; equilibrium therapies may be included. Exercise with its anabolic effect, may at the same time stop or reverse osteoporosis. Conventional medical wisdom puts people in an impossible position: exercise with impact, jogging, for example, is needed to stimulate the cells that build bone, but unfortunately, such exercise fairly reliably brings about joint destruction. No-impact exercise is harmless to the joints, but unfortunately, leaves the bones to slowly weaken even to the point of breaking. At the same time, it is universally acknowledged that not exercising at all tightens joints and ligaments, weakens muscles and bones alike, and is the worst of both worlds.

Yoga for Osteoporosis
Evidence in the animal literature confirms that unconventional tugs of the sinews and ligaments can not only arrest, but reverse osteoporosis.(7) The transcriptional coactivator PGC1-alpha is liberated from muscles in exercises such as yoga, and suppresses a broad array of inflammatory responses, likely including arthritis. A recent pilot study on the effects of a yoga program on patients with osteoporosis corroborates these findings. (8) There are also physiological reasons to believe that yoga improves the circulation of synovial fluid inside joints, thereby slowing the normal “wear and tear” that leads to osteoarthritis.

Risk of Falls
Physiological changes associated with aging can impair the sensory systems, including the vestibular, auditory, and visual systems, as well as neural integration of sensory infor­mation. These changes, along with cognitive impairment, orthopedic and musculoskeletal conditions, and other health conditions, affect functional capacity, reduce balance, and increase the likelihood of falling.

The American Academy of Orthopedic Surgeons re­ports that among people 65 years and older, falls are the leading cause of nonfatal injuries and hospital admissions for trauma, and nearly one-third of older adults suffer from some type of fall each year. Falls are the leading cause of fatal and nonfatal injuries in older adults; 30% of those over 65 fall annually, with over 11 million falls and 20.2 billion dol­lars spent for treatment. (9) The primary risk factors for falls are strength, gait or balance impairments.

Yoga for people at risk for falls
Yoga helps improve balance and strength, thereby enhancing a person’s ability to hold their balance and catch their self in the event of a loss of balance. One research study has suggested that yoga might be used to prevent falls in the elderly. (10) A total of 27 subjects over age 65 participated in a program of weekly 45-minute yoga sessions without the aid of props or assistive devices and excluding floor exercises. At three-month follow-up, beneficial effects on balance were demonstrated using a number of outcome measures. The authors suggested that future studies of fall prevention using a yoga intervention would be appropriate. Osteoarthritis is among the factors that may contribute to an unsteady gait in the elderly, and improvement in symptoms due to OA may account for some of the improvement in decreased fall risk noted in this study.

Older adults who fall must typically get up from the floor and call for assistance. The ability to rise from the floor, or floor transfer, is a key factor in over­all safety, independence, and quality of life. Floor transfers are also important when completing daily household and recreational activities. Bergland and Laake found that the inability to get up from lying on the floor is a marker of failing health and function in older adults and a significant predictor of serious fall injuries.(11)

In one recent study, researchers recruited 45 older adults to participate in a 13-week program which included one 90-minute Hatha Yoga class each week and completion of a 30-minute Yoga DVD program five times a week. (12) Collected data included four physical measures: active and passive ankle joint dorsiflexon, seated knee extension/quadriceps strength, standing balance, and floor transfer ability, all measured by a licensed physical therapist, as well as two self-report measures: the Rating of Perceived Fitness & Mobility Scale and the Transfer Difficulty Scale. The results of the study revealed that all of these variables showed moderate to large im­provements. The change in transfer ability, which was the primary focus, was statistically significant (p<.001). Results indicate that this 13-week yoga program assessed significantly improved the ability of older adults to transfer from the floor, a key component of independence and functionality in later life. In addition to this result, participants in the program showed improved balance, leg strength, and ankle range of motion. Most important for floor transfer appears to be balance and leg strength, with passive and active range of motion show­ing little relation to transfer ability. (12)

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