Teaching Older Beginners: Medical Considerations to Keep in Mind

Senior Yoga Medicine® teacher Rachel Land explains which medical conditions become increasingly common with age and how teachers can adapt their classes for them.

Injuries and medical conditions exist in any population, but the prevalence increases with age. Older beginners aren’t fragile, but even if they have been lucky enough to avoid injury or surgery they may be experiencing other challenges less common in younger beginners. As teachers, it’s not our job to diagnose injuries or medical conditions, but it can be helpful to know more about those we’re likely to encounter most often. That way, we have an idea of how to help our students work with them and make our classes more accessible.

Older beginners aren’t fragile, but even if they have been lucky enough to avoid injury or surgery they may be experiencing other challenges less common in younger beginners.

Here are some of the most common conditions you may come across while working with older students, as well as how they might impact a yoga practice.

1. Inflammation and soft tissue changes 

Some of the degenerative changes we call “aging” are thought to be linked to persistent low-level inflammation,(1)(2) and natural changes to soft tissue. 

Inflammation is a natural process required to fight infection or repair tissue damage. However, it should be balanced by equally important anti-inflammatory processes that tend to become less effective as we age. Chronic inflammation has been linked to many of the conditions we will discuss later including arthritis, heart disease, Alzheimer’s disease, Type 2 diabetes, autoimmune conditions, and certain kinds of cancer. Several studies have suggested that regular yoga practice can help reduce inflammatory markers. (3) (4) (5)

General considerations:

Be aware that older students are more likely to feel stiff and sore after exertion. In addition to this, our skeletal muscle tends to lose mass and strength as we grow older—a condition called sarcopenia—while our connective tissue, or fascia, often becomes more fibrous, less elastic, and less readily hydrated. Due to these natural changes, our students’ range of motion, strength, and endurance may decrease.

It can help to:

• Start gently and progress slowly.

• Incorporate simple practices that lubricate and mobilize the body, such as joint circles, gentle twists, and side bends. 

• Include varied poses rather than overemphasizing a single muscle group.

• Allow rest between poses and between yoga sessions to allow for full recovery.

2. Osteoarthritis and joint replacement 

In 2015, the Centers for Disease Control and Prevention (CDC) estimated that almost half of Americans aged 65 and older had osteoarthritis (OA). This condition involves gradual deterioration or loss of the cartilage that covers and cushions the articulating surfaces of our bones and the formation of bony growths (called osteocytes) around the joints, potentially leading to joint pain and inflammation and reduced bony range of motion. OA can occur in any joint, but is seen most often in the knees, hips, spine, wrists, fingers, and toes. If the condition progresses far enough, joint replacement might be required. 

General considerations:

Students with OA might find it painful to bear weight on or through affected joints, so kneeling, all-fours positions, or standing on the balls of the feet could be uncomfortable. Bony changes in the hip, knee, or ankle joints could make it difficult or impossible to step forward from downward facing dog, come into a deep lunge, transition readily between standing and the floor, or practice postures like hero (virasana), supine hero (supta virasana), pigeon (eka pada rajakapotasana), cow face (gomukhasana), or garland pose (malasana).

It can help to:

• Focus on achieving the benefits of yoga poses—such as strength, tissue elasticity, standing stability, and better posture—rather than on enforcing traditional alignment.

• Include poses and practices that build stability and symmetry around the joints, potentially reducing further wear and tear.

• Use props, walls, furniture, or (better yet) poses and sequences that avoid weight-bearing on affected joints. 

• Be prepared with standing sequences that allow for reduced range of motion and avoid frequent transitions between standing and the floor.

• Try supine stretches that reduce body weight on any painful joints—like a supine figure four instead of pigeon or happy baby (ananda balasana) instead of malasana.

• If your students have given you permission to touch them, use light, directional adjustments rather than trying to move them into an idealized version of the pose that may not be possible due to bony changes around their joints.

• Be aware of any joint replacements. Joint replacement surgeries are more successful than ever, but some positions will still be contraindicated postoperatively. Make sure your student has been cleared for practice by their medical team and get clear guidelines on what range of motion is considered safe.

3. Osteopenia and osteoporosis

Osteoporosis is a condition in which loss of mass makes the bones porous and brittle, much more vulnerable to collapse or fracture from even minor injury. Osteopenia, also called low bone mass, is lower than normal bone density that has not reached the point of osteoporosis. These conditions are increasingly common as we age; data from the 2010 census suggests that more than half of Americans aged over 50 had either osteoporosis or low bone mass, particularly postmenopausal women of Caucasian or Asian descent. The joints most commonly affected are the spine, ribs, hips, and wrists. 

General considerations:

Many people don’t know they have low bone mass until they experience a fracture, so as a teacher of older students it’s worth taking basic precautions whether your student is aware of having low bone mass or not. The simplest of those is to reduce the likelihood of falls. 

However, some bone fractures can occur due to even more subtle factors, like chronic postural changes. Osteoporosis tends to exacerbate thoracic kyphosis, or rounding of the upper back, so positions that put additional force through this area—like standing forward fold (uttanasana), seated forward fold (paschimottanasana), seated twist (ardha matsyendrasana)—are not generally recommended.

It can help to:

• Incorporate poses and practices that improve coordination and balance like crescent lunge, eagle pose (garudasana), or the kneeling balance bird dog. At the same time, reduce the risk of falls by avoiding jumping, bouncing, and rapid changes of direction as well as removing tripping hazards like props, electrical cords, low furniture, and loose rugs.

• Focus on poses that counter thoracic kyphosis—like mountain pose (tadasana), bird dog, and active backbends like locust pose (salabhasana).

• Avoid rounded-spine forward folds and twists, and replace them with those where the spine is neutral (such as the supine hamstring stretchsupta padangusthasana) or supported (such as a reclined spinal twist).

• For students with known osteoarthritis, avoid positions that place unaccustomed weight directly on weakened bones. Headstand (sirsasana) and shoulderstand (salamba sarvangasana) are contraindicated if there is osteoporosis in the spine, because of the weight these poses place on the neck.

4. Vascular and heart conditions

The CDC names heart disease as the leading cause of death for Americans over 65, so it’s reasonable to assume that some of your older students may have heart disease or hypertension (persistently elevated blood pressure) if you are teaching in a group setting.

General considerations:

The implications of heart disease in yoga practice relate to poses and practices that require cardiovascular exertion, or strongly influence circulation. Known conditions should be monitored closely by your student’s doctor, but it’s sensible to take general precautions.

It can help to:

• Emphasize practices that soothe the central nervous system. These include slow and mindful movement, restorative poses, guided relaxation, savasana, yoga nidra, meditation, and calming pranayama techniques. Humming bee breath (bhramari), left-nostril breathing (chandra bheda), and lengthened exhalations are considered particularly calming.

• Start gently and progress slowly. There’s nothing wrong with building strength, stability, and endurance, but allow your student’s circulatory system to gradually adapt to yoga practice.

• Avoid rigorous or heated practice and observe your students' breathing, color, and facial expressions closely to ensure that they don’t overexert themselves and overtax their circulatory systems.

• Avoid forceful breathing exercises, including bellows breath (bhastrika), skull shining breath (kapalabhati), or breath retention (antara kumbhaka), all of which have the potential to overstimulate the nervous system and thereby increase blood pressure.

• Avoid strong inversions, which significantly increase blood pressure in the head; headstand, shoulderstand, forearm stand (pincha mayurasana) and handstand (adho mukha vrksasana) are commonly contraindicated. You may also suggest that your student consults their doctor for advice on more gentle inversions including downward facing dog (adho mukha svanasana), standing forward fold, or legs up the wall (viparita karani).

5. Other conditions: respiratory, diabetes, cancer

Any population can experience serious health concerns (such as cancer, diabetes, spinal stenosis, respiratory illness, stroke, Alzheimer’s, or dementia), but prevalence does increase with age. Any serious illness requires specific advice from the student’s medical team, but even if yoga practice is unable to help the student’s symptoms directly, a growing body of research suggests that it may be able to help indirectly.

• Reflective practices that soothe the nervous system can reduce perceived pain and support faster healing and improved immunity. 

• Any condition that limits our capacity to breathe freely, including respiratory disorders and chronic pain, could benefit from gentle, gradual pranayama. 

• Yoga philosophy offers concepts designed to build mental and emotional equilibrium in the face of hardship. It may be appropriate to discuss non-attachment (vairagya), reflection or self-study (svadhyaya), contentment or gratitude (santosha), and surrender to a higher power (ishvara pranidhana).

• Even something as simple as connecting regularly with a friend or two in a private or small group yoga session can have a hugely positive influence on energy and mood.

It can be daunting to start working with anyone who has an injury or medical condition. While it helps to know about the conditions we commonly encounter when working with older beginners, there’s no need to be fearful, or treat older students as fragile. We don’t even need to be experts—our role is to simply help and support however we can. Even when we are unsure how to start, we can rely on simple and time-honored practices like progressive relaxation or mindful breathing to help our students feel better.

Footnotes:

1. Inflammaging and anti-inflammaging: A systemic perspective on aging and longevity emerged from studies in humans: Claudio Franceschi, Miriam Capria, Daniela Monti, Sergio Giunta, Fabiola Olivieri, Federica Sevini, Maria Panagiota Panourgia, Laura Invidia, Laura Celani, Maria Scurti, Elisa Cevenini, Gastone C.Castellani, and Stefano Salvioli, https://www.sciencedirect.com/science/article/pii/S0047637406002491.

2. Innate immunity and inflammation in aging: a key for understanding age-related diseases: Federico Licastro, Giuseppina Candore, Domenico Lio, Elisa Porcellini, Giuseppina Colonna-Romano, Claudio Franceschi, and Calogero Caruso, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1166571/.

3. Exercise, Inflammation and Aging: Jeffrey A. Woods, Kenneth R. Wilund, Stephen A. Martin, and Brandon M. Kistler, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320801/.

4. Impact of Yoga and Meditation on Cellular Aging in Apparently Healthy Individuals: Madhuri Tolahunase, Rajesh Sagar, and Rima Dada, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278216/.

5. Yoga, Meditation and Mind-Body Health: B. Rael Cahn, Matthew S. Goodman, Christine T. Peterson, Raj Maturi, and Paul J. Mills, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5483482/.