People with Knee Osteoarthritis
Can Practice Yoga Safely
by Janet Cuthrell

Yoga East 200hr Teacher Training, June 2022

 Global aging, sometimes referred to as the “Silver Tsunami” or the “Age Wave”, has become one of the greatest sociological shifts in history ^[1]. Americans ages sixty-five and older, make up the fastest growing sector of the U.S. population; this diverse group are living longer, practicing yoga and even running marathons ^[1]. Furthermore, according to the CDC, 41% of these older individuals report that they are in good or excellent health ^[2]. However, although a large percentage report back positively, seniors are often faced with a variety of adverse health conditions which can have detrimental effects on overall quality of life ^[2].  Among these conditions is osteoarthritis ^[2]. 

The most common form of arthritis worldwide is Osteoarthritis (OA), a progressive disease that destroys cartilage and joints, is a frequent cause of pain, functional limitation and disability ^[3].  Osteoarthritis of the knee is a common form of arthritis, and affects nearly 12.4 million seniors, the majority of which are women ^[3]. 

Exercise therapy, including mind-body exercises, yoga, and mental focus along with controlled breathing, have become key elements in the treatment for knee osteoarthritis ^[3]. Additionally, yoga has proven itself to be the superior form of exercise therapy, not only because of decreased pain and improved function, but yoga’s inclusion of meditation and standing exercises has helped seniors decrease anxiety and fear of falling ^[3].

 Sharon Kolasinski, MD, a professor of clinical medicine and a rheumatologist at the University of Pennsylvania in Philadelphia, produced a study on the impact of yoga on those suffering from knee osteoarthritis ^[4]. Kolasinski’s study demonstrated that people who participated in a 90- minute Iyengar yoga class, once a week, for 8 weeks, using props and pose variations, had decreased pain, increased physical function and less joint stiffness ^[4].

Because of yoga’s gentle movements, people with osteoarthritis are increasingly drawn to yoga for a safe and gentle form of exercise along with a way to lower stress, improve mobility and balance. Additionally, yoga is fun and presents people with arthritis a type of exercise that can be done on a regular basis ^[4]. Practicing with an experienced yoga teacher, modifying poses and using props, help to promote knee joint safety and provide a beneficial practice ^[4]. Iyengar yoga, is recommended for people with knee arthritis because it allows the use of props ^[4].

People with knee arthritis should modify yoga poses and use props to protect the knee ^[5]. In poses where the legs are straight, such as Trikonasana (Triangle Pose) hyperextending the knee should always be avoided ^[5]. To prevent knee hyperextension, a slight bend in the knees and keeping weight evenly distributed in the four feet corners is recommended ^[5].

Avoiding deep knee bends and maintaining proper knee alignment in poses like Virabhadrasana II (Warrior II) is another way to protect the knee and avoid knee injury when practicing yoga ^[5]. The bent knee should be aligned over the ankle and in line with the second toe ^[5]. If the knee should go beyond the ankle, the stance should be widened ^[6]. During Warrior II a frequent, but destructive, misalignment is for the thigh to fall inward turning the knee towards the big toe, placing too much stress on the knee ^[6]. Likewise, allowing the thigh to turn outward shifts the knee towards the little toe creating knee stress ^[6]. Pointing the knee in line with the second toe, making sure that the knee and the toe are on the same plane as the sit bone will protect the knee ^[6].

Finally, a common pose where props should be used to alleviate pain and to make the pose achievable is Virasana (Hero’s Pose) ^[7]. Many people with knee OA cannot perform Virasana by sitting upright, with hips in between the feet and knees together ^[7]. One solution is to raise the floor with props, like a sitting on a folded blanket or one - two blocks under the hips ^[7].

Today, “sixty is the new forty”, someone celebrating a sixtieth birthday can expect to live two decades or more, yoga presents the potential for making this chapter of life truly the golden years ^[1]. As a holistic practice that intersects body, mind and spirit, yoga can be a deep and transformative practice during this cherished time, even for those with knee osteoarthritis ^[1].

Bibliography

1. Relax into Yoga for Seniors, Carson, Kimberly MPH, C-IAYT & Krucoff, Carol, C-IAYT, (2007). p. 7-11.
2. Top 10 health concerns for seniors: ASC blog. ASC. (2021, November 17). Retrieved May 23, 2022, from https://www.asccare.com/health-concerns-for-seniors/ 
3. Conservative treatment of knee osteoarthritis: A review of the literature. Lim, W. B., & Al-Dadah, O. (2022). World journal of orthopedics, 13(3), 212–229. https://doi.org/10.5312/wjo.v13.i3.212
4. Yoga Benefits for Arthritis, Susan Bernstein, Arthritis.org
5. Avoid Knee Pain and Injury with Yoga, August 28,2007, Catherine Guthrie, Yoga Journal, yogajournal.com
6. Yoga Therapy for Your Knees, Doug Keller, Yoga International
7. Yoga for Health Knees, Hips and Ankles: 3 Ways to prop Virasana, September 18, 2020, Allison Ray Jeraci, Yoga U Online, yogauonline.com

Question from a student: How to practice when one side is injured?

 Question: 

I’ve run into a small obstacle in my practice and I’d love your opinion. As my knees continue to slowly open back up I’m beginning to work on some poses that I have been skipping (Janushirshasana B, and Mariciasana B in particular). While hiking I fractured one of the little bones in the top of my right foot. In these poses where there is pressure on the foot I’m feeling like on my left foot side I can start working but on my right the foot is still very painful/sharp when pressure is there. My question is, do you think it’s better for me to work the poses on one side even though I can’t yet on the other side? Or is it better to wait until I can work both sides?

Laura's Answer: 

Go ahead and continue to do both sides, but on the right side, be very gentle so as not to cause pain. It's necessary to continue to work that foot so the bones will knit. Studies show that bones knit faster if they are put under some stress. By "stress" I mean the engineering definition: "force per unit area within materials (tissues: bones, muscles, tendons, ligaments) that arises from externally applied forces". You don't have to work the two sides equally. Studies also show that exercise on only one side still affects the other side. Good question!

The Death of Yoga?

One of our teachers sent me this link to an article in The Elephant Journal and asked me for my thoughts: COVID 19 Didn't Kill the Yoga Industry: It's Been Slowly Dying for Years.

Here are the points the article makes: 1. Yoga as fitness turned yoga into just another workout. 2. Drop-in classes killed yoga by allowing students to attend without commitment to studying yoga or being part of a community. 3. Fancy pants. Yoga is often described as a multi-billion dollars a year business, but yoga stuff rather than yoga instruction is where the money is going. 4. The teacher training puppy mill, on which studios rely for income, churns out lots of unqualified yoga teachers every year.

I began practicing yoga over 50 years ago, but I didn't take classes until 1990. Reason?  Yoga classes were hard to find. It wasn't until I moved to Louisville and met Maja Trigg, founder of Yoga East, that I began taking yoga classes.  Back then, class met once a week and you could only enroll for a series of 8 classes.  All the other days of the week, you were expected to maintain your home practice.  Class was not intended to be a "workout". It was yoga instruction. It was intended to give us finer points of practice, individual attention where we needed it, and to answer our questions. 

Maja told us that in a series of 8 classes, she would have all students up in Sarvangasana (Shoulderstand) by the sixth class. I asked our Yoga East teachers how often they are even able to teach Sarvangasana in a class. Answer: rarely.  Why?  Students attend class so sporadically that's it's hard to teach a technically difficult asana like Sarvangasana. When students drop in and out of classes, it prevents everyone from making progress.  Students, regardless of ability, often stay stuck at the level of the least experienced student. This is a problem, but this is why we have different levels of classes. Perhaps we need to refine the class levels and establish  requirements for attending levels 2 and 3. 

Classes used to be longer.  Maja's classes were 90 minutes back then. Classes have gotten shorter and shorter. One of our teachers told us that after the shutdown when her classes resumed, the management of the fitness facility where she was teaching shortened the classes to 45 minutes.  Even a 75 minute class does not allow enough time for teaching pranayama, meditation or an adequate relaxation at the end.

The yoga pants problem, as I see it:  Studies show that when women invest their money, their investments pay off better than men's investments. Unfortunately women's investments are 40% that of men.  I would like to see women take the money they spend on clothes and invest it instead.  Why spend $200 on a pair of yoga pants at a company which doesn't care anything about women? Take that $200 and invest it instead.  

The teacher training mill:  After Maja retired and moved away, she phoned us to tell us that we should begin training teachers. We were reluctant to do that, thinking that we were not experienced enough.  However, students began asking for training.  When a student asks about teacher training, we understand it to be a desire by the student to take the next step in their practice.  In the general yoga classes, we don't teach the philosophy and history of yoga, nor can we give advanced instruction.  Teacher training is our opportunity to give interested students a deeper dive into yoga.

Initially, we took the notes we had made in our training with Maja, and we did a training using our notes starting in 1995.  Our first training was a month long.  By 1999, our teacher training was over 600 hours long.  Since then, we have trained over 240 teachers at various levels.  We did a 40 hour gentle yoga training in 2009 to train students who each had been attending classes at Yoga East regularly for at least five years to teach yoga as volunteers for community non-profit organizations.  We have given chair yoga training, MS Yoga trainings, and 200, 300 and 500 hour courses.  We always tell our students that a teacher training course does not turn you into a yoga teacher.  The way to become a yoga teacher is by being a dedicated yoga student and by maintaining a relationship with an experienced teacher as a mentor.  

Teacher training is the beginning point for a new yoga teacher, who has to follow up the training by getting out into the community to teach as many classes as possible. This is the only way to become an excellent teacher. 

Comments are welcome. 

Mujadara Recipe

This is a vegan dish from the Middle East. It's easy to make.

Lentils

1/2 cup of rinsed brown or French lentils and a bay leaf - cook in water to cover until tender. Remove the bay leaf and set the lentils aside for now.

Carmelized Onions

While the lentils are cooking, saute the following ingredients in a heavy skillet until the onions are carmelized. Don't let them burn.
1/2-1 cup of thinly sliced onions, shallots or leeks
Garlic clove, chopped
1 teaspoon of sugar (jaggery or brown sugar is recommended)
olive oil

Soaked Raisins

While the lentils and onions are cooking, soak 
1/2 cup of raisins in
juice of a 1/2 lemon, and
1 tablespoon of hot water

Rice

When the onions are ready, in a separate heavy skillet, combine the following ingredients:
1/2 cup basmati rice
1 cinnamon stick
1 tablespoon whole coriander seeds
1 tablespoon whole cumin seeds
If you are not using powdered spices, reduce the quantities to 1-2 teaspoons. I like to use the whole spices and grind them fresh.
Saute the rice and spices in olive oil then add 1-1&1/2 cups of water, cover the rice and cook it until tender. 

When the rice is done, add the lentils, onions and raisins and stir. At this final stage you can also add 1-2 cups chopped tender greens like arugula, tender kale, etc...

Salt to taste.

Laura Spaulding

GREEN YOGA! Or Environmental Action as a Spiritual Practice by Karen Cairns

View of Kedarnath and Chaukumbh from Guptakashi, India.

Yoga is about balance, about ethics and relationships within the web of life.  All yoga is ecological by nature.  We can look at the Yamas and Niyamas first as relating to ourselves, then expanding these outward to our shala, our community, our region, country, the planet.  Like skimming a stone over the surface of water.

Environmental awareness and action is based upon ahimsa (not harming by actions including ethical issues about purchases and materials), asteya (not using more than my share of resources- as the Quaker saying goes:  Living Simply So That Others May Simply Live), sauca or cleanliness and non-polluting.  

There are many actions we can take to honor these fundamental limbs of yoga.  We need broad action, collective action, voting and protesting when applicable, changing laws and holding corporations accountable…of course.  Individual action is not the complete answer but it is a step we can take:  it is right action.

So…in our shala we can support ourselves and Bhumi Mataji (Jai, Mother Earth!) through many steps.

• Using candles that are non-polluting and that have less waste.  No tea lights- these are made from fossil fuels and also produce indoor air pollution, increasing respiratory difficulties.
• No more burning incense inside.  The least polluting I have found are the Japanese ones made without a stick in the middle, but even these have smoke and put particulates in the air we breathe.
• Buying and using toilet paper that is made from recycled paper with a high post-consumer recycled content.  This has a double benefit:  virgin forests and trees are being cut down for regular toilet paper.  The average person using regular toilet paper is responsible for 384 trees being cut down in their lifetime (NRDC).  When we buy recycled paper products (toilet paper, paper towels, and tissues), we are not only saving trees but we are supporting the market for recycled products, which is extremely important for recycling to work.
• Using regular, good old-fashioned soap bars instead of soap in plastic bottles.  Research has shown that this is both effective and just as healthy (or more healthy than soaps that are “anti-bacterial”).  This goes for lotions also- if possible buy in glass or buy in bulk by bringing your own glass container.  Many health food stores now have soaps and lotions in bulk.
• Flowers: best are local and/or homegrown, next would be flowers grown in USA, and worst would be flowers from South America (cheap roses often grown in Colombia and cared for and picked by women and children with much exposure to horrible working conditions and high levels of pesticides).  Many flowers are labeled with country of origin; if not, we can ask where they are from.
• Cleaning: we want to avoid harmful chemicals, especially bleach.  Most cleaning can be done with white vinegar and water and soap!

Yes, this is somewhat more expensive but so worth it.  Perhaps we can have an Eco-Fund for donations to support these efforts.  Certainly when we donate (bless you, donors!), we can donate with awareness about packaging and products.  Maybe large bags of chocolate that is not in individually wrapped pieces? Oh, have I gone too far?  Okay, baby steps!

Karen Cairns, RN, MPH, EdD  is a member of Yoga East’s Board of Directors, a long-time dedicated Ashtanga practitioner and KPJAYI Authorized teacher.  She received her doctorate in environmental education from the University of Louisville in 2001 and worked at U of L in environmental research and environmental justice.

Madhur Jaffrey's Beet and Tomato Soup

As served at Kentucky Street on June 24.

Bunch of fresh beets
Equal weight of fresh tomatoes
1 tsp ghee
1/2-1 tsp whole cumin seeds (I used a full tsp)
1 tsp whole black peppercorns
4-6 whole cloves
1/2 piece stick cinnamon
1/2-1 tsp salt

Wash the beets and leave about 2 inches of tops on the beets. Not necessary to peel them. Cook the whole beets in water until you can pierce them with a fork.  Remove from water and let cool.
In the beet water, scald the tomatoes and remove from the water. Save the water.  Let the tomatoes cool enough to peel them.
Slip off the beet skins and tops and put the whole beets and the peeled tomatoes in a food processor or blender. Add enough water so that you thoroughly blend them to a soupy consistency.

In a heavy sauce pan or soup pot, heat the ghee until sizzling, but don't scorch it. Add all the spices and lightly saute until fragrant.  Add the beet/tomato mix.  Bring to a boil, then simmer for 10 minutes on low heat. Add salt to taste.  You can add a bit of cream, but I didn't do that.

Strain. Enjoy!

The original recipe can be found in Madhur Jaffrey's World of the East Vegetarian Cooking, Alfred A. Knopf, 1981. I made some changes which I think makes it faster and easier to prepare.

Heart of Yoga June 1, 2018

Today we discussed notes I had taken from the first Yoga and Sound I attended at Arsha Vidya Gurukulum in Saylorsburg, PA, with Ramanand Patel, Mukesh Desai, and Pujiya Swami Dayananda Saraswathi. This was September 4, 2002 - September 11, 2002.

Swami D. began by defining terms from the Vedanta tradition. Nishta or sthairya = to abide. Bhava, Bhavana = to have a command of abiding attitudes. Laya = absorption.

Niyama (first limb of Patanjali's Ashtanga Yoga) is a lifestyle conducive to accomplishing yoga, living a committed life, a life which leads to a desirable end.

Things to be done - niyama: purity, contentment, austerity, self-study, surrender to Isvara.
Things not to be done- yama: non-harming, non-lying, non-stealing, non-greediness, non-excessivness.

A yogic life is regulated and disciplined.
Tapah, svadhyaya, and isvara-pranidhanah constitute niyama.

Tapah - being totally committed, involved, dedicated. he remarked that in India, waiting is considered tapas. People say, "I've been doing tapas for you for 10 minutes."

Svadhyaya - he recommended studying the Vedas by studying one Upanishad.

Isvara- Pranidhanah - "God" is an abused word. "Isvara" is better. How does one worship Isvara? Pranidhana means "placing oneself".  This is not a matter of "belief" in God; it is a matter of understanding.

There are two ways of knowing: (1) direct perception, (2) indirect perception. Direct perception is seeing with your own eyes. Indirect perception is like reading an x-ray, knowing you have a flat tire by the way the car drives, inferring that you have gasoline from the gas gauge.

Belief: if you have a green light, the cars on the cross street have a red light and they will stop.

Only these two kinds of knowledge - there is no such thing as theoretical knowledge. (for a good discussion of theory, see this short discussion from the American Museum of Natural History).

All that exists is Brahman (Brahman is a word of neutral gender representing the ultimate reality underlying all phenomena).  All that is known or unknown is Brahman.  Isvara is to be understood and known. All knowledge, all karma, all dharma is Isvara. Isvara is the maker and material cause of everything.