YOGA FOR THE ELDERLY

I have always found myself more drawn to the elderly, in which has also probably led me to specialize more on the geriatrics department and found myself working in a nursing home. With the growing aging population in Singapore, more research is also looking into non-pharmacological approach in tackling the problems that comes with ageing. One common approach on the rise is Yoga, especially interested within groups of elderly who are still ambulant/ physically active who wants to make a change in their lifestyle. Because yoga recognizes that that body is not just a physical body, it incorporates the mind and spirit and raise questions of existentialism and philosophy, it has a higher draw to these group of people who recognizes that the span of their lifetime is nearing death.

 

Problems of aging

The ‘problems’ of aging (as compared to the younger self) is that, although it does not equate to developing medical conditions, they tend to be more at risk of fraility. There is lesser joint range of motion, strength and balance, which puts them at risk of falls and other secondary problems that comes with it. Some of the common conditions seen in this age group are osteoarthrisitis, Hypertension,hyperlipidemia, diabetes,  low back syndrome(mostly kyphosis), which may deter them from doing the actual asana pose properly and modifications needs to be done.

In a recent randomized controlled trial done by Osth et al (2019), showed that a 12 week yoga programme improved the health and well being, mobility, mood and cognition in physically inactive elderly age 65-85 years old.

They used the same treatment intervention (YESS-yoga empower senior study) that was previously done by Greendale et al in 2013.

 

What is the Yoga Empowers Seniors Study (YESS): Design and Asana Series?

YESS is formed by a group of people with knowledge in physical therapy, yoga, and movement science. They developed a hatha yoga asana series (included pranayama and asanas) meant for ambulatory participants of age 65 and had medically stable condition in their criteria group for 2 days/week of 1 hour session for 32 weeks. There were 2 series-series 1 progressively increase intensity to series2.

The main key points of designing the series is based on

  • Ensuring safe yet challenging pract (exclusion criteria on those whose medical conditions are not well controlled/ acute musculoskeletal injuries/awaiting for surgery)
  • Target major muscles that assist in their functional daily activities (eg reaching overheads to carry groceries, sitting to standing). Making the exercise more meaningful to the participants.
  • Asanas that improve balance
  • Asanas that increase their joint ROM.

 

Series 1 and 2 is described in detail in this website for more reference. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3639444/

For Series I : Chair, Wall Plank, Tree, Warrior II, Warrior I, Downward Facing Dog, Side Stretch, Chair Twist, Cobra, Bridge and Abdominal Cultivation.

For series 2: Chair, Wall Plank, Tree, Warrior II, Crescent, One-Legged Balance, Side Stretch, Chair Twist, Recumbent Leg Stretch, Bridge and Abdominal Cultivation

 

What kind of modifications was done for the elderly?

Props and hands on tactile cues were given for exteroceptive feedback to achieve better alignment in poses. Some of the examples were:

Series 1 Series 2(more advanced compared to series 1)
·         Chair pose done with yoga block inbwetween knees and back against wall for support

·         Chair pose

 

·         Planking against the wall instead of the floor to reduce upper extremity loading

 

·         Chaturanga with feet placed further and hands more caudally     

·         Tree pose done with hand on wall for support and 1 leg just slightly lifted

·         Tree without wall and on lifted leg on other side of medial foot
·         Warrior 1 and 2 done with rear foot against wall-floor and hand on chair for support

Warrior 1 and 2 without wall and chair support

·         Downward dog done on wall to reduce demand on hamstring flexibility

·         Uthita hasta pandangusthasana modified to 1 legged balance with back against wall and blocks under feet

·         Side stretch same with wall ·         Side stretch with use of chair instead of wall. Increase trunk forwards and hip flexion.

·         Bharadvjasana twist seated on chair to reduce hip and knees flexion demand and using the chair as a lever to twist from the trunk

·         Same as series 1

Most of the other sitting and supine poses uses towels/blankets to cushion the parts of the body which has more pressure (eg hip, pelvis, knees), and modifications of lesser ranging were done.

 

EVALUATION

Overall in the scientific research arena, there is still no exact yoga exercise prescription (frequency, intensity, time, type) for the elderly whether healthy or even those with medical conditions. The supposed gold standard of exercise prescription is ACSM (American College of Sports Medicine). In which the guidelines recommend elderly to participate in minimum 30 mins/ day of moderate intensity aerobic  , at least 3-5 days/week to total of 150mins/week and supplementing resistance, flexibility and balance exercise training.

Therefore, this YESS intervention study is useful in providing a starting framework for development of a yoga class for the elderly. However it is important to note that the 2 studies -Greendale et al (2013) and Osth et al (2019) were done on generally healthy elderly population with controlled medical conditions. It is best to get medical clearance from doctors and screening of each individual elderly is a must. Assessing their balance,joint range, strength, flexibility and physical function can give the instructor an idea of their impairments which will determine certain asanas to be more difficult to manage/needs modifications.

As yoga is not just as exercise intervention, explaining to the elderly the theory and philosophy aspect is equally important. Explanations like how the chakras can be stimulate for each pose, importance of pranayama and breath with movement can help them better understand the purpose and apply even on their daily function (eg, being more mindful and balanced with walking/standing/bending to pick things). This can translate to benefit them in the long term and may even help in preventions of falls and fraility, also reducing the reliance on pharmacological treatments.

 

 

References:

-Effects of yoga on well-being and healthy ageing: study protocol for a randomised controlled trial (FitForAge). Osth et al (2019)

-Yoga Empowers Seniors Study (YESS): Design and Asana Series. Greendale et al (2013)

 

Vrkshasana (tree pose)

Going with the theme of Isvara Pranidhana of the 8 limbs(as explained in the previous blog posts), I have decided to choose Vrkshasana as a reminder of our connection to the earth and surrendering ourselves to the universe.

 

HOW TO DO VRKSHASANA

STEP 1: Tadasana

Before we get into the asana, we have to ensure our base pose in standing is done correctly.

Image credits : https://www.fashionlady.in/tadasana-benefits/133166

 

However, quite often in our base pose can we already find certain parts that deviate from the ideal posture in standing.

Below are the list of some of the common causes and impairments contributing to a misaligned Tadasana in table format: (from base foot up to head )

Cause: Impairments:
Toe in/toe out Tight hip external rotators
Foot flat/arched Anatomically flat/arched foot/ stretched tendons
Knee hyperextended Poor motor control of quads(tends to overactivate concentrically), laxed posterior ligaments of the knee, lengthened hamstrings
pelvis is anteriorly tilted/ lumbar lordotic/arched Tightness/overactivation of hip flexors, weakness of hip extensors. Can also lead present with hyperextended knees
Pelvis is posteriorly tilted/ Lumbar kyphotic/slouched (sway back posture) Can also present with hyperextended knees when pelvis shifted forwards. Poor activation of hip flexors, overactivated hamstrings
Thoracic kyphotic, Rounded shoulders/protracted shoulder blades Tightness of pecs, weakness of rhomboids, mid traps
Forward head and Poked chin

 Image credit:

https://learnmuscles.com/blog/2018/05/02/the-critical-component-of-upper-crossed-syndrome/

Upper cross syndrome-weakness(lengthened) cervical deep neck flexors, rhomboids and lower traps

Overactivated and tight upp traps, Levator scap,suboccipitalis, pec

image credits: https://www.elliehermanpilates.com/ellies-blog/2017/11/20/how-to-help-hyperextension-its-all-in-your-mind

 

STEP 2: (As according to the picture)Getting to Vrkshasana

-R hip flexed, abduct then externally rotated(concentric contraction of the mm assisting in the movement).

-R knee flexed and ankle dorsiflexed(concentric contraction) One might use the upper limbs to assist the foot to be placed properly on the medial thigh.

-Flex/abduct shoulders over head(concentric contraction), while keeping elbow extended

Image credits : https://www.tummee.com/yoga-poses/vrksasana

List of some common misalignments

Causes Impairments:
L foot/ankle wobbling/rolling Reduce foot intrinsics gripping toes on ground, can also be reduce proprioception within the ankle joints
L toe out Tight L hip external rotators/weak internal rotators
Reduce R hip externally rotation, compensates with trunk rotation to R Tightness of R hip Internal rotators and adductors
R and L hip not aligned, usually R hip dropping Reduce L gluteus medius activation
elbows not extended and palms not pressed against each other Inactive upper limbs
Raised scapula and shoulder and neck towards ear Overactive scapular elevators

 

STEP 3: Vrkshasana

Once in the asana and holding the post for 5-10 breaths.

All muscles are in isometric contraction as there should be stillness and no movement.

 

 

BABY STEPS TO IMPROVE OUR ASANAS:

By identifying our impairments (non-exhaustive list above), we can work towards it in isolation first, before finally incoroporating to the final pose.

Some examples of the impairments listed above to work on:

1) Postural correction in standing against a wall

-Heels, glutes, shoulder blades and occiput of the head should be aligned with the wall. Tuck in the chin and slightly retract the shoulder blade.

-Looking forwards to first align vertically  using a mirror/ or comparing to an object that is vertical and straight(eg pillar/grills of a window)

-Check that the left and Right ears, clavicles, shoulders, pelvis, knee and foot are aligned horizontally and whether body is rotated L/R.

-Consciously soften the knee(slightly flex to avoid knee extension in standing. Add in functional movements (eg marching on the spot, toe raise in standing, walking).

 

2) Foot intrinsics strengthening and activation

image credits: https://d3i71xaburhd42.cloudfront.net/be55fd2668ba20b109c941be9de1500079d24ec8/3-Figure3-1.png

-flexing and extending the toes of the foot at the start to understand the movement

-using the mat/yoga towel to ‘grip’ the mat with the toes (can be first done in sitting to isolate movement to only the foot)

-Progress to standing at the back of the yoga mat in standing, extend toes, then flex and grip the mat to pull the foot forwards (+/-ankle DF and PF) , till the foot reaches the head of the yoga mat.

-Another variation is in bilateral foot standing with heel raise while being aware to activate gripping of the toes. Progress to single leg standing with heel raise, while maintaining balance(also helps to improve proprioception)

-repeat 10 reps X3 sets

 

3) Stretches for tight hip internal rotators and adductors:

-passive stretches(gravity-assisted). Lie down in supine in supta baddha konasana(single leg to double leg stretches) or in sitting baddha konasana- using the palms to assist knees in external rotation closer to the ground

-active stretches with lizards pose (utthan pristhasana). Lunge with the forwards knee in external rotation and weight shift to the lateral side of the foot, actively rotating the hip externally.

Image credit: https://www.popsugar.com/fitness/How-Do-Lizard-Pose-aka-Utthan-Pristhasana-3442560

-progress to standing with 1 leg hip external rotations and abduction +/- against a wall for balance and aligment, ensure nil rotation of the trunk towards the side lower limb that is moving. Repeat 10 reps with holding of minimum 30 secs.

 

4) Gluteus medius activation in single leg standing to maintain neutral pelvic alignment

-standing perpendicular with the wall, place the thumb on the ASIS. Lift up the leg that is against the wall in single leg standing. Ensure that both the left and right side is aligned by activating the gluteus medius. Repeat 10 times with both Left and Right sides.

image credit: https://www.precisionmovement.coach/gluteus-medius-exercises/

-Now, stand away from the wall, using the same technique as above, put both thumbs on each ASIS to ensure no hip hiking on single leg standing.

 

5) Finally, Vrkshasana

-incorporate the above steps 1-4 can help you to feel more stable and balanced, but this is just the start of getting into the Vrkshasana. Practising the pose in a longer duration will help to strengthen the muscles isometrically.

Eventually this asana together with the steady breath, will bring about  a state of clarity, balanced energy and lightness of the body and the mind.

Conclusion

Understanding how to get into an asana pose and identifying our impairments can help us to be more align to the ideal posture. Using our breath with the movements can increase our awareness and concentration going to the pose. The list of impairments above are non-exhaustive and are mostly linked to muscle/joint impairments (does not cover the nervous system, ligaments, fascias,proprioceptors of the joints). One may also be anatomically disadvantaged (eg leg length discrepancy) or have predisposed medical conditions (eg spinal fusion) that may make it difficult to achieve the ideal posture. It is also possible that the cause of the misaligned foot can be a result of the upper chain of the body(eg hip) or vice versa, and not limited to one predisposition.

 

However, it is important to note that the goal of any asana is not in achieving the perfect posture. It is in developing your self awareness of the relationship between your physical body, mind and spirit.

CONCEPT OF ZERO (SUNYATA) IN ISVARA PRANIDHANA

Ishwara pranidha is the last of the Niyama in the 8 limbs of yoga.

WHAT IS ISVARA PRANIDHANA AND WHY IS IT IMPORTANT?

Written in chapter  2.45 of the yoga sutra:

samadhi siddhih ishvarapranidhana

-samadhi = deepest meditative state

-siddhi = attainment

-ishvara = God, Supreme Being, Divine, a Deity, Goddess, all names

-pranidhana = devotion, surrender, awareness of Ishvara

 

Here it states that Surrendering to the supreme being leads to samadhi which is the central concept of yoga for deep inner stillness and silence for extraordinary insight.

 

The concept supreme being is not so much of a fixed ‘God’ but rather, is aptly referring to the original source of knowledge and wisdom/ something of higher power.

And Pranidhana which is being in a state of humility and trusting in prescence of something higher, not just in good times but in everything all the time. Surrendering ourselves to the higher force is one of the key concepts of becoming one with the greater being.

 

“If Isvara is the compass, Pranidhana is remembering to stay connected to that essence, not just occasionally but throughout the day… Isvara Pranidhana connects every action to its sacred source.” (Yoga Journal, “Isvara Pranidhana: The Practice of Surrender,” Shiva Rea)

 

 

HOW DO WE SURRENDER OURSELVES TO THE DIVINE?

When the word surrender comes to mind, it brings up the issue of losing control or becoming powerless. Fear may sink in when our egoistical self realize that we need to lose ourself/give up our identity and can’t control our environment/result.

But let’s dive deeper to realise our true self. The self is a process and there is no end. In reality, we are always changing, interdependent with our surroundings and environment.

 

Sunya or Sunyata is sanskrit word loosely translated to zero/nothingness/empty/void, but it is not nihilism. It is pure consciousness, the non-conceptual state of mind, absent of both negative and positive thinking. It is emptying out our illusionary constructions and come out of our ignorance. It is zeroing out our desires and purifying to meet our true nature of mind, realizing that the essence of the true nature of all realms is sunyata.  Understanding this will let us experience the complete absence of I, me and mine which binds us to Samsara. It also helps us understand the universal oneness with nature and develop compassionate traits.

 

By using the concept of zero in yoga, it helps us to zero our desires, attachments and ego, and conditioning our mind to become like zero (‘’sunya’’) through meditation. In so doing, yoga helps us to establish the identity-which is the union between the finite self, the Atman(inner spirit) and the infinite All (Brahman). Brahman is all and yet Brahman is without attributes. Having zero attributes, Brahman is also called “sunya,”.

 

 

WAYS TO KEEP IN CHECK

-Knowing what is beyond my control and the limits of my understanding.

-Let go of expectations, hope and attachments to others.

-Letting go of worries/fear/anxiety on results, knowing that I have down my best with the right intention.

-Being grateful for everything, including dislikes/undesirable situations, seeing it as an experience to gain/learn from it..

-Being humble knowing that everything is closely interlinked and how dependent I am with my surroundings. (eg during a meal, think about the source of each food->cooked and preparation by someone. All of this assisted me to be nourished from my meal)

-Using zero as a symbol as a self reminder to apply it in whatever I do.

 

 

We can turn egoistical thoughts into more loving and connected view of the world. Being more aware (without any judgment) of our mind, emotions, feelings, environment leads us to realise that we are not in charge of life or the universe. This further reinforced the notion that achieving samadhi cannot be accomplished purely by effort, but that it result from the grace of not knowing and being open to wisdom and guidance that is greater than ourselves.

 

 

“He who contemplates on sunya…is absorbed into space…think on the Great Void unceasingly. The Great Void, whose beginning is void, whose middle is void, [and] whose end is void. . . By contemplating continually on this, one obtains success [enlightenment].”

The Siva Samhita

 

Credit references:

-The yoga stura of Patanjali.Sanskrit-english translation & glossary, chip hartranft

-A Logical Model of Yoga Philosophy, 1998 Ian Williams Goddard

– Yoga sutra 2.45 Effects of humility, 2021 simple yoga organisation. https://simple-yoga.org/2-45-effects-of-humility-ishvara-pranidhana/

-Blogpost by Prithiman Pradhan on Sunyata-http://pirthiman.blogspot.com/2014/01/sunyata.html

-The book on the Taboo Against Knowing Who you Are. Alan Watts, 2019.

Credit image:

-https://sunyatamusic.bandcamp.com/track/sunyata

 

 

 

MEDITATION ON ISVARA PRNIDHANA

The essence of practicing of Isvara Pranidhana is to surrender your ego with humility and cultivating trust in the universe no matter what the circumstances. It is only by losing our made belief self that we gain our true self.

 

In meditation, we can try to use these steps:

  1. Sitting on your yoga mat in a comfortable half lotus/lotus position with back straight with eyes closed
  2. Using shunya mudra-Bend the 3rd finger and place it on the base of the thumb, press the thumb over the middle finger.

 

image credit:https://savy-international.com/yoga/hand-gestures/attachment/shunya-mudra/

 

  1. Inhale and exhale to settle your body and mind
  2. Visualise the number “0” inside myself. Or a symbol/image of higher power than yourself that you can relate to, which resonates with symbol of ishwara.
  3. Chanting the mantra A-U-M, as done below:

 The first syllable A, pronounced as a prolonged “awe.” The sound starts at the back of your throat and you stretch it out. You will start feeling your solar plexus and chest vibrating.

The second syllable U, pronounced as a prolonged “oo,” with the sound gradually rolling forward along your upper palate. You’ll feel your throat vibrate.

The third syllable M, pronounced as a prolonged “mmmm” with your front teeth gently touching. You will now start to feel the top of your mouth vibrate.

The last syllable is the deep silence of the Infinite. As intelligence rises from the deep silence, you have to merge your chant from the M to the deep silence.

Chanting this can help me physically tune in to acknowledge my connection to nature and the universe.

  1. maintain the awareness inwards on the zero. With each inhalation and exhalation, visualise “0” getting brighter and stronger, growing from the insides of your body to surrounding your body.
  2. Acknowledge the thoughts, emotions, ideas arising in the contents of your mind but do not engage.
  3. Slowly, reduce the mind-body engagement (Surrendering the ego and identity) by emptying it out with the symbol of zero-now circling you. This shifts your awareness to expand the space-time experience instead.
  4. Whenever these conscious contents arises, go back to your breath and repeat the zero technique as above
  5. Continue the session for 10 mins
  6. End the session by chanting A-U-M again
  7. Maintain silence for another 10-15 mins

 

At the end of meditation session, try to let go of all expectations. Do not harbour on what you should try to achieve or gain from this meditation experience. Surrender and trust in the universe.

 

“However, he will be least afraid of becoming nothing in death who has recognised that he is already nothing now.”- Schopenhauer