Yoga for and Fall Prevention, a Research in

Progress

WIHA, Healthy Aging Summit Workshop

Paul Mross RYT, LMT

Chair (Utkatasana)Anatomical significance

Rectus abdominis, Gluteus maximus, medius and minimus, adductor group, quadriceps and hamstrings, tibialis anterior, soleus and intrinsic muscles of the feet

Contraindications Headaches Low blood pressure Severe Hypertension Seated: Colostomy or Hemorrhoids

Modifications for specific issues Flat feet

o Focus on all four corners of foot, pulling upo More energy in heel

Weak kneeso Use a block to support thighs from knocking ino Draw the strength of the thighs upward, make the knee caps smile

Lower back paino Reduce curve of spineo Breath fully into side bodyo Reduce external rotation of hips

Arm and shoulder weaknesso Bring hands to hipso Use a chair to stabilize

Checklist Protect knees with minimal external rotation of hips. Make sure the knees line

up with feet and that the knees do not hyperextend past the toes Protect against overarching of lumbar spine

Basic pose: () are used to describe one side, substitute opposite left or right when switching to other side

Begin by standing with chair next to you on your side (left). Turn the chair around so that the back is closest to you. Place both hands on chair for balance. Make sure both feet are facing forward and your heels are behind your toes. Place the block between your tights (see below). Apply just enough pressure, inward, to keep the block in place. Slowly, extend your hips back by bending your knees. Go only as low as to provide a moderate bend in the knees. Make sure you can still see your toes, as not to over bend knees. Keep a slight curve in the small of the spine. Do not bend torso past 90 degrees at hip joint. There will be a zig/zag form to your body: heels are rooted down, knees are bent (hip distance apart and extending out towards little toes), hips back and top of the head is lifted.

Block Placement: Place the block between your tights. Apply just enough pressure, inward, to keep the block in place.

Advancement 1 is the same as the basic pose, however your arm (right) is raise up above the head. Relax/soften the raised arm into the shoulder joint. Your palms face in. Do only if you feel safe, balanced and have no pain.

Tips for Chair: root into feet* be on 4 corners of feet not just toes* keep feet hip distance apart* image a block between the shins and you are squeezing the block in* knees bend even with hips/feet* see your toes* zig/zag of motion: find form, root heels, bend knees, extend hips, lift navel in towards spine, lift through top of head, breath. Repeat and deepen zig/zag* relax/soften arms in shoulder joint* top of head lifts* chin draws in along jaw line* find visual focal point* have a steady and even breath

High Lunge (Alanasana)Anatomical significance

Rectus abdominis, obliques, psoas, quadriceps and hamstrings, front leg: sartorius, semitendinosus, back leg: Rectus femoris, iliacus, soleus, gastrocnemius,

Contraindications Heart problems High blood pressure Achilles Tendonitis or Bursitis Torn Meniscus Plantar Fasciitis Anterior Cruciate Ligament (ACL) Hyperlordosis Spondylolisthesis Spondylolysis Severe Lumbar Stenosis

Modifications for specific issues Balance issues

o Wider stance and longer (front to back) distance of feet will allow for greater balance.

o Keep feet positions at or greater than hip distance Weak knees

o Front leg: Do not hyperextend knee, 90% or greatero Back leg: draw the strength of the thighs upward, make the knee caps

smile Lower back pain

o Reduce curve of spineo Breath fully into side bodyo Back leg: reduce external rotation of hips

Arm and shoulder weaknesso Bring hands to hipso Use a chair to stabilize

Checklist Protect front leg knee with by lining up with feet ( towards little toe) and that the

knee does not hyperextend past the toes Protect against overarching of lumbar spine Hips point forward

Level one: Basic High Lunge

Basic Pose: () are used to describe one side, substitute opposite left or right when switching to other side

Begin by standing with chair next to you on your side (left). Turn the chair around so that the back is closest to you. Place one hand (left) on chair for balance. Turn the chair around so that the back is closest to you. Make sure both feet are facing forward and your heels are behind your toes. With your back foot (left), step back a wide, comfortable distance. Keep your back foot (left) on the base of the toes; do not bring your heel down. Your front knee (right) will bend at an angle. Do not let the knee move forward past the toes. You should be able to see your toes. Your back leg (left) will be straight. Do not lock the back leg (left), have a tiny give in the back knee (left). Vision is on horizon. Do only if you feel safe, balanced and have no pain.

Foot Placement

Advancement 1 is the same at the basic pose, however you can lift one hand and arm (right) up. Point the arm straight up towards the ceiling. Relax/soften the raised arm into the shoulder joint. Do only if you feel safe, balanced and have no pain.

Level 2: High Lunge with visual pulsationBasic Pose: () are used to describe one side, substitute opposite left or right when switching to other side

Begin with standing next to chair (to left), place hand (left) on chair. Front knee (right) is bent, back leg (left) is straight and back foot (left) is on the base of the toes. Lift arm (right) up to ceiling. Pulsate your arm to side (right) and back up to ceiling. Look straight ahead, with arm (right) up and then pulsate vision on horizon to side (right) you are bringing arm down to and then back to center when arm is back up over head. Layer the breath over the pulsation of the arms. As you lower your arm (right) and look to the side (right), exhale. As you bring your arm (right) overhead and look straight ahead, inhale. Do only if you feel safe, balanced and have no pain.

Tips for High Lunge: *keep hips even, facing forward*don’t over extend the front knee*keep back leg straight with soft knee*lift navel in towards spine*relax/soften arms in shoulder joint* have a steady and even breath

Tree (Vrksasana)Anatomical significance

Standing leg: quadriceps soleus, gastrocnemius, Tensor fascia lata, Gluteus medius and minimus. Balancing leg: Psoas, piriformis, sartorius, gracilis and gluteus maximum Standing foot: intrinsic muscles of foot and ankle

Contraindications

Inner ear issues Vertigo Balance disorders Meniere’s disease Headaches High Blood pressure: if raising arms over head

Modifications for specific issues Balance issues

o Root through 4 corners of the balancing footo Breath into and extend the side body on the balancing foot side

Weak kneeso Balancing leg: Keep a slight give in knee. Engage thigh muscle to protect

kneeo Bent, lifted leg: Only extend or rotate knee to an angle that is safe and

comfortable Lower back pain

o Reduce curve of spineo Breath fully into side bodyo Bent, lifted leg: reduce external rotation of hips

Arm and shoulder weaknesso Bring hands to hipso Use a chair to stabilize

Checklist Root down into balancing foot Keep the balancing side body extended/long Allow pivoting knee to be comfortable, maybe that means it is facing more

forward Lift navel in towards spine Relax/soften arms in shoulder joint

Level one: Tree VariationBasic Pose: () are used to describe one side, substitute opposite left or right when switching to other side

Begin by standing with chair next to you on your side (left). Turn the chair around so that the back is closest to you. Place one hand

(left) on chair for balance. Make sure both feet are facing forward and your heels are behind your toes. Place your feet in one of two optional positions.

Foot Position 1: Start with both feet parallel, hip distance apart. Make sure both feet are facing forward and your heels are behind your toes. Keep the foundation foot (left) where it is. Pivot the heel of the balancing foot (right) up the ankle of the foundation foot (left). Keep your knee (right) in a comfortable position. The knee (right) does not have to look completely to the right or side.

Foot Position 2: Start with both feet parallel, hip distance apart. Make sure both feet are facing forward and your heels are behind your toes. Keep the foundation foot (left) where it is. Pivot the heel of the balancing foot (right) up the inner edge of the foundation calf (left). Keep your knee (right) in a comfortable position. The knee (right) does not have to look completely to the right or side.

Keep your hand (left) on the chair. Extend your other hand (right) up your heart center. Palm of hand (right) is facing in. Do only if you feel safe, balanced and have no pain.

Advancement 2 Begin with chair (to left) and place hand (left) on chair. Balance on foot (left) that is on side by chair. Lift your knee (right) up in front of you, with your thigh (right) parallel to floor. Foot (right) is engaged, toes pointing up, parallel to floor. Extend your other hand (right) up your heart center. Palm of hand (right) is facing in. Do only if you feel safe, balanced and have no pain.

Level 2: Tree Variation Basic Pose: () are used to describe one side, substitute opposite left or right when switching to other side

Begin with basic pose in level 2: chair (to left), hand (left) on chair, balance on foot (left), lift knee (right) up in front of you, thigh (right) parallel to floor, foot (right) is engaged and other hand (right) up your heart center. Pulsate the knee (right) between straight ahead and out to side (right). As you bring knee (right) to side (right) allow your vision to move to the opposite side (left). As you bring your knee (right) back to center, bring vision along the horizon, back to center. Layer the breath over the pulsation of the arms. As you lower your arms and look to the side (right), exhale. As you bring your arms overhead and look straight ahead, inhale. Do only if you feel safe, balanced and have no pain.

Tips for Tree: root down into balancing foot* keep the balancing side of the body extended/long* allow pivoting knee to be comfortable, maybe that means it is facing more forward* keep hips even, facing forward* * lift navel in towards spine * relax/soften arms in shoulder joint* top of head lifts* chin draws in along jaw line* find visual focal point* have a steady and even breath

4 Corners of Bottom of Feet, Seated and Standing

Anatomical significance: Intrinsic and extrinsic muscles of the foot, 3 arches of the foot

ContraindicationsArthritis, bunions

Relaxation TechniquesBody awareness:

Begin by setting a timer for 5 minutes, to bring you out of relaxation. Find a quiet room, with no music. Sit in a standard chair (straight back, without much cushion). Place both feet flat on the ground (shoes on or off). Place your hands softly on your lap. Close your eyes if that is comfortable and safe. Follow the next few steps as best as you can. There is no right or wrong way to proceed.

4 deep breaths: Take in 4 deep breaths that are slow and deep, but are not overpowering or make you feel short of breath. After the 4 deep breathe, return your breathing to normal.

Internal scan of the body: Take 2 minutes and allow yourself to internally scan your body with their eyes closed. This is simply being aware of each part of your body. You can start with the soles of your feet, the heaviness of your legs, the chair beneath your hips, the softness of your shoulders, your fingers open on your lap and with the mouth open, the softness of your jaw. (Not all of these specific awareness have to happen, only a few. The purpose is for you to take the time and become aware of how your body feels. There are no judgments of good or bad, just awareness.)

Breathing exercises take about a two minutes and practice one of the breathing techniques below.

When the timer rings, slowly become aware of your environment. Open the eyes gently and tune into your environment: colors and shapes in the room, sounds, smells and even the air as it brushes over your skin. You may feel dizzy or off balanced. Do not get up until you feel steady.

Breathing Exercises: (Choose one of these, once practiced in class)

Be a witness to your breath: Take the remainder of the time, after the body awareness, to watch your breath. Like an audience member watching a play, just observe your breath. Do not try and change it in any way. Simply notice the passage your breath follows: through the nose and/or mouth. Notice the depth the air extends into your body: does it stop in the chest, the rib cage or deep in the belly. Notice how the air is cooler coming in, and then it is going out. Notice the rhythm of your breath: is there an even inhalation and exhalation. You will do this as a witness, therefore try not to place judgment on your breathing, i.e. this way is right or wrong.

(Breathing exercises continued)

Count your breath: Once you have worked on witnessing the breath, move to counting the breath. This involves simple counting the inhalation and exhalation. Example: 1st inhalation is 1, 1st exhalation is 2, 2nd inhalation is 3, 2nd exhalation is 4… There is not a number you are trying to reach. This is a simple way to focus the mind. If you lose track of the number you are on or

if your mind wanders and you notice you are no longer counting, then just start all over: 1 inhalation, 2 exhalation, 3 inhalation, 4 exhalation…

Finding a place of ‘pause’ in breathing: Once you have worked on witnessing the breath, focus more on your inhalation and exhalation. Specifically, the place of ‘pause’ in the breath. Become aware of the ‘pause’ that existed after you inhale, but before you exhale. Then again the ‘pause’ that existed after you exhale and before you inhale. This is not holding the breath. Your breathing remains normal.

Visualize the breath: Another option, once you have practiced witnessing the breath, is to visualize the breath. If you are not a visual person, skip this one. It may be more frustrating than beneficial. First, become very aware of the air as it flows in and out. Enhance this awareness by visualizing a color, of your choosing, on the form of the breath. It helps to have an image of your body being clear first. As you inhale, you visualize the colored air comes into you and internally watch it traveling throughout your body. When you exhale, you will visually see the colored air leave your body. Repeat this with each inhalation and exhalation.

You may feel dizzy or off balanced practicing these breathing exercises. Do not move about the room unless you feel stable.

Abstract From Upland Hills Health Research Study:

Can yoga reduce fall frequency in seniors- a pilot study

Paul Smith MD1, Paul Mross RYT, LMT 2 , Nate Christopher PT, OCS2

1. Department of Family Medicine, University of Wisconsin-Madison; 2. Upland Hills Health Hospital, Dodgeville, WI

Key words: Yoga, fall prevention, balance, seniors

Background: Unintentional falls are a common among the elderly affecting with up to 30% of people over age 65. Falls are the leading cause of injury death in adults over the age of 64 and the most common cause of nonfatal injuries and hospital admissions for trauma. Yoga has been shown to have a variety of health benefits including improved balance and core body strength, yet there is very little published research about yoga as an intervention for falls prevention.Methods: A program of Hatha yoga was developed with poses specifically intended to improve core strength and balance. A convenience sample of adults over age 59 was enrolled in an 8 week yoga program with weekly group classes and home yoga practice 3 times per week. Subjects completed pre- and post-intervention surveys including the Tinetti Falls Efficacy Scale, and balance and strength assessment using the 30 Second Chair Stand and Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT-4).Results: Twenty-one subjects were enrolled. Twenty started the program and 19 (95%) completed follow up evaluation. Ten of 20 (50%) subjects had at least one fall in the previous year. Based on Sign Test analysis for improvement, here were significant changes in 30 Second Chair Stand test (14 improved, 2 worsened, 3 no change, P<0.05). However, FICSIT-4 improvements were not significant (10 improved, 5 worsened, 4 no change, P>0.05). Fall frequency in the previous month decreased from a total of 4 falls pre-intervention to 1 fall at the end of the intervention, but did not reach statistical significance (p = 0.34). There was a non-significant trend toward improved confidence in 8 of 10 domains of the Tinetti Falls Efficacy Scale including: 1) Take a bath; 2) Reach into cabinets/closets; 3) Walk around the house; 4) Prepare meals; 5) Get in/out of bed; 6) Get in/out of a chair; 7) Getting dressed and undressed; and 8) Getting on/off of the toilet. Fifteen of 19 (79%) subjects plan on continuing yoga.Conclusions: This small pilot project suggests that a yoga program specifically designed to improve core strength improves 30 second chair stand, may improve confidence in performing physical activities of daily living and decrease fall frequency. These findings need to be confirmed in a larger, longer randomized trial.

Contact Information:

Paul Mross RYT, LMT

mr_oss@hotmail.com

608-469-5784

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