Yoga for OsteoporosisSitting down with Rehabilitative Medicine Specialist Dr. Loren Fishman

Loren Fishman M.D. has been a practicing rehabilitative medicine specialist for over thirty years. As a pioneer in integrative medicine, from the start of his practice, he incorporated yoga into patient care. A prolific, published researcher, he is the author of eight books, including Yoga for Osteoporosis, Yoga for Osteoarthritis, and Yoga for Back Pain. His research into Yoga for osteoporosis has provided valuable insight into adapting yoga practice to support building bone and maintaining health.

Currently based in New York, Dr. Fishman will be visiting Los Angeles to share his research and experience at Exhale’s Center for Sacred Movement in November.

Leslie Kazadi: What made you start yoga?

Loren Fishman M.D.: When I was about nine, I saw a TV show called “Ram of the Jungle,” where a kid rode on the neck of an elephant. He also did some yoga.  And I said to myself:  That’s for me!  I just loved it.

LK: You have been doing Iyengar yoga for 40 years every day?

LF:  I sure have.  I was in Paschimotanasana for 30 minutes this morning.  It’s better now than when I started.  Yoga works better and better for me.

LK:  What is the greatest benefit of yoga for you?

LF: Yoga has helped me understand myself and how I relate to the rest of the world.  Yoga brings out a sense of calm seeking, where you are interested in finding things out, but you are not anxious about it. It’s a quiet keying-up

LK:  What led you to go to India?

LF: I was at Oxford studying the foundations of mathematics.  It seemed to me that the real foundation of mathematics lay in grammar.  The rules for equations are part of language, just as grammatical rules are.  I thought about Patanjali. He didn’t just write the Yoga Sutra, he also was a physician, and wrote one of the earliest books on grammar.  So I went to India to study Sanskrit grammar.  It didn’t take long before I realized I was never going to know as much Sanskrit as people who’d been studying it all their lives.  So I went in the other direction, the direction of Patanjali. I began searching for people who’d attained some liberation through yoga.  I knew that Mr. Iyengar had gone some distance in that direction , because I had read his book “Light on Yoga.” His yoga was so much more refined, more conscious than anything I’d ever encountered.  So I went to see him. I knocked on his door and he wasn’t there.  I had to wait a week.  But when we finally met we immediately hit it off. So much so that I didn’t want to leave. Actually I stayed for a whole year.  He was very generous.  Everything I asked him, he would answer fully.

LK:  I have gone to Pune to study with Iyengar.  But now it is a whole process to apply for acceptance with a long waiting period.  When you went in 1972, what was it like?

LF:  He lived on one side of the street in Pune in a little bungalow, which was very nice, very small.  And on the other side of the street, he had an almost identical bungalow where he taught yoga.  He was very open and informal in spite of his absolute certainty about how the poses should be done.  Even though he was dead serious about the poses, he had a good sense of humor.  He was very open and loose and friendly. And whether he was teaching or not he was like a Jewish grandmother, saying, “Eat some more dinner!”

LK:  You are 72 years old.  From your own practice and practicing with Mr. Iyengar, who is 94, do you think there are any poses that are contraindicated strictly due to age?  If people don’t have osteoporosis or other things, are there just poses that you think:  you don’t need to do that anymore?

LF: No, people age at very different rates. Some eighty-year-olds seem like they’re thirty, and vice  versa. Three factors are key in this  process:  genetics, epigenetics and environment, and a lot of interplay.  Various excellent studies have shown that yoga can change which parts of your DNA are upregulated, and which are downregulated.  Whether a person can or should do a particular pose is dependent not on calendar age but on the condition of the person who is practicing.

LK:  Your workshop at Exhale is entitled “Yoga Therapeutics.”  How do you distinguish yoga from yoga therapeutics?

LF:  It’s a continuum.  The yoga therapist takes a person who is below sea level — who has something wrong — and brings him up to sea level, brings him up to normal. I call it medical yoga. But what the yoga teacher does is different.  The yoga teacher does indeed take students to above normal, over the rainbow, as far as they want to go, along the way to liberation.

LK: What makes an effective yoga therapist?

LF:  In order to be a good therapist, you have to be a good teacher.  One ought to  have taught for 10 years before you become a therapist.  But when you have the experience of teaching and you have studied, yoga can be done one-on-one, in which case it becomes much more like medicine.  A yoga therapist should listen to what you say, have seen or experienced the problem and seen or experienced something that cured the problem before. Without direct experience, the yoga therapist should be able to sit there and think over the individual’s problem, not just react on the spot. Yoga therapy shouldn’t be a cookie-cutter endeavor.  It should be tailored to the individual.

LK: Your integrative medical practice uses many modalities.  When do you use yoga rather than other modalities?

LF: It depends on what the patient needs: Tai Chi is excellent for balance; Alexander technique helps with body awareness. Yoga is best for blood pressure, arrhythmias, rotator cuff syndrome, scoliosis, osteoporosis, back pain, and a host of other medical conditions. Just about every day I get a new idea about how to use yoga for medical problems.

LK:  You introduced yoga into your medical practice long before it was popular.  How has it evolved over the years?

LF:  At first, I had to almost disguise it.  I would say, “You know, I taught you that maneuver and it worked to make you feel better; actually It’s a yoga-like exercise.”  I wouldn’t even call it asana.  Somewhere between the late 90’s and the early 2000’s, it changed, partly because yoga had become so popular and so widespread.  The medicinal properties of yoga became common knowledge. People began coming to me because I knew about yoga and did it myself.

LK:  In your integrative practice, do you prescribe yoga practices other than asana? Do you also teach meditation?

LF:  Yes, I teach it one on one.  I learned from Mr. Iyengar’s elegantly understated breathing and meditation sessions.  Meditation is like a Japanese drawing. Much of the meaning is in the space between the lines: what is not said.

LK: Whom do you think meditation is the most effective for?

LF: I think meditation is effective for everyone. I’ve never met anyone who couldn’t benefit from it, patient or friend or family member. It almost always enhances whatever you are doing.  I have pure one-to-one meditation sessions with people who are experiencing intractable pain, sometimes with stunning results.

LK:  It’s difficult for most people to start and to maintain a meditation practice.  How do you inspire people to create that home practice?

LF: I introduce it slowly. At first, we may do as little as three minutes. Then I mix pranayama with more contemplative techniques.  I use Tantric stuff.  I try to figure out how to blend different techniques together. Blending different ways to meditate together appears to me to be even more effective than any one of them alone. Maybe it’s sort of heresy to say it, but I must say there are times when I take something from a Kundalini person and mix it with something I learned from Sally Kempton.

LK:  In your osteoporosis study, you have twelve evidence-based poses.  Could you explain what that means?

LF:  It’s based on the pilot study I published in a peer-reviewed journal in 2011. After all the participants had bone density scans, half of them were taught the twelve poses, and encouraged to do them every day for two years.  The other half wasn’t taught any yoga. Then  we got another DEXA scan on all of them.  The non-yogis lost a little bone.  But the yogis gained more than .6 on the T-scale for their lower backs and almost an entire point — .94 –with regard to their hips. This was so impressive I made a DVD for participants and now am now doing an international study.

LK:  You made a couple of changes when you expanded the study.  What are they and why did you make them?

LF:  Right now, I have over 65,000 hours of people doing these poses.  We have about 575 people in our study all over the world.  The protocol is basically the same as the pilot.  Only this time I am asking for a lot of blood work to make sure participants are normal.  And I changed two of the poses to make them safer because I am not there with the study participants directly to give them personal adjustments when they are doing the yoga.  There are three forms of each of the poses.  There is a very modified pose, sort of a transitional pose and then the classical pose.  Participants are asked to use the DVD I supply and to accurately record how much yoga they are doing.  We have a score card online with all the poses so they tell us which poses they did.  Using that method we get a dose/response relationship, the way the drug companies do.

LK:  Have you had any adverse events to report in the study?

LF:  So far in 65,000 hours, there have been no adverse events related to yoga.  Twelve people have had fractures but none of the fractures have anything to do with yoga.  Most of them are in the foot.  No spinal fractures whatsoever.  No hip fractures.  We have had 40 people who have completed the second DEXA scan.  And 80 percent of them are better than they were when they started the study.

LK:  A lot of people think of osteoporosis as a women’s disease.  What percentage of men get it?

LF:  It’s hotly contested.  But at last one quarter of men; nobody would deny that.  Some people say it’s closer to a third or even half.  I have a number of men in my study who are getting better, just as the women are.

LK:  You are doing research on osteoporosis.  Are you also doing research on osteoarthritis?

LF:  I am, but not with yoga.  I’m using packed platelets and regenerative medicine.  I am injecting people who have arthritis of the knee with platelet-rich plasma which stimulates the cells to make cartilage.  I have seen MRIs of people who before the injections had 3 millimeters of cartilage and a year later, they have not 3 millmeters  but 9 millimeters. So it really appears to work.

But you asked about research. I am doing research on scoliosis and have  had fantastic results using yoga.  We use one pose, or sometimes we go all out and we use two poses,  done on one side only.  The results are very impressive, and I intend to publish them:  30 percent reduction in the curve in 4.4 months.  That’s a big deal.

LK: Do you see evidence that yoga can arrest or reverse osteoarthritis?

LF:  Osteoarthritis is a process.  Yoga can slow the process and possibly even arrest it.  When you do yoga or endurance-type exercise, you also free a molecule, PGC – 1 alpha, a powerful anti-inflammatory that slows down arthritis.  Yoga stretches, and will also improve your range of motion, raise your strength, is excellent for balance and using muscles appropriately so the joints don’t suffer. It reduces anxiety which makes you get tight and puts more pressure on your joints than you need. Certainly, yoga can reduce the ill effects of arthritis.

LK:  In your recent New York Times  series, you thanked your audience for giving you new ideas for research topics.  Would you care to name any?

LF: Sure. Can we look at the epigenetics of arthritis and can we see if yoga will change which genes are active?  There is excellent work by Dean Ornish showing that yoga does change the epigenetics, meaning which genes are up-regulated so they are producing proteins; and other genes are down-regulated.  You could also do that with arthritis or osteoporosis and I think it would be very interesting to do.  It might also be possible to do for central parts of the brain.

LK:  One reason you became a doctor was to understand how yoga works.  What is unique about how yoga works?

LF:   To me, yoga is a self-improvement program that really works. To me, yoga is a beautiful thing.  The beauty starts at the outside with the pose, and with persistence gets deeper and deeper into you.

Leslie Kazadi, CYT, E-RYT500, is a yoga therapist, anatomy geek, and yoga researcher who is passionate about making yoga accessible to every body:

Dr Loren Fishman is teaching a weekend workshop on Yoga for Osteoporosis and Osteoarthritis November 14-17 (open to the public) as part of Annie Carpenter’s teacher training program at Exhale, Venice:

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