Arthritis relief with yoga

Mary P. Schatz, MD

[Yoga Journal May-June 1985]

Joy was desperate. The intense pain she had been experiencing for five days and nights revealed itself in her face, her body carriage, her movement. Her arthritic knees hurt her so badly that she was no longer able to exercise. She knew that she had to keep moving to stay sane and mobile, yet her program of running and walking had begun to cause pain and swelling in her knees. As we talked, I realized that her stretching routine was inadequate, so I showed her several of B. K. S. Iyengar’s modified asanas (yoga poses) for knee problems

Almost immediately she felt some relief, and with continued practice she gradually began to walk and run again. Now, after several years of faithful yoga practice, her disability has diminished and her sense of well-being has vastly increased.

Over 40 million Americans are struggling with arthritis. From one end of the continent to the other, growing numbersare discovering that yoga can help heal and rehabilitate joints and lives ravaged by this debilitating disease. In this article, we will develop an understanding of how arthritis destroys both joint structures and the quality of life and how yoga postures and the positive attitude of yoga psychology can heal them.

Arthritis defined

The term arthritis (literally “inflammation of the joints”) refers to a number of diseases that cause deterioration of different joint structures, resulting in pain, immobilization, and loss of function. To understand the two main types of arthritis, osteoarthritis and rheumatoid arthritis, one must first understand how joints work and how joint health is maintained.

How a joint works

The ends of two bones meet to form a joint, which is enveloped by a fibrous capsule lined by a synoviai membrane (synovium). The synovium manufactures thick, mucus-like synovial fluid, which lubricates, nourishes, and cleanses the cartilage on the ends of the bones.
Joints are moved by muscles whose tendons attach to the bones. Flexor muscles bend joints (as in making a fist or bending the elbow or knee). Extensor muscles straighten joints (as in opening the hand or lengthening the elbow or knee). These muscles and their tendons provide important support for the joints, as do ligaments, dense fibrous bands connecting bone to bone.

Maintenance of joint heatlh

To stay healthy, joints must do what they me supposed to do: move and bear weight. (“Weight-bearing” means that there is mechanical stress during active movement.) Since cartilage has no blood supply, it must be bathed by normal synovial fluid in order to receive oxygen and nutrients and to discharge its waste products. The thick, viscous synovial fluid also acts as a lubricant for the gliding surfaces, just as grease acts to lubricate moving metal surfaces in an engine. Movement stimulates the synovial membrane to produce synovial fluid. Therefore, the old concept that an injured joint must be rested is now understood to be incorrect. Movement is crucial to induce the manufacture of synovial fluid, to distribute it over the cartiiage and to circulate it through the entire joint space. In this way, movement helps cartilage to heal. If the synovium is unhealthy (as in the case of rheumatoid arthritis and related conditions), abnormal synovial fluid is produced which is less efficient at nourishing,: cleansing, and lubricating the joint cartilage.

Movement is vital for increasing circulation of blood and lymph into and out of the joint structures and adjacent soft tissues. This increased circulation reduces swelling, removes waste products, and increases delivery of nutrients and oxygen to facilitate healing of joint tissues.

Cartilage and bone require the stimulus of weight-bearing for normal metabolism and repair. Cartilage depends on the squeezing-releasing action of weight-bearing to force fluids containing waste out of its matrix and allow fresh fluid to enter. The electrical currents created in bone by weight-bearing are vital for stimulating bone remodelling and repair — an ongoing process in which old bone is removed and replaced. Further, this weight-bearing stimulus induces bone to “hold on” to its calcium molecules. Without weight-bearing, bone loses excess calcium and becomes fragile and prone to fracture and collapse — a condition called osteoporosis.

What arthritis does to a joint

Rheumatoid arthritis and osteoarthritis attack different parts of the joint. In rheumatoid arthritis (and the related rheumatoid diseases: lupus arthritis, ankylosing spondylitis, scleroderma, mixed connective tissue disease) the cells of the immune system (inflammatory cells, lymphocytes, and plasma cells) receive a signal that causes them to attack the joint lining as if it were an outside invader. They migrate to the synovium and congregate there in Iarge numbers, releasing tissue-destroying enzymes that bring about inflammation (sweIling, redness, pain) and deformity. This inflammation can cause tendons to weaken and rupture, leaving their muscles functionless. As the synovium swells, it stretches the ligaments, the joint capsules, and the muscular tendonous support of the. joint. Reduced joint support in turn permits abnormal movements, which cause further damage. Bones can even become dislocated.

The synovium itself — stimulated to proiferate in an attempt to heal itself— begins to grow over the surface of the cartilage. This literally “smothers” the cartilage, cutting it off from its source of nutrition, the synovial fluid) .The synovial fluid declines in quality as a result of the inflammation of the synovium. Its ability to nourish, cleans and lubricate is diminished, and the cartilage begins to deteriorate. The cartilage may even fragment and break off into “loose bodies” or “joint mice” that float within the joint space. Rheumatoid arthritis and the rheumatoid diseases most often affect fingers, wrists, shoulders, knees, feet, and spine but can also affect other tissues, including the heart, skin, and kidneys.

Osteoarthritis — a disorder of the normal remodeling processes that constantly repair joint cartilage and the underlying bone — can result from trauma, malalignment, fractures, infections, apd metabolic diseases. Repeated hemorrhage to joint (as in hemophilia), which alters cartilage by interfering with the normal synovia fluid functions, may also result in osteoarthritis. Inactivity has recently been recognize as an important cause of osteoarthrisis joint deterioration. (As we have already seen normal movement is necessary for maintenance of proper synovial fluid physiology as well as cartilage nutrition and bone integrity.) These abnormal conditions can cause shearing of the surface layer of the cartilage and unbalanced remodeling. New bone and cartilage are laid down in an abnormal configuration as projections or spurs on the edges of the previous cartilage plate. As result of improper nourishment and circulation and abnormal shearing forces, the cartilage progressively thins. Finally, the cartilage may erode away entirely as bone grates on bone with each movement.

Although inflammation is not an initiating factor in osteoarthritis as it is in rheumatoid arthritis, an inflammatory response (i.e., heat and swelling) will often occur. Osteoarthritis most frequently affects the hips. knees. fingers, and spine.

What arthritis does to one’s life

A vicious cycle of deterioration begins in the joints and spreads inward to affect the rest of the body; mind and outward to relationships with family and friends. The results can be devastating: joint pain. immobility, deformity, weakness, fatigue. depression, fear, grief, and dependency. A young mother may no longer be able to care for herself and her children; an active older person must depend on others for daily assistance.
The cycle begins with joint pain and swelling. The logical response is, “If it hurts to move, don’t move it.” Decreased use results in muscles that shorten from lack of stretching. thus creating deforming contractures. Unused muscles become weak, and this weakness, coupled with the stretched joint support structures caused by swelling. produces instability of the joints. Unstable joints are vulnerable to dislocation, further injury, and more pain. With increased weakness and vulnerability, fear and dependency swiftly enter the equation, along with fatigue and depression, and the motivation to move is reduced even further. Since all human physiological processes require body movement, health deteriorates. Normal functioning of the immune system declines with grief and depression, and vitality is sapped. The cycle continues to feed upon itself. The end result is a hopeless. dependent, deformed human being.

What yoga can do for arthritis

Yoga’s multifaceted approach to life and health offers arthritics powerful tools for restoring not only joint health, but psychospiritual health as well. Yoga provides the means for helping internal healing processes and for creating an environment in which other therapies (such as medication and diet) have a chance to work.

Movement into and out of the asanas (modified and supported, if necessary) can begin so resstore health to synovium and cartilage. Strength improves, and joint vulnerability decreases. As shortened muscles stretch, more normal range of motion returns. Weight-bearing asanas improve bone health. Yoga in the Iyengar tradition teaches movement with proper joint alignment, helping to move deformed joints back to normal position as muscles are lengthened and strengthened. The constant awareness of posture that yoga encourages helps patients avoid injurious positions in everyday activities

Yoga psychology stresses the healing powers of positive states of mind: friendship, fellowship, love, compassion, joy. Focusing on positive emotions while working with yoga, one begins to regain hope: “I am doing this because I care about myself.” With continued practice, self-awareness develops and helps one to avoid becoming overtired or giving in to despair.

The relaxation response of Savasana (Corpse Pose) and meditation helps counter-act the energy-draining effects of prolonged stress and chronic pain. Deep relaxation helps restore more normal functioning of the immune system, which deteriorates with chronic stress, chronic pain, grief, and depression.

The negative language of arthritis

Arthritis sufferers ask. ‘Arthritis victim’,‘Mv bad knee’, ‘A bad day’, ‘This frozen shoulder’, ‘These ugly hands’, ‘I can’t do anything anymore’.

The use of negative language in arthritis solidifies a negative self-image and leads to further immobilization and deterioration. How can a stiff knee ever become flexible if it is constantly told that it is stiff? How can one ever change ones activities to help an arthritic knee when one constantly conceives of it as ”my bad knee”? These repeated verbal affirmations accept the status quo and contribute to further deterioration. Consider she destructive, self-fulfilling prophecy, “I’m having a bad day.” Instead, substitute positive language and positive body imagery: “Bad days” become “slow days.” “Bad joints” become “healing joints.” “Stiff joints” become “improving joints.” “Disabled” does not mean “unable.” “Disabled patients” become “recovering individuals,” Delete entirely “victim,” “sufferer,” “I can’t.”

With each exercise or movement of an affected joint, visualize swelling subsiding, joint surfaces healing, muscles strengthening, and inflammation decreasing. Carl and Stephanie Simonton have had marvelous success with positive healing imagery in cancer patients. The very same mechanisms can also work with arthritis.

Importance of professional assessment

With arthritis, as with all serious illnesses, a precise diagnosis is of utmost importance in preparing an intelligent program of therapeutic movement. For instance, most hip pain is due not to arthritis in the hip joint, but to bursitis (inflammation of a bursa, or synovial sac, next to the hip joint) or to pain referred to the hip location from lumbar spine disease. Consider the danger of treating the hip pain of bone cancer as if it were arthritis. Clearly, different conditions require different forms of treatment.

In addition to evaluation by a physician (a rheumatologist or orthopedist), evaluation by a registered physical or occupational therapist is frequently of great benefit. These health professionals evaluate range of motion, functional ability, and strength; they create functional splints to stablilize fragile joints and prevent futher deformity; and they make assessments of an individual’s daily activities, with helpful recommendations for saving energy and protecting joints.

Yoga and arthritis

Moving hurts, but not moving destroys.
Incorrect moving harms, but intelligent moving heals.

“Smart exercise” is the key to restoring health to arthritic joints. One must recognize the necessity of working within the limitations imposed by the disease without being paralyzed by them. This situation is ideally suited to the therapeutic use of the principles of Iyengar yoga.

Improper movement of deformed and unstable joints can cause further deformity and injury. Properly aligned movement designed to strengthen weak muscles and stretch shortened tight ones is crucial to restoring stability and range of motion. Movement, as we have seen, enhances the health of synovium, bone, and cartilage.

Weight-bearing movement helps heal cartilage and strengthen bone, but weight-bearing phases of an exercise program must take into account the very real problem of fatigue. Fatigued muscles do not provide adequate musculotendonous suport for arthritic joints.

A yoga program must be based on the following guidelines:
• Respect pain.
• Balance rest and work.
• Breathe properly.
• Maintain muscle strength and range of motion while.ayoiding positions of deformity.
• Do not hold a single position for prolonged periods of time.
• Warm up.
• Consider logistics and energy conservation.

Respect pain. A healthy yoga student must learn the difference between the feeling of muscle stretch and the feeling of pain. The yoga student with arthritis must learn to distinguish between the usual discomfort of moving involved joints and the pain caused by a destructive, malaligned movement or excessive demand on a joint. Pain must be avoided because it causes reflexive spasms in flexor and adductor muscles, further limiting mobility and exacerbating contractures. Continuing an activity in the presence of sudden or severe pain is likely to cause joint damage. A good rule of thumb is that if pain lasts more than two hours after an activity, alignment should be checked and corrected or, if alignment is good, effort should be reduced.

Balance rest and work. This principle applies to yoga practice as well as to the activities of daily living. Total body fatigue is a real and ever-present danger. primarily in the rheumatoid diseases but also in osteoarthritis. There is also the more localized problem of fatigue in individual muscle groups. Weakened, fatigued muscles set the stage for joint instability and injury. Therefore, it is important to rest muscles during yoga practice. following the axiom: “Stop and rest before it becomes necessary.’

Breathe properly. Proper breathing is the basis for a sound yoga practice. Without full expansion of the lungs, exercising muscles are not adequately supplied with oxygen. Holding the breath during an asana causes mental and muscular tension and prevents relaxation. Performing a movement while exhaling reduces pain or tension that might otherwise occur.

On the inhalation, gently, smoothly, evenly, and quietly fill the lungs, feeling the ribs expand to the front, sides, and back. The breath should never be forced, and the abdomen should remain soft. On the exhalation, effortlessly, quietly, and softly release the breath. Breathing well takes practice. While you’re learning, remember to breathe — don’t hold your breath.

Maintain muscle strength. Maintain muscle strength and range of motion while avoiding positions of deformity; use each joint in its most stable and functional anatomical plane.
These are some of the basic principles of Iyengar yoga. Yoga asanas provide a system of movement that can strengthen all muscles and improve range of motion. For those working with joint limitations, B. K. S. Iyengar’s modifications of the classical poses are ideal. These modifications take into account joint strength and limitations in assuming positions of properly aligned movement. They increase strength, joint stability, and range of motion while protecting joints through right movement. Never bounce. This causes reflex tightening of muscles and can result in torn muscles and tendons. Do not hold a single position for prolonged periods of time. Although establishing the stillness of perfect balance is one of the great joys and benefits of yoga, one must be careful not sohold a pose too long. How long is too long? There can be no set answer. For some, sitting 10 minutes will create stiffness. whereas others may be able to sit for a half hour or longer. One must be attentive. especially in standing poses, to avoid leaving muscles in a static position too long. Static muscles fatigue, transferring damaging positional stresses to joint surfaces and ligaments. Be alert for early signs of weakness or shakiness: come out of the pose under control before muscles tire.

Warm up. Although affected joints should be moved through a full range of motion at least once a day, it is unrealistic and potentially harmful to expect to attain the full range of motion on the first try. Work into a pose gradually. It may be helpful so take a hot bath or shower before you practice.

Consider logistics and energy conservation. Poses should be sequenced to avoid getting up and down unnecessarily. For instance, do seated poses together, followed by lying poses and then standing poses. End with a relaxing lying pose. For psychological reasons, always end with something that you can do well.

Three types of yoga practice for arthritis

Recognize that you will have occasional slow days (formerly called “bad days”), and occasional flare-ups of joint inflammation and pain. Be ready so adjust your mind-set and yoga practice accordingly.

Moving On. This is the workout mind-set on good days. Do more weight-bearing asanas that also involve active movement and stretching, such as the standing poses (with support, as necessary). Remember to relax at intervals during the workout and at the end of the practice.

Maintenance. This mind-set is for practice on slow days when energy is not too low but movement is more painful than usual or joints are swollen and hot. Avoid working a joint that is hot, red, and swollen. (It is, however, important to move an inflamed joins through its range of motion twice a day.) Concentrate on maintaining muscle strength with more isometric work. For arthritic knees, do other standing poses that do not bend the knees. For arthritic elbows, do standing poses with the arms actively extended. Do not push yourself to stretch, as this can cause pain-induced muscle spasms. Hold a pose for 1-2 breaths, then rest for 1-2 breaths, then repeat. Practice evenly, smoothly, and rhythmically — with the aid of peaceful. uplifting music, if desired. During a flare-up of the knees, shoulders, or hips, focus on joints that are less involved. This will avoid the negative mind-set of having “arthritis all over”. Remember to relax at the end of practice.

Relaxation. For low-energy days, concentrate on replenishing energy reserves through Savasana and supported supine relaxation poses such as supported Setu-bandha and Savasana on a chest-opening prop. Quiet observation of the breath while using positive, relaxing imagery sets the stage for the healing psysiologi-cal state inouced by the relaxation response. A guided relaxation, either read or spoken by a friend or recorded on tape, may be used at this time. Remember not to stay in any position too long.

When to Practice

• Following a warm bath or shower
• After medication has had time to take effect
• When you won’t be in a hurry
• At the “best” time of day for you —that is. when you feel most flexible and energetic
• Once a day, if that is sufficient to maintain range of motion; twice a day may be necessary for some

The Importance of Smooth, Rhythmic Movement. Many therapists experienced with arthritis recommend smooth, rhythmic movement in exercise. Herbert deVries of the Exercise Physiology Laboratory and Gerontology Center. UCLA, has emphasized the tranquilizing effects of moderate rhythmic exercise. J. B. Adlersberg, MD of the Mount Sinai School of Medicine has developed “Dancescript”, a successful dance therapy for arthrisics. Research has shown that arthritics have lost part, of their ability to produce beta endorphin, the body’s internal pain killer. Synovial joints manufacture endorphin. The tranquilizing effects of exercise coupled with improved synovial health through movement can thus help alleviate arthritis pain. Yoga beautifully incorporates these principles, for smooth movement into and out of a pose is basic to a good yoga practice.

Asanas for arthritis

For the purposes of this article, we will focus on the three areas most commonly involved by arthritis: hands, hips, and knees;

HANDS

Deforming Tendencies: When normal hand mechanics are altered, the fingers develop ulnar deviation — that is, the fingers begin to slant toward the little finger side of the hand (toward the ulnar bone). As joint-stablilizing structures overstretch from swelling and deteriorate as a result of inflammation, dislocation can occur in the fingers and wrists. Muscular shortening resuIts in contractures that make it impossible to open the hand fully or to separate the fingers. Swelling in the wrist can cause hand pain and numbness (carpal tunnel syndrome).
Rationale: Hands and wrists should not be placed in any position that accentuates or encourages deformity. Every movement should be designed to move the hand back toward normal.

Asana: Namaste (prayer, position). This position provides a good way to work on ulnar deviation and flexion contractures. (Caution: If there is wrist involvement or carpal tunnel syndrome, practice Namaste with the forearms touching.)
1.• Gently press the palms and fingers of each hand against the palms and fingers of the other hand.
• As you breathe smoothly and evenly, encourage the fingers away from their position of ulnar deviation.
• Hold for 1-2 breaths.
• Release pressure but maintain contact for 1-2 breaths. Hold and encourage. Release. Hold and encourage. Release.
2.• Gently, firmly, and evenly press the palms together.
• Smoothly spread the fingers as wide as possible. Encourage even spreading with less and less ulnar deviation.
• Hold and encourage for 1-2 breaths. Release for 1-2 breaths. Hold and en-courage. Release,
3.• Firmly and evenly press the palms together, especially the parts of the palm that form the base of each finger.
• Pull the fingers back into hyperextension, trying to increase the distance between the fingers of the left hand and the fingers of the right. Again encour-age the fiigers away from ulnar devia-tion.
• Hold and encourage 1-2 breaths. Re-lease 1-2 breaths. Hold and encourage. Release. Hold and encourage. Release.

HIPS:

Deforming Tendencies: Like the knees, the hips develop flexion contractures that limit full straightening of the thigh at the pelvis (extension). As a result, the hip joint is always bending forward (flexing) to some degree. With decreased movement, the muscle and soft tissues around the hip shorten, causing a decrease in joint space and more wear and tear on the gliding surfaces. Decreased use means less weight-bearing stimuli for bone and cartilage health. Bone spurs may develop to further limit movement.
Rationale; Standing poses such as the Warrior Poses described next are crucial for stretching out contractures and building supportive strength in the hip, buttock, and thigh muscles. Moving the head of the femur in the hip socket in the standing poses and in the range of motion exercisehelps to distribute synovial fluid over all the joint surfaces.

Asanas:

1. Virabhadrasana 1
• Stand facing a window ledge, a ballet barre. or the back of a sturdy chair. Hold this support with both hands.
• Inhale. While exhaling, step straight back several feet with the left foot. leav-ing the right foot in place.
• Inhale. While exhaling, activate the front thigh muscles of both legs by pulling up on the kneecaps to extend the legs as straight as possible. This is Posi-tion 1. If the legs cannot be straightened fully, decrease the distance between the feet. (Avoid overarching your lower back.) Hold this pose for 1-2 breaths.
• Inhale. While exhaling. go into a lunge position by bending the right knee so that it is directly over the ankles. Keep the left knee firmly extended. This is Position 2.
• Hold this pose for 1-2 breaths. Push down on the chair back for support and to help lengthen the torso upward.
• lnhale. While exhaling, straighten the right knee back into Position I.
• Hold this position for 1-2 breaths. Explore for signs of collapse. Are muscles becoming fatigued and the legs unsteady? If so, come out of the pose. If not, repeat Position 2.
• Repeat this entire sequence on the other side, going from Position 1 to Position 2, breathing and exploring.
Note: Move into and out of the pose smoothly. joyously, and rhythmically.
Music may be helpful in achieving this lightness and rhythm. If a deep lunge position is not possible, do not despair. The important thing is alignment. Remember that the bent knee should be over the ankle and the back knee firmly extended.

2. Virabhadrasana 2
• Stand in front of a ballet bane, the back of a sturdy couch, or two chairs.
• Inhale. While exhaling, step the feet a wide distance apart. (This distance depends on hip and knee flexibility. If the knees cannot be fully straightened or if the torso seems to be leaning forward at the hips, bring the feet closer together,) Hold the bane, couch, or chair backs for support. Activate the thigh muscles to straighten the knees. Lift the sternum to avoid collapsing the chest. This is Position 1. Stay here one or two full breaths, exploring the stretch and the feelings of strength.
• Inhale. While exhaling, bend the right knee so that it is directly over the ankle. This is Position 2.
• Repeat Positions 1 and 2, staying in each for 1-2 breaths. If weakness or unsteadiness occurs, stop and rest.
• Repeat this sequence on the other side. Note: The same principles of light and happy rhythmic movement apply here as well, See note for Virabhadrasana I.

3. Hip range of motion with strap
• Lie on your back with one knee bent
• Put a long strap around the opposite foot.
‘With one or both hands. move the strap so that the foot makes small, then larger circles in the air, clockwise, then counterclockwise (to a diameter of about 12 inches).
• Repeat on the other side.
• Use 1-2 breath periods of rest between 1-2 breath periods of activity.
Note: Keep the knee as straight as possible. Actively stretch upward and out-ward with the heel of the foot to avoid joint compression. Visualize smooth, healthy joint surfaces as you move. (Caution: If this is painful for the hip or ankle. try bending the knee of the moving leg. If there has been some cartilage damage or bone spur formation, this action may not feel smooth.)
4. Eka pada bhekasana and modified natarajasana are also important to release and prevent hip flexion contractures.

KNEES:

Deforming Tendencies: Prolonged pain and consequent disuse of the knees cause flexion contracture (inability to straighten the knee because of shortened hamstring muscles and tendons). Shortened muscles around the knee, including the front thigh muscles quadriceps, cause decreased space in the joint. Disuse also causes weakness of the thigh and calf muscles whose strength provides stability and support for the knee. Swelling of the soft tissues of she joint causes compression and further loss of space.

Rationale: The standing poses recommended for hips, Virabnadrasana I and 2, are also critical for knee rehabilitation. They provide stretching forces to relieve contractures, make more space in the joint for synovial fluid circulation, and develop strength for the thigh and calf muscles to more adequately support the knee The psychological benefits of increased strength and stamina and the ability to “stand on your own two feet” are immeasurable. Modifications of knee flexion positions such as Virasana (Hero’s Pose), Bhekasana (Frog Pose), and Natarajasana (King Dancer Pose) are helpful as quadriceps (front thigh) stretches. They also initiate a squeezing action on the soft tissues of the knee, which helps reduce swelling.

Note: To increase comfort, it may be helpful to use a rolled face cloth, sock, or “knee saver” behind the bent knees to inaease space in the joint.

Asana

I. Virasana
• Kneel with buttocks on a block or pad to raise the hips until the knees are comfortable.
• As you go into the sitting position, pull the calf muscles out to each side to create more space in the knee joints.
• Sit 1-2 breaths. This is Position 1.
• Then, without moving the feet or lower legs, go into an all-fours position on hands and knees for 1-2 breaths. This is Position 2. (Photo 6)
• Sit 1-2 breaths in Position i.
• Position 2. 1-2 breaths.
• Position 1, 1-2 breaths.
• Position 2. 1-2 breaths. Caution: Be sure that the toes are pointing backwards, the foot in line with the shin. Stop before collapse or loss of muscular support occurs. Pads can be put under the feet and knees for comfort. Position 2 should be eliminated if I there is severe wrist or knee involve-ment, as is puts stress on these joints.

2. Eka pada bekasana
• Lie face down with both legs out, stretched.
• Bend one knee. While grasping the foot with the palm of the hand, bring the foot down and toward the outside of the hip.
• Hold for 1-2 breaths. Release pressure for 1-2 breaths. Hold 1-2 breaths. Release. Hold. Release.
• Repeat on the other side.
Note: If the foot can’t be reached or if there is discomfort in the lower back, loop a belt around the foot and hold that. This will decrease the amount the knee has to bend and lessen the ten-dencv of the lower back to overarch

3. Modified natarajasana
This pose stretches the front thigh and groin of the bent leg. A strap is used to create more space in the knee and hip. The standing leg is strengthened.
• Adjust a soft cotton strap or belt into a loop long enough to place in the bend of one knee while standing on the other end of the loop with the opposite foot. There should be a gentle pull downward on the knee.
• Hold pressure on the foot of the bent leg for 1-2 breaths (as in Bhekasana). Release the hand pressure for 1-2 breaths. Press 1-2 breaths. Release 1-2 breaths.
• Repeat on the other side.
Note: If you can’t reach the foot, or if the lower back complains, use a strap to reach the foot (as described above in Eka Pada Ehekasana). This will decrease the amount the knee has to bend.

Cautions for Lower Back Protection:

Working on knee and hip flexion contractures can be problematic if there is an associated lower back problem. The poses given (Eka Pada Bhekasana and modified Natarajasana) can increase the lumbar curve and aggravate lower back pain.

Yoga through the day

Keep the yoga principles of (I) respect for pain, (2) avoidance of malalignment, (3) balance of rest and activity, and (4) positive thoughts throughout the day. In each activity, check to see whether alignment can be improved to place joints in a more stable and functional position.

Stop and take a rest break during energy-intensive chores. While vacuuming, stop and rest 5-10 minutes with legs stretched up a wall and the back flat on the floor. While bathing or showering, stretch and massage affected joints.

Before taking a nap or going to sleep. lie prone, face turned to the side, with the feet hanging off the edge of the bed. Lying prone provides gentle, passive hip extension. Pillows can be used under shoulders, if necessary, to increase comfort. Start with 10 minutes and build up to 20 minutes several times per day.

Allow adequate time for sleep to replenish enegy and rest fatigued muscles. According to some rheumatologists, 10-12 hours sleep each day, including a 1-2 hour nap. may be necessary for those with rheumatoid diseases. Sleep flat on the back with legs out-stretched. (This provides a passive knee and hip extension stretch.) Only those with lower back problems should use a pillow behind she knees. Using a pillow behind the knees allows continued shortening of the hip and knee flexors and fosters development of flexion contractures.

Use getting-out-of-bed-time creatively. Electric blanket users can turn it up to warm muscles before arising. Stretch and move as many joints as possible in bed before starsing the day.

Walking is great exercise to accompany a yoga practice. The well-known tranquilizing effect of moderate rhythmic exercise described by deVries comes into play to decrease pain. The movement and weight-bearing aspects of walking improve joint health. And getting outside and moving is good for she spirit. Walk as often as possible, starting with short distances and increasing very gradually. Plan a route to include a number of rest stops until endurance is predictable on good days as well as slow days. Remember the destructive force of continuing an activity with fatigued muscles. Walk lightly, joyously, with an awareness of the beauty around you. If hands are involved, move them lightly and smoothly while walking. Visualize spaces between the joints of the fingers. See swelling decreased and smooth surfaces restored. Savor the joy of moving, and watch strength and endurance improve.