Aging comes subtly. The risks and changes sometimes have a harbinger, like the pain in my hip, and sometimes they don't. Signs such as graying hair, the softening underbelly of a chin, and joint stiffness are easy to see and feel. Yet other changes are completely hidden. Just after my 50th birthday, my physician suggested a bone-density scan since I had many risk factors for osteoporosis—including being a thin, postmenopausal woman with a family history of the disease. Osteoporosis is a disorder that thins and weakens bones, making them more porous. The resulting danger is a possible break, which is when many people discover they have this "silent" disease.

In my case, the bone-density scan revealed that I have osteopenia, or low bone density, a precursor to osteoporosis that puts me at an increased risk of fracture. And I'm far from alone. It's expected that by 2020, half of all American men and women over age 50 will have, or will be at risk of developing, osteoporosis of the hip; even more will be at risk of developing it elsewhere.

The National Osteoporosis Foundation cautions people with osteoporosis in the spine to avoid certain kinds of movement that could lead to vertebral compression fractures, a hallmark of the disorder that can result in shrinking and a stooped posture—the so-called dowager's hump. But only about a third of vertebral fractures are diagnosed, often because the pain may be mild or mistakenly thought to come from something else. Risky movements include bending forward from the waist, twisting the spine to a point of strain, and doing toe touches and sit-ups.

This information left me reeling. Could the yoga practice I love actually be damaging my skeleton? Should I stop doing forward bends and deep twists? Did I need to give up yoga entirely? It turns out that, like many other signs of aging—both plainly felt and out of sight—osteopenia requires me to have patience, honesty, and, perhaps most important, humility as I adapt my yoga practice to avoid injury and maintain the bone mass I still have.

Boning Up

Although many people think of the skeleton as solid and lifeless, it's very much alive, constantly breaking down and renewing itself in a two-step process called bone remodeling. The rate at which bone remodeling happens is affected by how much calcium is stored in the bones and introduced in the diet, as well as by three catalysts (vitamin D, hormones, and exercise) that determine how effectively the body uses calcium to build new bone and prevent bone loss through resorption. Osteoporosis results from an imbalance in remodeling—where too much old bone is broken down and removed, or too little new bone is formed, or both.

About 90 percent of an adult's bone mineral content (calcium) is deposited by the end of adolescence, with peak bone mass achieved by age 20, says Kathy M. Shipp, an adjunct associate professor of physical therapy at Duke University School of Medicine who was a contributing author of the surgeon general's 2004 report on bone health. Osteoporosis prevention begins in childhood with good health habits (such as proper nutrition and exercise), she notes. After about age 40, bone's withdrawal period starts, and less bone is replaced during remodeling. For women, a drop in estrogen at the time of menopause leads to a more rapid and significant loss of bone mass. For men, a drop in testosterone—often beginning around age 70—can cause it. So will certain medications (notably steroids), medical conditions (such as rheumatoid arthritis and eating disorders), smoking, and excessive alcohol consumption.

Maintenance Plan

It's not possible for adults past the peak growth years to add significant amounts of bone. (In the past, hormone replacement therapy was widely used to strengthen bones and reduce fracture risk in postmenopausal women until the Women's Health Initiative study showed that it significantly increased the risk of breast cancer and stroke. There is also emerging evidence that vitamin D can be useful in significantly increasing bone strength.) But you can strengthen bones by exercising to maintain the bone mass you already have. "Bones get stronger from exercise by changing shape and by getting larger in diameter, even with the mass remaining constant," says Shipp. "Progressive-resistance exercise [such as jogging, jumping, or walking], where you move your body or a weight against gravity while you remain upright, has been shown to help strengthen and maintain bone density." In fact, a meta-analysis of trials shows that after menopause, "women who exercise have up to 1 percent greater bone density compared to control groups who did not exercise and also lost 2 to 3 percent of bone mass," says Shipp.

In yoga, Shipp says, anything that involves jumping (such as when you transition from Down Dog to Standing Forward Bend or from a wide-legged stance to Mountain Pose) could be beneficial for fit, premenopausal women. For people of any age, weight-bearing postures (Table Pose and Plank, for example) can also be useful for strengthening bones, especially if the demand is novel to the body. Moving the body against resistance—as is done in Chaturanga Dandasana—can also help strengthen bones, so Shipp generally gives her patients some version of a pushup, even if her frailer patients need to do a modified variation that has them standing in front of a wall, palms pressing against it.

Practice With Care

Not everyone is in agreement on which postures are safe and effective for people with compromised bone mass. In Yoga for Osteoporosis, the authors—yoga therapist Ellen Saltonstall and Dr. Loren Fishman, medical director of Manhattan Physical Medicine and Rehabilitation—caution against a convex rounding of the spine, as in Cat-Cow Pose, which can cause tiny fractures in the spine. Twists have the potential to do the same, but Fishman contends that twisting poses are "the only way I know to strengthen the anterior part of the vertebral body."

Fishman's pilot study of 11 people and 7 controls found that those who reported doing 10 minutes of yoga daily increased bone mineral density with no injury. While the findings are encouraging, Fishman acknowledges that the numbers are small, so he's continuing research. This involves sending a yoga video (with modifications for postures such as Triangle Pose, Camel Pose, and several twists) to those who registered with his website and asking them to practice daily and take supplements, including vitamin D3 and calcium. So far, he says, 32 people have practiced for two years and had before and after bone density scans. While most showed improvements in the bone density of their hips, he says, "in the spine they didn't do as well—half got better, and half got worse or stayed the same." None, he says, have reported serious injury.

To avoid injury, people with osteoporosis should work individually with a yoga instructor with specialized training until cleared to safely participate in an appropriate group class, says yoga and physical therapist Matthew J. Taylor, director of the Dynamic Systems Rehabilitation Clinic in Scottsdale, Arizona. Proper alignment in poses maximizes the bone's ability to resist any applied force, making good instruction and awareness critical in reducing the risk of fracture, he says. In particular, it's important to maintain a neutral spine—which for many people means bending the knees in postures such as Downward-Facing Dog. In addition, Taylor advises those with osteoporosis to avoid Headstand, Plow, Shoulderstand, and abdominal crunches, and to do twists in a moderate range with a long spine.

The stress response also affects bone remodeling, notes Taylor, who puts great emphasis on Savasana (Corpse Pose), pranayama, yoga nidra, and meditation because these practices can shift the balance in the autonomic nervous system from sympathetic to parasympathetic dominance, which in turn can promote a better ratio of old bone being broken down and new bone being built. In addition, he says, these practices increase balance, reduce the fear of falling, and elevate mood, which research demonstrates are key for maintaining bone health.

Great Modifications

While I've dealt with the diagnosis of low bone mass, my yoga practice has undergone a profound shift. As a teacher, I'm clear that ahimsa (nonharming) is my first priority, which means I'm conservative in my classes for older adults and follow the National Osteoporosis Foundation's guidelines: no bending forward from the waist and no end-range twists. In my asana practice I've switched from Sun Salutations to warm-ups that don't involve continual forward bends. On the rare occasion when I do Uttanasana (Standing Forward Bend), I bend my knees so my back doesn't round into a position that may increase my risk of vertebral fracture. I still twist, but I no longer tuck my elbow outside my thigh or thread my arms through my legs and clasp my hands.

Since weight-bearing exercise has been shown to strengthen bone, I try to include postures that involve moving my body against gravity, particularly poses that use my arms and upper body—for example, Side Plank, Handstand against a wall, and repetitions of the middle portion of Sun Salutations (Down Dog, Plank, Staff Pose, Upward-Facing Dog). I also focus on balance postures (such as Half Moon Pose) to reduce my risk of falling, since falls are a leading cause of injury among older adults and can lead to life-threatening hip fractures in people with osteoporosis. To counter a tendency toward age-related rounding of the upper spine, I include back-strengthening postures such as Baby Cobra (with arms at the sides) and Locust Pose variations. And I've developed a new appreciation for the wisdom of balancing effort with surrender. This means that on some days, my entire practice is a restorative posture—often a supported backbend or Viparita Karani (Legs-up-the-Wall Pose).

Finding Balance

But perhaps the most healing yoga of all has come from bringing yogic principles into my life on and off the mat. Patanjali's Yoga Sutra offers a wealth of wise advice about posture, attitude, and aging gracefully. Sutra II.46, says, "Asana must have the dual qualities of alertness and relaxation" and calls for a balance of effort and ease in postures. I try to challenge myself without strain, letting my breath indicate if I'm crossing the line into risky territory.

For example, I used to love Tolasana (Scales Pose), which requires a forward-crunching action that could put me at risk for spinal fracture. Then I began to notice myself holding or forcing my breath during the posture, which I took as a signal to back off the pose. Observing my reaction to this warning became an opportunity for svadhyaya (self-study)—a process of watching myself with compassionate, detached interest. When I did this, I noticed a storm of emotions arising. There was a hint of anger, some alarm, and a reluctance to move to a gentler variation, all surrounded by a bruised ego and a shaken sense of self. As I sat with these emotions, without trying to push them away or draw them in, what arose was a feeling of deep sadness that I could no longer comfortably do a posture I once found easy. Surprisingly, this was followed by a wave of peacefulness as I recalled yoga's central teaching that we are not our bodies—that although everything else changes, our essential nature is a state of unchanging awareness.

These days, learning to welcome whatever arises is an integral part of my practice. So is shifting my perspective to santosha (contentment). Rather than fixating on what's wrong, I try to view the situation through a lens of gratitude for what's right. I've stopped doing Tolasana and other postures such as Headstand, but I still do bone-density-maintaining inversions and arm balances, including Forearm Balance and Half Shoulderstand.

And at our teacher trainings, I no longer sit cross-legged for hours. Instead, I regularly shift my position and use props—including blocks, blankets, and a meditation cushion—and sometimes sit in a chair. Rather than setting an example of the ideal Easy Pose for my students, I'm much more interested in modeling the importance of honoring truth. In this way, my aging bones have helped me recognize that progress in yoga is not measured by the mastery of complicated arm balances but by the ability to move through the world with kindness, wisdom, generosity, and an open heart.

Bone-Strengthening Poses

The asanas on the following pages were designed by yoga therapist Ellen Saltonstall, co-author of Yoga for Osteoporosis and creator of a DVD of the same name, to help strengthen the spine, hips, and arms. They are appropriate whether you have osteoporosis, osteopenia, or neither. Each asana includes important preparatory actions to make the pose safe and effective. You can simply do the prep, or if you feel secure and strong, continue on to the full pose that's pictured. For stability, practice on a mat, carpet, or another surface with good traction.

Before you begin, start with your favorite warm-up (if you have low bone density and do Sun Salutations, skip the forward bends or do them with bent knees and a long spine). Finish your practice with Tadasana (Mountain Pose) and Savasana (Corpse Pose).

Balancing Table

This warm-up pose helps to develop balance and strength in the spine, hips, and arms.

First: Starting on your hands and knees, align your hands under your shoulders and your knees under your hips. Lengthen the sides of your torso, and firm your abdomen and hips. Straighten and reach your right leg back, tucking the toes under, and strongly stretch through the entire leg. Tone your abdominal muscles to stabilize your midsection, and then lift the leg and extend it backward. Repeat these actions with the other leg.

Next: Now lift your right leg and left arm at the same time. You may lift them just a little or up to horizontal if you can. Lift both the inner and outer edges of your leg and arm evenly. Exhaling, bring the arm and leg down. Inhaling, raise your left leg and right arm in the same way, remaining strong in your abdomen and lower back. Reach back through your heel and forward through your fingertips. Switch and repeat 5 or more times on each side.

Salabhasana (Locust Pose) variation

Help prevent rounding of the upper spine as you stimulate the vertebrae and strengthen the back muscles.

First: Lie on your stomach with a blanket under your abdomen. Stretch your arms to the sides in a T with the palms down. Rest your forehead on the floor. Firm all the muscles of your back body—arms, spine, and legs—and pull your limbs in toward the center of the body for integration. Tone the buttocks while maintaining width, and lengthen your tailbone. Draw your shoulder blades in toward your spine, which will lift your upper arms away from the floor. As you inhale, lift your arms and head, just a little at first. Pull your ribs forward, away from your legs. Spread the work throughout your back body to avoid pinching in the lower back or overextending your neck. Every part of your body extends away from the center with strength. Hold the pose for several breaths, and then rest on the floor.

Next: Float up again with your upper body, and also lift your legs, stretching them back. Hold the pose for a few breaths or longer, and then release back to the floor. Repeat up to 3 times.

Utkatasana (Chair Pose) variation

Build strength in the legs, hips, spine, and arms.

First: Begin sitting in a chair with your feet and knees hip-width apart. Using your hands, turn your upper thighs back and apart to help your lumbar spine retain its forward tilt. Lean slightly forward, and stretch your arms to the sides with your shoulder blades pulling down your back. Avoid rounding your back, and keep the front of the torso long, chest lifted. Vigorously firm your legs, spine, and arms.

Next: Inhaling, come up off the chair and maintain the pose with steady strength, breathing smoothly. Be sure that your knees and feet both point forward, your weight is well balanced on the four corners of your feet, and your sitting bones reach back and apart as you hold the pose. After several breaths, come to standing or sit down before repeating.

Vrksasana (Tree Pose)

This familiar pose builds strength and better balance.

First: Stand with your back near a wall to build confidence. With your feet parallel, spread your toes, and actively feel the floor under your feet. Stretch your legs straight. Bring the tops of your thighs back, and widen your sitting bones and upper thighs. Reach your hips back slightly, as if you were about to sit down in a chair. Then pull your tailbone down, firm your pelvic floor, and lift your lower abdomen. With your pelvis now directly over your legs, stretch down through your legs, up through your spine, and out through your arms, which are outstretched to the sides and lightly touching the wall. Bring the sole of your right foot onto the inner ankle of your left foot, and press it in firmly. You can keep your toes touching the floor lightly if you need to, or bring the entire right foot off the floor. Vigorously stretch your standing leg, your spine, and your arms. Embody the strength and dignity of a tall tree. Bring the top foot down, switch standing leg, and repeat on the other side.

Next: When you feel secure, increase the challenge as you stand away from the wall, bring the foot higher on the inner edge of your standing leg, and reach your arms overhead for as long as you feel comfortable.

Ardha Chandrasana (Half Moon Pose), supported

This sidebending pose engages and opens the hips and teaches balance.

First: Stand near a wall with a chair (parallel to the wall) on your right. Turn your right foot to face the chair. Bend your right knee, pointing it toward the toes. Place your right hip lightly against the wall for stability. Balance your weight evenly on the four corners of the right foot. Place your right hand or forearm on the chair seat. Slightly lift your back foot, but keep your toes touching the floor as you establish balance on your right leg. Rest your left hand on your top hip. Inhale, and firm your leg muscles. Roll your left shoulder and ribs back and your right ribs forward to align your torso with the wall, but keep your gaze down to help you balance. On your next inhalation, lift your left leg and stretch it behind you along the wall. Bring it up to horizontal if you can. Breathing fully and smoothly, hold strongly with your hip muscles, and expand from your pelvis out to your legs, spine, arms, and head. Broaden your shoulders, and strongly stretch your left arm up. After a few breaths, come back to standing on two feet, and repeat the pose on the second side.

Next: For more of a challenge, simply avoid touching the wall or use a block instead of a chair.

Virabhadrasana I (Warrior Pose I), supported variation

With the help of a wall and a chair, your hips and spine are stretched and stimulated.

First: Place a folding chair about 4 feet from a wall, facing out. Stand against the wall, and then step your right foot forward, bending the knee until the right shin is vertical. Hold the chair lightly with your hands. Place the left heel up on the base of the wall with the ball of your foot and your toes on the floor. Inhale and lift up through your spine. Lean forward a bit toward the chair, and fully stretch the back leg, straightening the knee and facing the kneecap straight downward. To stabilize your stance, widen the back of your pelvis, and then reach your tailbone down, drawing up through your lower abdomen. Bring your torso upright, and then pull the shoulders and head back until they are in line with your hips. Remain steady in all these actions as you expand out from your core in all directions.

Next: If and when you feel steady, let go of the chair, and stretch your arms vigorously out to a T. Lift your chest as you stretch through your back leg. Remain poised in this strong lunge with full attention and strength for several breaths. Then repeat on the other side.

Carol Krucoff is a co-director of Therapeutic Yoga for Seniors teacher training and the author of Yoga Sparks: 108 Easy Practices for Stress Relief in a Minute or Less.

September 2013

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