A side effect of the numerous medical advances made in recent decades is the dramatic rise in the number of people living with chronic illness. Approximately 80 percent of older adults have at least one chronic health condition, and 50 percent have at least two.41 And in addition to diagnosed disorders, a significant proportion may have a “silent” disease, such as heart disease or osteoporosis, that has no obvious symptoms. In fact, an estimated 35 percent of postmenopausal white women have osteoporosis but may not be aware that they have this bone-weakening disorder and are at increased risk of fracture42 (see “Osteoporosis,” page 29).
Yoga practice can—and should—be adapted to address any health challenges that may arise. Sometimes these adaptations may be temporary. For example, someone with a broken arm may need to eliminate postures that place weight on the arm; modify those in which the arm is extended or elevated; and switch to more lying-down postures, breathing, and meditation. This may be necessary just until the arm is healed, after which it may be possible to resume the original practice.
However, with some health challenges, including many of those related to aging—such as the onset of arthritis, osteoporosis, or hypertension—more lasting adaptations may be advisable. For example, someone with glaucoma may need to stop practicing handstands, and someone with osteoporosis may switch from doing forward bends with a round back and straight legs to doing them with a straight back (neutral spine) and bent knees (see “Healthy Body Mechanics,” page 52). We have partnered with medical experts to get their recommendations about potentially risky movements. Their wisdom is integrated into our Relax into Yoga postures. Below are specific recommendations for the most common health conditions.
Age is one of the most significant risk factors for all cardiovascular ailments. This includes coronary artery disease, which is the most common type of heart disease and the leading cause of death for both men and women in the United States, as well as numerous other cardiovascular conditions such as hypertension, congestive heart failure, arrhythmias, valvular disorders, and stroke. With advancing age, the elastic elements of the blood vessels are progressively replaced by more leathery, fibrous tissue.
In addition, progressive deposition of cholesterol plaque in the inner walls of the arteries—known as atherosclerosis, or hardening of the arteries—can also compromise blood flow to vital organs such as the brain, kidneys, and the heart itself. Loss of elasticity in the heart muscle can lead to symptoms of heart failure. Wear and tear on the blood vessels over time can lead to aneurysms and clots, while wear and tear on the heart valves can lead to narrowing and leaking.
For the reasons mentioned above, we recommend that people with cardiovascular disorders communicate their interest in practicing yoga with their physician (see “Partnering with Your Health Care Provider,” page 24).
In addition, here are some cautions:
We offer these recommendations as ways to enhance for your practice:
The word “osteoporosis” means “porous bones” and is a disorder of impaired bone strength that results in skeletal fragility and increased fracture risk. Caused by an imbalance between the natural process of bone breakdown and bone formation, this bone loss generally occurs in women after menopause and in both men and women with aging. The longer you live, the greater your likelihood of developing osteoporosis—with the disorder affecting about 15 percent of women in their fifties and about half of all women in their eighties.44 You are at greater risk for osteoporosis if you:
With the aging of the population, the prevalence of osteoporosis is expected to increase so that by 2020 one in two Americans over age fifty is expected to have or be at risk of developing osteoporosis of the hip; even more will be at risk of developing osteoporosis at any site in the skeleton.49 Four out of every ten white women age fifty or older in the United States will experience a hip, spine, or wrist fracture sometime during the remainder of their lives.50 And these fractures can have devastating consequences. For example, people who break a hip have a higher risk of dying during the first three months after the fracture than individuals of similar age who do not break a bone.51
By 2020, one in two Americans over age fifty is expected to have or be at risk of developing osteoporosis of the hip; even more will be at risk of developing osteoporosis at any site in the skeleton.
Since osteoporosis has no obvious symptoms, it’s possible to have compromised bones and not know it. In fact, many people learn that they have osteoporosis only after they break a bone. Osteopenia is the name sometimes given to low bone density that is not low enough to be called osteoporosis. People with low bone density are at higher risk for osteoporosis and are more likely to break a bone compared to people with normal bone density.52 These conditions are diagnosed by a test called a DEXA scan that measures bone mineral density at the hip and spine. The U.S. Preventive Services Task Force recommends this testing for women ages sixty-five and older as well as younger women at increased fracture risk.53 But not everyone who is eligible gets this test. And, surprisingly, two-thirds of vertebral fractures do not come to clinical attention.54 This means it’s common for people to suffer this kind of fracture either without pain or with pain that is misidentified—as a pulled muscle, for example—and not recognized as originating from a vertebral fracture.
Physical activity can enhance bone health, particularly weight-bearing exercise such as walking, and muscle-strengthening movement such as weight training.55 Many yoga postures and practices can be extremely beneficial in maintaining or improving strength and balance as well as restoring function and relieving pain for people with compromised bone. Weight-bearing postures such as Chair pose and Plank pose may help strengthen bones, as can poses that move the body against resistance, such as a Yoga Push-Up. However, some common yoga poses should be appropriately modified because they have potential for significant harm. In particular, forward bending (spinal flexion) and twisting (rotation) can place large and compromising loads on the front of vertebral bodies56 and are often implicated in vertebral fracture.57
If you have osteoporosis, the National Osteoporosis Foundation advises against the following movements:
Keeping your spine in proper alignment—with good posture and healthy body mechanics—puts less stress on the spine and is particularly important if you are at risk of fracture (see “Healthy Body Mechanics,” page 52). Be aware, too, that sitting puts more strain on your spine than does standing or lying down. For this reason, you won’t find seated forward bends, seated deep twists, or any floor-sitting poses in our Relax into Yoga postures. We have substituted safer variations that help build and maintain spinal strength and flexibility with reduced risk.
Here are our additional recommendations for safe alignment during your yoga practice:
Be sure to follow these movement tips for a safer practice:
If any or all of your joints are achy or painful, chances are you have arthritis. In fact, the word “arthritis” means “joint inflammation” and refers to more than one hundred different diseases that affect the joints and tissues around the joints. The onset of symptoms can be gradual or sudden and typically involves pain and stiffness around one or more joints. Symptoms may come and go but generally persist over time. While arthritis can affect people of any age, including babies, the prevalence increases as people get older. Nearly half of people sixty-five and older report doctor-diagnosed arthritis.59 A major cause of disability in America, arthritis frequently limits people’s ability to perform everyday activities such as dressing, climbing stairs, and walking.
A generation ago, people with arthritis were told to rest and “save their joints.” Unfortunately, that practice did more harm than good since, as we now know, inactivity causes joints to stiffen and unused muscles to atrophy. In recent decades, study after study has confirmed the benefits of physical activity for people with arthritis, and it’s now clear that appropriate exercise can greatly improve the quality of life for people with arthritis—relieving pain and stiffness, improving function, and boosting mood.60 It can also help manage other chronic conditions, such as obesity, that may affect arthritis and its symptoms.
Three of the most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and fibromyalgia.
Typically when people say they have arthritis they mean osteoarthritis, which is the most common form of arthritis and is generally related to aging, injury to a joint, and/or being overweight.61 Sometimes called “wear and tear” arthritis, or OA, osteoarthritis is characterized by breakdown of the cartilage that covers the ends of bones in a joint. As the cartilage wears away, bones rub together, which can permanently damage the joint. It’s possible to have osteoarthritis in just one joint—for example a knee that was injured playing football. It most commonly affects the larger joints of the body—the hips, knees, spine, and shoulders—on one or both sides.
Sometimes called RA, rheumatoid arthritis is a systemic inflammatory disease that affects multiple joints on both sides of the body. While the cause is unknown, RA is an autoimmune disorder, which means the body’s immune system attacks its own tissues.62 It commonly affects the smaller joints—such as the fingers, wrists, feet, and neck—on both sides of the body. RA can begin at any age, although it often starts in middle age and is most common in older people.63 Two to three times more common in women than in men, RA is associated with fatigue, prolonged stiffness, and joint deformity.64 While there is no cure, medications may help slow disease progression, and appropriate physical activity may help decrease pain and reduce the risk of joint deformity.
Sometimes considered an arthritis-related condition, fibromyalgia is not actually a form of arthritis because it does not cause inflammation or damage to the joints.65 But like arthritis, fibromyalgia can cause pain and fatigue, and it can affect the ability to perform daily activities. Other common symptoms include sleep disturbance, headaches, irritable bowel syndrome, cognitive problems with thinking and memory (sometimes called “fibro fog”), and numbness or tingling of the hands and feet.66 Most people with fibromyalgia are women diagnosed during middle age, however men and children can also be affected.67 While the cause is unknown, disease onset may be associated with a stressful or traumatic event, repetitive injuries, or illness and may be related to problems with how the central nervous system processes pain.68
Physical activity—including muscle strengthening and aerobic exercise—has been shown to be beneficial for people with fibromyalgia, as has cognitive behavioral therapy and relaxation. In fact, people with fibromyalgia who participated in the Yoga of Awareness program developed by Kimberly and her husband, Dr. Jim Carson, experienced reductions in pain levels that were greater than the reductions typically seen with medications.68
The American College of Rheumatology states that exercise should be an essential part of treatment for arthritis, noting that “people with arthritis who exercise regularly have less pain, more energy, improved sleep, and better day-to-day function.”70 Yoga offers similar benefits to a Western exercise program—including enhancing balance, boosting endurance, and strengthening and stretching muscles surrounding the joints, all of which can decrease pressure on the joints and relieve pain. In addition, yoga teaches many physical, mental, and emotional skills that can be profoundly helpful for people with arthritis, including relaxation breathing, mindfulness, learning to move with compassion, recognizing and changing harmful habits (such as breath holding and jaw clenching), and pacing activity with rest.
The practice of mindfulness meditation can be an important tool for self-care, since it can improve depression, fatigue, stress, pain, attention regulation, emotion regulation, memory, and more.
If you have arthritis, it’s helpful to work with a physical therapist who can design an individualized exercise program that takes into account the kind of arthritis, the affected joints, and your overall conditioning. Your physical therapist can be a helpful partner in answering any questions you have about starting or continuing a yoga practice.
We offer these cautions for modifying your yoga practice:
Here are some strategies to enhance your practice:
Certain joints that have been damaged by arthritis or other causes may be surgically removed and replaced with an artificial joint. This often occurs when the pain becomes so severe that it interferes with the ability to function. The surgery is performed most often on hips and knees but also can be done with shoulders, fingers, ankles, and elbows.71 The modern hip replacement was pioneered in the 1960s and is now, along with knee replacement, among the most commonly performed operations in the United States.72 An estimated 4.7 million Americans have undergone total knee replacement, and 2.5 million have had a total hip replacement.73 The prevalence of these surgeries is higher in women than in men and increases with age.
Typically, people with joint replacements are given specific movement precautions by their surgeon and work with a physical therapist to regain full mobility of the new prosthetic joint during the postoperative period and recovery process. Specific precautions are related to the particular surgical approach—that is, whether the surgeon approached the joint from the front of the body or the back of the body. For example, people who have a hip replaced with an anterior approach are told to avoid hip extension, which means not extending the affected leg behind you or stepping backward with the affected leg. People who have had a hip replaced with a posterior approach are told not to bend their hip past 90 degrees, which is why patients are given a raised toilet seat to use during the recovery period. For both hip replacement approaches, people are advised not to cross their legs or ankles.74 In general, these precautions are followed for about six months, but in some cases they may be in effect for longer.
People who have knee replacements are generally encouraged to walk as soon as possible, often using a support—such as a cane, crutches, or a walker—during the first few weeks after surgery. Gradual resumption of daily life activities is typically recommended. In time, many people with knee replacement are able to kneel—for activities like gardening as well as to do kneeling postures in yoga—although it can be helpful to kneel on a cushion or folded blanket for comfort.
If you have had a joint replacement, it is essential that you get clearance from your surgeon, along with any special instructions, before beginning or resuming a yoga practice. In most cases, postsurgery precautions will be lifted in time, and you will likely be able to do all—or most—of the Relax into Yoga postures.
Chronic obstructive pulmonary disease (COPD) is an umbrella term for a group of progressive lung diseases that causes blockage to airflow and makes it difficult to breathe. The two main types are emphysema and chronic bronchitis, and some experts also include certain forms of asthma.75 The main cause of COPD is long-term exposure to substances that irritate the lungs, which—in the United States—is typically cigarette smoke. Outdoor and indoor air pollution, occupational dusts and chemicals, and respiratory infections can also play a role. In 2011, COPD was the third-leading cause of death in the United States76 and is most common among people over age sixty-five.77
More than half of adults with impaired lung function are unaware that they have a problem, since—at first—symptoms may be nonexistent or mild.78 Often people mistake early warning signs, such as breathlessness and coughing, with normal aging. For this reason, lung disease is often not diagnosed until the condition is very advanced.79 While there is no cure for COPD, early detection can allow intervention before major loss of lung function occurs. Treatments include medications, supplemental oxygen, and—in severe cases—lung transplantation. Removing exposure to the source of irritation—for example quitting smoking—is essential.
In people with COPD, the airways become swollen and narrowed, losing their elasticity and making it hard to get air out. This “trapped air” leaves less room for new, fresh air and can create a sense of physical and emotional struggle as breathing becomes more and more difficult. Feeling breathless can lead to anxiety, which can exacerbate breathlessness and sometimes lead to panic. Pulmonary rehabilitation can be a powerful way to help people with lung disease become stronger and better able to function by teaching proper breathing mechanics, exercises, and other strategies to help improve quality of life. These classes are often affiliated with a hospital or clinic and are generally led by a pulmonary rehab team that may include doctors, nurses, physical therapists, respiratory specialists, exercise physiologists, and dieticians who can create a program that meets your specific needs.
Teaching healthy breathing mechanics is an essential part of pulmonary rehabilitation and is also a central aspect of yoga practice. Learning diaphragmatic breathing—sometimes called “abdominal breathing” or yoga “belly breathing”—can be a powerful way to help people with lung disease strengthen and learn to properly use the diaphragm, which is the main muscle of breathing. When people have COPD, it is difficult for them to breathe, so they often compensate by using muscles in the neck, shoulders, and back (sometimes called “accessory muscles of breathing”) to try and move air in and out. Over time, practicing diaphragmatic can make breathing more efficient and less effortful.
While yoga breathing generally advises breathing in and out through the nose, breathing out through pursed lips can be extremely helpful for people with COPD, since this technique slows the breathing, improves the exchange of oxygen and carbon dioxide, and keeps the airways open longer to release more trapped, used air.80
A useful way to remember this approach is with the phrase Smell the roses, blow out the candles. Follow these steps to practice pursed-lips breathing:
Since many people with lung disease take medications that may weaken their bones, it may be helpful to practice the guidelines for osteoporosis (see “Osteoporosis,” page 29). In addition:
Be sure to:
Unlike acute pain, which is a normal sensation that alerts you to possible injury and goes away when the underlying cause has been treated or has healed, chronic pain persists; it’s often defined as daily pain for at least three months.81 Older adults are at particular risk for chronic pain because many of the medical conditions common to aging—such as arthritis, cancer, osteoporotic fractures, and diabetic neuropathy—often involve persistent pain. In addition, injuries or accidents from earlier in life can continue to cause pain throughout the life span. In fact, chronic pain is considered a “meta-condition,” which means persistent pain is a common symptom in many different types of illness; it is rapidly becoming a major public health concern. In 2011, the Institute of Medicine’s special report, Relieving Pain in America , noted that chronic pain affects about 100 million American adults, more than the total affected by heart disease, diabetes, and cancer combined.82
Chronic pain involves a complex series of processes in the brain and central nervous system, and physicians often have a difficult time offering ways to fully manage pain. Medications, such as opioids, may help chronic pain but are habit-forming with potentially serious side effects—such as drowsiness and impaired judgment, constipation, nausea, and itching. Opioids also require increased doses over time to maintain their effects, which can lead to accidental overdose deaths.83 Surgical procedures are not always effective and sometimes can make things worse.
It is important to move your body to break the vicious cycle of inactivity that occurs with persistent pain.
Recent neuroscientific research offers insight into why traditional pain treatments like drugs and procedures often have limited success. Despite the outdated belief that pain experienced is directly proportional to the injury suffered, new studies show that pain is strongly influenced by a broad array of other dimensions of experience, including thoughts, emotions, and movement patterns.84 For example, emerging evidence indicates that negative emotions such as anger and fear can increase the experience of painful sensations and that positive emotions can dampen the pain signals in the central nervous system.85 This is why programs that aim to change behaviors, thoughts, and feelings—and increase coping strategies—seem to hold the most promise for managing chronic pain. Yoga and meditation are examples of such programs.
The yoga practice’s focus on moving mindfully and with compassion can be a helpful way to break the vicious cycle of inactivity that is common to people with chronic pain. Reintroducing gentle and appropriate movement back into your daily routine is an important step in changing this cycle. Using postures that improve strength and range of motion can help enhance vitality and boost your ability to function.
Yoga’s focus on the breath is also an important tool for people living with persistent pain, and learning to use the breath skillfully can be a powerful tool in finding relief. It is common to discover that you hold your breath when you are under stress. Breath holding is a typical stress reaction that interferes with your body’s ability to quiet itself and relax. The yoga practice develops an awareness of the breath and encourages fluid patterns of breathing. Learning breath patterns, such as the three-part diaphragmatic breath, also cultivates deeper states of relaxation, which can help dampen pain signals. Breathing in rhythm with the yoga movements can help settle your nervous system. Setting the intention to invite your breath to soothe a painful area can also have healing effects. Although clearly lung tissue only exists within the rib cage, studies demonstrate that the simple act of bringing attention to different parts of the body—for example, “breathing into your lower back”—increases blood flow to these areas.86
Another therapeutic aspect of the yoga practice that is important for living with persistent pain involves generating a shift in your relationship to the pain sensation itself. For many people this is an unfamiliar practice. When the body is experiencing persistent pain, a typical response is to tense the muscles and to consciously or unconsciously consider this painful sensation the “enemy.” As part of yoga’s “self-study” principle, people with chronic pain may learn to reconceptualize the experience as “sensation” rather than “pain” and practice accepting rather than reacting to the painful sensation—recognizing that acceptance is not giving up but simply being willing to have the experience you are already having. Over time, practicing acceptance can help the body and mind learn to quiet the reactivity to the experience and begin to shift the neurological wiring that occurs with chronic pain.87
The meditative practices of yoga can also help to ease persistent pain. Bringing awareness to the inner dialogue and commentary that constantly go on in the thinking mind can reveal “habits of mind” that may be exacerbating the pain experience. Catastrophizing , or the tendency to anticipate the worst possible scenario, is one such “habit of mind.” Catastrophizing is not uncommon in people with chronic pain and is known to worsen the pain experience.88 For example, thoughts like This pain is going to destroy all my plans for the future , or This cursed pain has ruined my life , or It is not worth the effort to try and get better, nothing ever changes can all contribute to heightening the intensity of the sensation. Deepening our awareness of our inner experience through yoga practice can help develop a perspective that doesn’t give so much credence to such habits of mind. A deep awareness can also assist with being able to choose inner dialogue that is more supportive of healing. Recognizing that no one can predict the future and that what is happening in this moment is simply what is happening in this moment has the real potential of reducing suffering.
Likewise, being able to recognize our present-moment emotional response to pain can be a powerful tool. Although anger, sorrow, frustration, and fear are normal responses to pain, if these become emotional habits they can increase the level of pain that we feel. Being aware of the coming and going of the emotions without getting stuck in one particular emotion is a skill that can be developed with yoga practice.
Before beginning a yoga practice, older adults with chronic pain may want to check with their physician or physical therapist to determine whether a particular movement is appropriate (see “Partnering with Your Health Care Provider,” page 24). Remember that it is important to move your body to break the vicious cycle of inactivity that occurs with persistent pain. Also, when areas of your body have been in persistent pain, it will be unlikely that you can avoid pain . So the common yoga directive “If it hurts, don’t do it” may not apply. Instead, be aware that if a posture increases your pain significantly during or immediately after the movement, you will need to modify or omit this posture.
If you have chronic pain, be sure to:
Cancer is considered a disease of aging because the older we get, the greater our chances of developing cancer become. The incidence of cancer in people over sixty-five is ten times greater than in those younger than sixty-five, and the cancer death rate is sixteen times greater in patients over sixty-five compared to younger patients.89 Treatments have also advanced to a degree that cancer survivorship is more and more common, with an anticipated 19 million cancer survivors in the United States by 2024.90 Some survivors experience very little ongoing effects of treatment, while others may struggle with troublesome side effects—such as fatigue, neuropathy, and lymphedema—for many years.
Fortunately, a yoga practice can be adapted to help people navigate any phase of the cancer journey, from diagnosis through treatment, survivorship, and/or progressive disease. Each phase of the cancer experience brings with it various struggles and dis-ease in the body. By learning the benefits of various yoga practices, yoga can be an ideal supportive-care choice.
The initial diagnosis can be overwhelming and frightening. Facing the unknown of the stage and aggressiveness of the disease, as well as the possible outcomes, can lead to high states of anxiety and many sleepless nights. Yoga’s Three-Part Breath pattern (see page 72) can be helpful in settling the body when awaiting results of surgical reports and lab work. Likewise, the postures help the muscles release the tension that can build up during this difficult time.
Treatments for cancer—which include surgery, chemotherapy, and/or radiation—are often quite challenging for the body, mind, and emotional heart. Nausea, fatigue, pain, and weakness are common side effects that can be difficult to mitigate. Yoga provides simple ways to help the body through this rough patch. For example, studies have demonstrated that diaphragmatic breathing can provide pain-relieving effects91, 92, 93, 94 and improve sleep disturbance and anxiety in cancer patients receiving chemo.95 Yoga practices have also been shown to significantly reduce chemotherapy-induced nausea and vomiting96 as well as treatment and/or disease-related pain.97
Further, even in the difficult context of undergoing cancer treatments, it remains important to continue moving the body. Movement helps maintain a basic degree of physical fitness, which can help offset the debilitating effects of deconditioning that occur when the body is sedentary for long periods of time. In addition, physical activity can invigorate the body as well as facilitate subsequent relaxation. The gentle, mindful movements of the yoga practice are well suited to introduce movement in this phase of the cancer experience.
Mindfulness meditation practices can also support healing for older adults dealing with cancer. Studies of cancer patients demonstrate that the practice of mindfulness can improve quality of life, anxiety, depression, fatigue, sleep disturbance, stress, pain, cancer-related sexual dysfunction, physiological arousal (for example, blood pressure), immune function (immune cell count, cytokine production), and cortisol levels.98, 99 In addition, studies of changes in brain structure and function suggest that mindfulness meditation helps with attention regulation, emotion regulation (especially capacity to calm fear), body awareness, learning, cognition, memory, perspective taking, empathy, and compassion.100, 101, 102, 103, 104 The practice of mindfulness meditation can be an important tool for self-care.
As with any serious medical condition, people with cancer are advised to seek advice from their health care provider to ensure that their yoga practice is appropriate. (See “Partnering with Your Health Care Provider,” page 24.) It’s also advisable to: