Editor's note: The below are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional. Yoga teachers should remain within their scope of practice: This means not attempting to diagnose, treat, or offer medical advice to students.
With more than 21 percent of adults in the U.S. living with arthritis—46.5 million, projected to rise to 67 million by 2030—it’s useful for yoga teachers and students to know how to adapt the practice for this common condition.
For a general understanding of how to approach yoga with arthritis, I visited with Bill Reif, who, in addition to being a physical therapist and the author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It, is experiencing some early symptoms of arthritis himself. He shared some of what he has learned through four decades of teaching patients how to alleviate pain using movement, and through the management of his own arthritis.
“Arthritis doesn’t necessarily mean drastic changes to yoga practice, but it does mean you might need to lessen the load on the joints,” Reif says. But before we get to his specific do’s and don’ts for practicing yoga with arthritis, as well as some sample modifications, let’s take a look at the condition itself.
Arthritis doesn’t necessarily mean drastic changes to yoga practice, but it does mean you might need to lessen the load on the joints.
Types of Arthritis: Causes and Symptoms
Of the many types of arthritis, the two most common are osteoarthritis (OA) and rheumatoid arthritis (RA). Both are associated with stiffness, tenderness, and swelling of the joints, but there are a few distinctions between the two.
According to the Arthritis Foundation, OA affects the knees of one in two adults during their lives, and one in four people will develop OA symptoms in their hips by age 85. Sometimes conceptualized as “wear and tear arthritis,” this type of arthritis occurs when the cartilage padding joints roughens and deteriorates. OA can be caused by repetitive movement and joint injuries, but advancing age, gender (women are more likely to have OA), genetics, and larger body size can also increase risk of the condition.
Though OA can affect any joint, and may occur in the lower back, neck, fingers, and toes, it is very common in the larger, weight-bearing joints of the knees and hips. “You may also notice reduced range of motion in the knee or hip joint, or ‘crepitus,’ which is a ‘catching’ or ‘clicking’ in the joint after doing a difficult yoga practice, climbing stairs, or standing or walking for long periods,” Reif says. (OA symptoms are generally worse after activity, better after rest.)
RA affects one percent of the population. Unlike osteoarthritis, rheumatoid arthritis is caused by an immune response that damages the joints and organ tissues, sometimes changing the shape of the joints. Though its exact cause is unknown, some risk factors and correlations are known. It is widespread among adults who are middle-aged and older, especially women, commonly striking between the ages of 40 and 60. In addition to a genetic component, larger body sizes and smoking can correlate to having RA. Environmental exposures may also play a role.
It is more symmetrical than OA—the same joints are often affected to a similar extent on both sides of the body—and often affects different joints: “While OA will initially show up in your larger weight-bearing joints, RA will typically present in the smaller joints of the hands and feet,” Reif says. RA usually gets worse after periods of inactivity, so the symptoms may be worse when first getting up in the morning. At times, the distinction between osteo and rheumatoid arthritis may be blurry. “Many of those with early symptoms of arthritis, like me, may not know which type they have, or they might have both,” Reif explains. “Fortunately,” he says, “both types can often be helped by mindful, controlled movement like yoga.”
Common Treatment for Arthritis
Exercise, which does not have the side effects of some medications often used to treat OA and RA, has been shown to be safe and beneficial for those with arthritis, and it is a cornerstone of The American College of Rheumatology guidelines for treating it. However, it is important that the exercise be “joint-friendly,” that is, focused on low-impact strengthening, balance, flexibility, and aerobic conditioning. Yoga, one type of joint-friendly exercise, seems to relieve symptoms of both types of arthritis while also improving mood.
Despite the benefits of exercise, people who are experiencing pain may be tempted to curtail movement—two in five of those with RA and nearly half of those with knee OA are inactive, perhaps due to fear of movement, which is the belief that movement will lead to injury or increased pain.
Those with severe OA who find that symptoms are worse after strenuous activity, or those who are new to yoga, may appreciate restorative yoga or a gentle yin class. Those with RA who have difficulty bearing weight in the hands may wish to forego the push-up-like movements common in vinyasa practice and opt for a hatha, Iyengar, or other potentially “hands-free” practice. Those with either type who have difficulty standing for long periods may prefer chair yoga.
Practicing Yoga With Arthritis
In any type of practice, people with arthritis can avoid aggravating their joints by considering the following general “do’s” and “don’ts” and adhering to the personalized advice they receive from their doctors.
For a practice that puts many of these do’s and don’ts into play, see “A Joint-Focused Yoga Sequence for Arthritis."
As is the case with a variety of underlying conditions, there is one overriding “don’t”: Don’t ignore any increase of symptoms from a yoga practice or any other sort of activity.
“I make a distinction between discomfort and pain,” Reif says, explaining that those with arthritis may commonly have some discomfort in their joints; in his view, doing yoga while feeling some discomfort is acceptable as long as yoga doesn’t increase these symptoms to the point of pain.
“I believe this needs to be emphasized, since I’ve heard the suggestion that those with arthritis can work through pain,” Reif says. According to the Mayo Clinic, staying in a pose or continuing a movement despite pain can cause further joint damage.
While experienced yogis may know their limits, for those with arthritis who are new to yoga, Reif suggests initially doing “less than you think you can do,” for instance, starting with a few gentle poses in a short practice, then if you feel you experience no increase in symptoms during or after the practice, gradually increasing intensity and duration.
Use recommended joint supports.
“Ask your doctor if you should be using a splint or other supportive device to protect the affected joints when you do yoga,” Reif says. “These can minimize flare-ups.” Splints for the wrists and hands, knees, and ankles are often recommended to decrease stress on the joints and ligaments as well as provide proprioceptive feedback.
Warm up...and stay warm.
A hot shower or brisk walk before yoga might make your joints more amenable to the demands of a practice, especially on days when symptoms flare. Especially for someone with RA, pain or stiffness may be worse when they first wake up, so warm-ups are valuable before a morning yoga practice. For others, falling barometric pressure and lowering temperatures seem to cause increases in symptoms; longer warm-ups may be helpful on those days as well.
“Keep warm during practice, too,” Reif advises, which may mean practicing in a well-heated room or wearing an extra layer of clothing.
Take weight off aggravated joints.
Reif says, “Your body will thank you if you routinely ‘off-load’ affected joints.” Since RA and OA often affect different joints, different poses may be bothersome. “Since OA usually affects the larger joints, like the hips and knees, asanas that stress the knee, like pigeon, might be more difficult. Whereas for those with RA, which primarily affects the smaller joints, poses that place weight in the hands, like upward and downward dog, crow, plank, and wheel might be an issue.”
The level of modification necessary depends on how advanced the symptoms are. To off-load minimally symptomatic hands and wrists in plank and downward dog, those with only mild symptoms could place their hands on a wedge, while those with more severe symptoms may need to keep their knees down and/or practice plank pose on their forearms. To keep the knees and hips comfortable while sitting, some students may need to sit on a bolster, while students with more severe symptoms may be happiest sitting in a chair.
Have support handy to help with balance if needed—or skip the balancing.
Those with OA in the hips or knees can be at a greater risk for falls, and the more lower-limb joints affected, the greater that risk. Those with RA also may have an increased risk of falls and related injuries. Decrease the risk of falling in yoga by standing near a wall, a barre, or have the back of a chair nearby to hold on to as needed during standing poses.
Approach balancing poses step-by-step, ensuring your stability at each step. A history of falls is the greatest risk factor for falling, so if you’ve fallen before, you may opt for chair yoga or a floor-based yoga practice (such as yin, restorative, or gentle yoga).
Furthermore, for those experiencing arthritis symptoms in the feet, knees, or hips, standing balance poses—which move all the body’s weight through already-aggravated joints—may lead to increased discomfort. For instance, those with minor symptoms in the feet, knees, or hips may take weight off the standing leg in a balance pose like tree by practicing it with their back to a wall, while those with more severe symptoms may want to keep the ball of their lifted foot on the ground in that pose, so that aggravated joints do not have to bear all their weight.
Stick to a range of joint motion that feels good.
While exploring range of motion in the joints is central to maintaining lifelong mobility, going too far into painful ranges may worsen pain and even cause further joint damage.
Reif suggests that those with arthritis in the lower back may feel better avoiding extremes of range in spinal movements such as twisting, forward folding, and backbending. Students with arthritis may choose to go less far into poses that call for these actions, for example, choosing a sphinx over an upward facing dog or hugging the knee for the seated twist marichyasana II instead of trying to put the elbow outside the knee. Similarly, those with arthritis in the knees may choose not to bend the knee to a full 90 degrees in a standing warrior pose, and not flex it fully for a hero pose—instead sitting up higher on bolsters or blocks.
“Each affected joint will have its own edge, which you should approach in order to gain mobility, but be careful not to exceed capacity,” says Reif. If a motion is outside your comfort level, such as when curling the toes under for a crescent lunge, substitute a warrior I, keeping your back foot down if that is more comfortable.
Feel free to limit repetitions.
“I like to practice some poses just once or twice, instead of repeating them many times,” Reif explains, since overuse or repetitive motion may worsen arthritis pain. While repeating any pose that makes demands on affected joints may be aggravating, vinyasas (the plank, chaturanga, upward facing dog, downward facing dog transition) may be especially difficult for those with hands affected by arthritis.
Prioritize the alignment that feels best for your joints.
“A painful joint will experience more strain when not optimally aligned,” Reif says. “And maintaining this alignment may be more important for students with arthritis than for those who are non-arthritic.”
Chronic knee misalignment, for example, may increase the progression of arthritis and decline in function. Students may find that it takes a few breaths in a pose to fully process a cue like “Track your knees toward the centers of your feet,” which aims to help them find their optimal alignment, that slow transitions help them to retain awareness of their positioning.
Reif acknowledges that “Some joint deterioration may cause difficulty attaining healthy alignment.” According to Reif, “It’s okay to deviate somewhat as long as pain does not increase.”
Decrease “ups and downs.”
Reif says that to avoid aggravating knees, or even feet or hips, some students with arthritis may find it helpful to minimize transitions down to and up from the floor. You may want to organize your practice so that you do all standing poses in succession, then come down to the floor for seated, supine, and prone poses and stay there for savasana.
According to one study, mantra meditation can effectively alleviate pain symptoms in those with knee OA. In addition, mindfulness meditation may improve coping skills and mood in those with RA. To practice mantra, repeat (aloud or silently) a word or phrase that calms you, like “peace,” or “shanti,” or “I've got this” in a seated or restorative pose. To practice mindfulness, come to an awareness of what the present moment contains, gradually moving your awareness inward, to, for instance, the sensations that accompany each breath.
Invest in a thicker mat if more padding is helpful.
A thicker yoga mat may help to take pressure off your feet when you are standing, and lessen the pressure on many joints when you are lying down. (Placing a blanket or non-slip towel on top of your mat might help, too, but could increase the chances of tripping.) “Be aware that padding might disrupt your balance,” says Reif. Warrior poses can be practiced with shorter stances to increase stability, and if you are able to balance comfortably, step off the mat for those poses.
In Daily Life
To keep arthritis symptoms at bay, Reif recommends breaking up periods of sitting during your day by getting up, walking around, and doing some stretches, like this gentle standing twist: “Turn your torso from side to side, letting your arms swing freely. This will loosen your shoulders, elbows, hips, and knees and provide some added space between these joints.”
In addition, you may want to seek out resources that offer suggestions specific to the joints in which you are experiencing arthritis. For instance, arthritis can cause bunions, malalignments of the big toes for which the information in this article may be helpful; if arthritis is contributing to a rounding of your upper back, you may wish to check out “Yoga for Kyphosis”; since arthritis can contribute to carpal tunnel syndrome, these tips may come in handy. For those whose arthritis affects the sacroiliac region, these “Do’s and Don’ts for Sacroiliac Dysfunction” may be of value.
Dietary modifications may also be helpful because certain foods, like salt, sugar, alcohol, and saturated fats (found in meat and some types of dairy, for instance) can trigger inflammation. A diet high in anti-inflammatory foods like olive oil, fruit, whole grains, legumes, and spices like ginger and turmeric can reduce symptoms of RA, and it seems that a diet low in cholesterol and buttressed by nutrients like vitamin K may benefit those with OA.
Socializing is a component of group yoga practices that may motivate students of all ages and abilities to seek out yoga classes, and this aspect of class may be particularly beneficial to those with arthritis: Face-to-face socializing appears to lower the probability of depression, to which some of those with arthritis are at risk. Yoga class, in addition to reducing pain and enhancing mobility, may offer mood-boosting camaraderie!