Steffany Moonaz, PhD RYT500, Susan J. Bartlett, PhD, and Clifton O. Bingham III, MD
Edited by Dana DiRenzo, MD 3/21/18
- What is yoga?
- What are the benefits of yoga?
- Have scientific studies of yoga been done in arthritis patients?
- What is the best way to try yoga?
- How do I find a qualified yoga instructor and classes?
- What can I expect to do in a beginning yoga class?
- Can I practice yoga even if I’m sedentary and inflexible?
- Are there any poses to avoid?
- What should I bring to a yoga class?
- Can I practice yoga at home?
- Where can I find more information?
Mind-body movement practices with origins in eastern philosophy and culture are receiving a great deal of attention recently. For many adults, yoga, t’ai chi, qi gong, and various dance forms are joining the treadmill and exercise bike as ways to safely and effectively increase physical activity. Having arthritis should not prevent individuals from trying these alternatives to traditional exercise. However, for many people, yoga, may bring to mind pretzel-like poses requiring considerable strength and balance. In reality, beginner yoga classes may provide simple, gentle movements that gradually build strength, balance, and flexibility – all elements that may be especially beneficial for people with arthritis. In this article, Steffany Haaz Moonaz, PhD and registered yoga teacher (RYT-500) will demystify yoga for arthritis patients and their providers. For her doctoral project, she worked with Dr. Susan Bartlett and Dr. Clifton Bingham in the Johns Hopkins Arthritis Center to develop and test a modified yoga program for people living with arthritis. The results of this study have recently been published as well as a review about arthritis for yoga from our group that readers may find beneficial.
What is yoga?
Yoga is a set of theories and practices with origins in ancient India. Literally, the word yoga comes from a Sanskrit work meaning “to yoke” or “to unite.” It focuses on unifying the mind, body, and spirit, and fostering a greater feeling connection between the individual and his/her surroundings. Yoga has spiritual roots, with the main goal of helping individuals to realize true happiness, freedom, or enlightenment. Beyond this, however, yoga has several secondary goals, such as improving physical health and enhancing mental well-being and emotional balance.1
As interest in yoga has increased in western countries over the last few decades, yoga postures are increasingly practiced devoid of their original spiritual context, solely for physical health benefits. This physical practice of yoga, often called Hatha Yoga, sometimes overlaps or includes references to the other aspects of yoga. A popular misconception is that yoga focuses merely on increasing flexibility. The practice of Hatha Yoga also emphasizes postural alignment, strength, endurance and balance, and incorporates breathing practices, as well as techniques such as relaxation or meditation. Table 1 offers an overview of several of the more common styles of Hatha yoga (including those most appropriate for people with arthritis).
What are the benefits of yoga?
Several hundred scientific trials have been published on yoga in major medical journals including a controlled trial from our group.2 Other studies have shown similar results confirming that yoga is a safe and effective way to increase physical activity that also has important psychological benefits due to its meditative nature. As with other forms of exercise, yoga can increase muscle strength, improve flexibility, enhance respiratory endurance, and promote balance.3–5 Yoga is also associated with increased energy and fewer bodily aches and pains.6,7 Finally, yoga is associated with improved anxiety, depression, and psychological stress.8 In summary, yoga is associated with a wide range of physical and psychological benefits that may be especially helpful for persons living with a chronic illness.
Physical activity is an essential part of the effective treatment of osteoarthritis (OA) and rheumatoid arthritis (RA), according to treatment guidelines published by the American College of Rheumatology.910 In persons with osteoarthritis, exercise is safe and does not exacerbate pain or worsen disease.11–15 In fact, exercise may play a key role in promoting joint health, since those who do not exercise often suffer more joint discomfort than those who do.16 The health and psychological benefits of exercise are widely recognized.17 However, regular physical activity is especially important for people with arthritis, who often have decreased muscle strength, physical energy, and endurance, in part due to their arthritis and the tendency to be sedentary.18–20 Being sedentary can began a downward spiral where pain increases, leading to more inactivity which leads to greater pain and disability. The psychological benefits of exercise such as stress reduction, fewer depressive symptoms, improved coping and well-being and enhanced immune functioning also contribute to greater overall health.21–25
Have scientific studies of yoga been done in arthritis patients?
Early studies showed promising results with some improvement in joint health, physical functioning, and mental/emotional well-being.26–28 Yoga has an important positive effect on quality of life. People with arthritis may also enjoy yoga more than traditional forms of exercise, and exercise enjoyment is an important predictor of adherence.29,30 This is particularly important considering that, on average, 50% of sedentary individuals will drop out of exercise within 6 months.31,32 Most importantly, a review of yoga studies has shown that serious injuries are rare if practiced under the guidance of certified instructors with avoidance of extreme positions.33,34
We have recently published an article with the results of a clinical trial of yoga that we conducted in the Johns Hopkins Arthritis Center.2 This was a large, rigorously conducted, randomized, controlled trial of yoga designed and conducted by health professionals including experts in rheumatology, psychology, public health, and yoga therapy. This is important because the medical community in Western countries remain concerned that yoga may not be appropriate for people with vulnerable joints. In our study we provided critical evidence showing that in people with arthritis who are sedentary, yoga appears to be safe, feasible, and enjoyable for people with both rheumatoid arthritis and osteoarthritis, and that it results in important physical and mental health benefits for people who practice it regularly. Importantly, almost all benefits that we saw in patients after they completed an 8-week program were still evident 9 months later including walking speed and physical function. Improvements in positive affect, perceived stress, and pain were also noted. Our same yoga program was used in a follow up study which also found improvements in balance, functional reach, upper body function, and pain after completing the intervention.35 Participants from this clinical trial communicate back to us that they continue to practice yoga, now almost a decade later.
Participants in this study practiced specially designed classes that used an Integral Yoga approach. They came to classes twice a week for 8 weeks to practice under the close supervision of a yoga therapist. They were also asked to practice once a week at home. Each class began with questions/comments (5 min), breathing exercises and chanting (5 min), a warm-up and moving sequence (surya namaskara; 15 min), and isometric poses (asanas) (20 min) to increase strength, flexibility, and balance. Classes ended with deep relaxation (sivasana; 10 min), a closing chant, and meditation (5 min).
The poses that were used in the study included gentle forward bends, backbends, twists, balances, standing, sitting and lying poses. These poses were modified based on concerns for the individual participant. Blocks, straps, blankets, and chairs were used as props to modify poses. The intensity poses and intensity was standardized to allow gradual progression. Eight weeks was selected for the intervention to give sufficient time to introduce independent practice and is a common duration of introductory classes. We also gave written instructions with pictures for home practice and selected readings that described potential benefits of yoga components (breathing, meditation, mindfulness). In this study we asked participants to keep their arthritis medications constant.
In summary, yoga can be a meaningful and enjoyable alternative to traditional forms of exercise such as aerobics or aquatic exercise with important health benefits. Yoga can play an important role in reducing stress and frustration that results from pain and disability, and increasing positive feelings and wellbeing. Drug treatments for OA and RA have improved markedly in the last few years. Despite this, arthritis cannot be cured, and even the best medications and medical care can only help so much. There is a great need for additional activities patients can do to reduce pain, disability, and take control of the overall impact arthritis may have on their lives. Thus, the evidence suggests that, when combined with a program of good medical care, yoga may provide important additional physical and psychological health benefits for arthritis patients. Anecdotally, many participants in our research study are still practice yoga many years later, and consider it to be an important part of their lifestyle and disease management.
If you are interested in learning more about yoga, read on. We hope you will find the following information and resources useful.
What is the best way to try yoga?
Yoga can be a safe and effective form of physical activity, but as with any new activity, it is important to take proper precautions. Talk with your doctor first and ask specifically if there should be any limitations or restrictions your doctor wants you to observe. For arthritis patients it is important to discuss with your rheumatologist or orthopedist. For everyone it is important to ask if other medical conditions or medications would limit participation (such as high blood pressure, lung conditions, or heart disease).
If your doctor has specific recommendations or concerns, ask for them to give you this in writing. You should give this information to your yoga instructor.
The best introduction to yoga is with a qualified yoga therapist or teacher. For group classes, generally a beginner, “gentle” or therapeutic class will be appropriate. There are even some classes available that are specifically geared toward arthritis. It is important that the class is led by a qualified teacher who can guide you in safe and healthy poses for you and to make changes as needed especially for any limitations you may have. Before every class, especially one with a new instructor, you should introduce yourself before the class and discuss your health and specific concerns. If you have significant limitations or would like more individual guidance, consider working one-on-one with a yoga therapist. A yoga therapist has more extensive training and will do a thorough initial evaluation and design an individual program for you. Your yoga therapist can also speak directly with your medical doctor about any specific medical concerns that should be considered and share periodic progress notes with your medical providers.
We have developed a checklist for doctors about yoga that can be useful for them to help you think about participating.
Recommendations for Health-care Providers to Consider for Rheumatic Disease Patients Before Yoga
(Modified from Bartlett SJ, Moonaz SH, Mill C, Bernatsky S, Bingham CO 3rd. Yoga in Rheumatic Diseases. Current Rheumatology Reports. 2013; 15: 387.)36
- Are there general health concerns? What is the overall endurance for physical activity right now?
- Are there any other co-morbid cardiovascular, pulmonary, or other medical conditions that are of concern?
- Are there any concerns for osteoporosis and a risk of fracture with falls?
- Which joints are especially vulnerable and of concern? Are there joints with instability, at particular risk of injury, with limited mobility, active swelling, or underlying damage, or any joints that have been replaced? If so what positions and movements need to be done with caution or not at all?
- Remind patients that they should be cautious especially when starting out and to always listen to their body during the class. Is there is pain then they should stop. Review warning signs of injury and appropriate management of discomfort (e.g. rest, cold, heat)
- Write a letter for a yoga instructor that outlines general and specific medical and musculoskeletal concerns can be helpful. Providing your phone number if the yoga instructor would like to speak with you may also be helpful.
- At follow up visits, talk with your patient about their yoga experience and concerns.
How do I find a qualified yoga instructor and yoga classes?
The Yoga Alliance is the national registration body for yoga instructor and facilities. You can search the Yoga Alliance website for a list of certified yoga instructors in your area. You can contact an instructor directly for information about classes and/or private instruction. Private lessons will be costlier but will ensure that you receive proper attention and guidance, particularly if you are just beginning, or have special needs or concerns related to your arthritis. To find a yoga therapist who offers small therapeutic classes or individual sessions, look to the International Association of Yoga Therapists . Additionally, to find teachers and therapists with specialized training in arthritis, consider contacting Yoga For Arthritis for a recommendation.
Another option is to find a yoga studio in your area (the phone book is a good resource). Some yoga studios may offer specialized classes for older individuals or people with arthritis or other mobility challenges. Beginning or Gentle Yoga classes also are widely available in YMCAs, health clubs, community and seniors centers. Always ask about the credentials of instructors at these locations, whether the class is appropriate, and their experience working with joint conditions. When attending your first class, be sure to arrive a few minutes early and take time to introduce yourself to the instructor and explain your condition and any movement limitations that may require modification of the practice. If your doctor has placed any specific restrictions or limitations on physical activity, tell the instructor about these before the class begins.
Questions you should ask when selecting a class
- What is the style of yoga offered in the class?
The combination of asanas (poses) and pranyama (breathing practices) is generically called “Hatha Yoga.” Because yoga has been passed down through many teachers to many students, many schools or styles have emerged with different methods of practice. Some of these styles are fairly gentle and safe for students with arthritis, while others should generally be avoided. See Table 1 for more information about various styles of Hatha Yoga.
- Is the instructor qualified?
Yoga Alliance is the accrediting body for yoga instructors worldwide, but it is not a certification. Being registered with Yoga Alliance requires a minimum level of training in techniques, anatomy/physiology, teaching methodology, philosophy/ethics, and practical experience (200 or 500 hours). You can find a certified teacher by visiting the Yoga Alliance and searching in your area. Yoga Therapists are credentialed by the International Association of Yoga Therapists (IAYT ). Certification as a yoga therapist requires a minimum of 1000 hours of training and experience.
- Do you offer beginner or gentle yoga classes?
Some classes combine students with varied experience, and provide modifications for each level. Especially when first beginning to practice yoga, it is helpful to be in a class geared toward beginning students.
- How long has the instructor been teaching?
While this is not always the case, teachers with more experience are often more adept at modifying poses for each individual and are likely to have continued training for students with special needs.
- Does the instructor have a medical background or experience teaching students with arthritis?
This is an ideal scenario. Some yoga professionals also have a nursing or physical therapy background. Try to find a teacher who is familiar with your condition and can guide you in making the proper adjustments for your body. Short of this, classes offered through hospitals or medical settings are often supervised or overseen by medical staff.
What can I expect to do in a beginning yoga class?
There are three main components to most western yoga classes: poses (asanas), breathing techniques (pranyama), and relaxation. Some classes will also include additional elements such as meditation or chanting.
The types of poses that are usually included in beginning or gentle yoga classes are simple standing and seated poses. This introduction helps students to increase their awareness of the body and its relationship to space in a safe and gradual manner. Many people have fears that they may be asked to try standing on their heads or twisting into a pretzel-like position. These practices are part of yoga, but are only recommended for very advanced practitioners and will not be included in beginner classes. Additionally, an important aspect of yoga is that it is non-competitive. Students work at their own ability level, being sure to respect the body and its limitations. You should never go beyond what is comfortable and reasonable and a good yoga instructor will help you determine what is appropriate for you in each pose. A common saying in yoga is that “with increased pain, there is no gain.” If something you are doing in yoga feels uncomfortable, there is always another option that is more appropriate. All yoga poses can be modified for your safety and comfort, to accommodate any special needs you may have.
Components of a Yoga Class
Asanas are a series of poses designed to bring about greater health and well being. The poses are combined in a predictable sequence that addresses strength, flexibility, and balance of the whole body. Poses are held for variable lengths, depending on the experience on the participant, characteristics of the pose and the style of yoga being practiced. Most poses can be easily modified to account for a student’s level of experience and physical condition. Some teachers utilize props, such as blocks, straps, or blankets to help students adjust challenging poses. While originally, the asanas were created to prepare the body for sitting still in meditation, they have evolved as a physical practice and are considered by many to be a moving meditation themselves.
Asanas are the yoga practices that require the most guidance and special attention for individuals with arthritis. If something seems too challenging or causes discomfort, you and the instructor can arrive at an appropriate modification.
Breath is an important aspect of many yoga classes. Movement should be connected with the breath throughout yoga practice. In some poses, this means moving one direction on an inhale and the opposite direction on an exhale. Some teachers also instruct students to hold a pose for a particular number of breaths. Independent of the asanas there is another set of breathing practices to invigorate or calm the body and mind, which should only be practiced with a qualified instructor. A good resource for learning more about breathing practices is “Science of Breath” A Practical Guide” by Alan Hymes, MD.
The breathing techniques taught in beginner yoga classes are generally safe for anyone, including those with asthma or COPD, as long as they feel comfortable. If you have a lung condition, you may want to speak with your doctor about the safety of advanced breathing practices, and be sure to tell your yoga instructor about any concerns you might have.
At the closing of class, most teachers incorporate some type of relaxation for somewhere between 1 and 15 minutes. This is usually done in Savasana or Corpse Pose (lying on the back with eyes closed). The purpose of this relaxation is to absorb the stress and tension-reducing benefits of the asanas, so that a sense of calm and ease will carry over from the practice after the class had ended. It also relates to the original purpose of Hatha practice, relaxing the body so that it can remain completely quiet for a more meaningful meditation. In American yoga classes, the deep relaxation is often considered a reward at the end of class, though for the restless, it can often be the most challenging.
Deep relaxation is beneficial for all persons and generally requires no modification. If you are pregnant, or if lying on your back for prolonged periods is painful, your yoga instructor can suggest alternate poses for relaxation.
Some classes include brief periods of seated meditation before or after the asana practice. During these times, some instructors give guidance on how to approach meditation. It is a time to quiet and focus the mind, relieving it of the unnecessary clutter of trivial thoughts that stream in and out during the day. This discipline of the mind is said to allow greater spiritual awakening, but can also simply provide relief from the day’s stresses. Meditation can have any focus, such as the breath, an image, an idea or affirmation, a sound, or a personal prayer.
Modifications to the traditional cross-legged seating pose are an option for those with arthritis. Other seated positions can be used, and props such as a chair or block may be helpful.
Sound vibrations can be very powerful, capable of breaking glass, or even causing an avalanche. The healing properties involved with making various sounds have also recently been studied(30). Beyond healing, chants have historically served the purpose of unifying communities, or fostering an individual sense of spirituality. Not all yoga classes incorporate chanting, but some more traditional styles consider chanting to be an essential aspect of Hatha practice. Most chants in yoga class incorporate words for peace (Shanti) or words that have no translation, but are said to reflect natural universal vibrations (Om). If you don’t feel like joining in with the chant, it is perfectly acceptable just to listen. It is important to note that, unlike singing, there is no judgment of quality in chant. It is a sound, not a song that is being created, though it is often beautiful and moving. (For more information on chanting, see Robert Gass, “Chanting: Discovering Spirit in Sound.”).37
No modifications are required for people with arthritis.
Can I practice yoga even if I am relatively sedentary and inflexible?
Absolutely. In fact, individuals with limited range of motion or poor flexibility, due to arthritis or otherwise, may benefit the most from yoga practice, as it can increase flexibility, strength, and balance. Even if you are unable to kneel or have difficulty getting up and down, modifications are available. There are some “chair yoga” classes that are taught entirely in a seated position! It may feel a bit disheartening at first when challenges arise, but overcoming such judgments and accepting where you are is an important part of yoga.
A core concept of yoga is to always honor what will allow you to benefit most from the practice. Your yoga teacher will emphasize the importance of always listening to your body, recognizing your current limitations, and approaching your yoga practice from there. Yoga is not competitive, and the focus should not be on how the pose looks (aside from ensuring safe anatomical alignment). It is about experiencing a connection of the body and mind through the breath. While there are some yoga poses that do require a great deal of flexibility, strength, and balance, those poses should only be attempted by very experienced yogis and are NOT for beginners or persons with activity limitations. Again, a good yoga teacher will provide alternatives and modifications to all activities so that students can work within their levels of comfort.
Are there any poses people with arthritis should avoid?
The general rule for arthritis patient (and people in general) is that if it hurts, stop. The old adage of “no pain, no gain” does not apply to yoga, particularly if you have activity limitations. When doing backbends, arthritis patients should keep them relatively small and be aware not to hyper-extend the neck, keeping the head in line with the rest of the spine. For those with arthritis of the hip, be cautious when doing “hip openers” or poses with extreme external rotation of the hips. Generally, you will notice pain if you are going too far with the pose, but sometimes the effects are not felt until the next day. It is important to be gentle with your practice, especially at first. If you do not experience any pain after a few days, you can decide to gradually increase the intensity of the poses. There have also been some indications that strength training targeted at the quadriceps muscles might not be recommended for those with misaligned or lax knees. However, interventions that balance opposite muscle groups and exercises that improve muscle awareness (such as yoga) might help stabilize the knee. As with any condition, it is important to be cautious and pay attention to your body. Also, be sure to consult your doctor and instructor if you experience any pain or difficulty resulting from yoga practice.
What should I bring to my first yoga session?
Wear comfortable clothing that allows for full movement of the body. If the clothing is too loose, the instructor will be less able to guide you in proper alignment, but it should also not be restrictive. Clothing specially designed for yoga is available, but unnecessary. Yoga is traditionally practiced barefoot, though it may be possible to wear socks at the start of class, until the body warms up. “Sticky” mats are used in modern yoga practice to provide some cushioning and prevent slipping. Some studios or gyms will supply mats for general use. You may want to inquire about this in advance. Also, be sure to bring water or an empty container for filling, in case they are not supplied. It is important to stay hydrated during any physical activity.
Can I practice yoga at home?
Even when thinking about doing yoga at home, it is very important for people to speak first with their doctors. For patients with arthritis it is important to speak with their rheumatologist or orthopedist about any particular concerns they may have. It is also important to speak with your medical doctor to see if there are any other concerns (such as blood pressure, lung problems, heart conditions or pregnancy).
We generally recommend that people have their first yoga experience with an instructor in person. As you become more confident and experienced, you may want to supplement classes with home practice. There are also many yoga books and videos available, but they do not necessarily address the needs of arthritis patients. We worked with the Arthritis Foundation to develop a video titled “Arthritis-Friendly Yoga”, which can be found through stores and online retailers. You can also visit their website. While the video is safe for most patients with arthritis, it cannot provide the same level of supervision and individual attention offered by working with a qualified instructor.
Where can I find more information?
Listed below are 3 articles from our group concerning Yoga and Arthritis and Rheumatic Diseases:
- Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial
- Yoga in Rheumatic Diseases
- Yoga for Arthritis: A Scoping Review
Listed below are several resources that offer safe and practical information about yoga.
- Arthritis Foundation DVD for arthritis
- This DVD was developed based on the program studied in our research program at Johns Hopkins
- International Association of Yoga Therapists (IAYT), bibliographies for yoga and specific health conditions
- Yoga for Arthritis provides training for yoga teachers and therapists to specialize in working with people with arthritis and related conditions as well as classes and workshops for people living with arthritis.
- Yoga For Arthritis: A Whole-Person Approach to Movement and Lifestyle by Dr. Steffany Moonaz.
- Maryland University of Integrative Health, offers a Master’s of Science degree program in Yoga Therapy that includes specific teaching related to people with arthritis.
- Yoga Journal, information for those new to yoga
- Yoga Journal is a monthly publication for yoga practitioners and instructors. It contains information about specific poses, places to practice, the history and philosophy of yoga, and links to many additional resources.
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- Middleton KR, Ward MM, Haaz Moonaz S, et al. Feasibility and assessment of outcome measures for yoga as self-care for minorities with arthritis: a pilot study. Pilot feasibility Stud. 2018;4:53. doi:10.1186/s40814-018-0248-x.
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- Gass R, Brehony KA. Chanting : Discovering Spirit in Sound. Broadway Books; 2000.
|*yellow indicates for arthritis patients|
*for arthritis patients in yellow
|Ananda||Swami Kriyananda||Very gentle. Preparation for meditation. Directing of energy. Affirmations combined with poses.||Longer meditation may be difficult for arthritis patients.|
|Anusara||John Friend (student of B.K.S. Iyengar)||Anatomically-based. Emphasis on opening the heart. Extensive teacher training.||Recommended for most arthritis patients.*|
|Ashtanga||K. Pattabhi Jois (student of Sri T. Krishmanacharya)||Specific sequence. Continuous movement. Very strenuous.||Not recommended for arthritis patients due to physical rigor.|
|Bikram/Hot||Bikram Choudhury||Taught in 100-110 degree room to expel toxins and increase mobility.||Not recommended for arthritis patients due to extreme heat.|
|Integral||Swami Satchidananda (student of Swami Sivananda)||Gentle practice including poses, breathing, chants, and meditation.||Recommended for most arthritis patients.*|
|Iyengar||B.K.S. Iyengar (student of Sri T. Krishmanacharya)||Strong anatomical basis. Uses props to individualize poses.||Recommended for most arthritis patients.*|
|Kripalu||Amrit Desai||Taught in three stages with evolving emphasis. Stage One focus on learning poses and understanding body.||First stage recommended for most arthritis patients.*|
|Kundalini||Yogi Bhajan||Intended to awaken latent spiritual energy through poses, breathing, meditation.||Intensity of breathing techniques may be challenging for some patients.|
|Sivananda||Swami Vishnudevananda (student of Swami Sivananda)||Gentle practice including poses, breathing, chants, and meditation.||Recommended for arthritis patients.|
|Viniyoga||Sri. T. Krishnamacharya||Individualized practice. Breath and movement very coordinated. Extensive teacher training.||Recommended in private sessions for most arthritis patients.*|
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