Topic: Exercise

Boost Lower Body Strength

Friday, September 30th, 2011 by American Senior Fitness Association   View This Issue of Experience!

This easy-to-learn buttocks exercise, which also works the legs, can help older adult fitness participants increase lower extremity strength, an important factor in preserving mobility and personal independence. Stand behind a sturdy straight-backed chair, placing both hands on top of the chair’s back. Your feet should be a comfortable distance apart (about shoulder width). Bend as if to lower your buttocks onto the seat of an imaginary chair directly behind you. This will involve pushing the buttocks backward somewhat while bending. Do not drop the buttocks below knee level. Return to starting position and repeat. Gradually build up to performing approximately 12 repetitions. One added advantage of implementing this version of the squat is that it includes balance support.


Stick With It

Monday, May 23rd, 2011 by American Senior Fitness Association   View This Issue of Experience!

The passage of time can be a good thing under the right circumstances. That’s the take-away from recent research conducted by cardiologist Paul Bhella of the JPS Health Network. He found that a lifelong (or long-term) devotion to physical activity can preserve the heart tissue of senior citizens – to a degree, in fact, that is comparable or superior to that of younger, healthy persons who don’t work out, according to a report by Alex Branch of the McClatchy-Tribune.

By now most people know that physical exercise is heart-healthy. But some may fear that they started their fitness programs too late in life to do them any good. Over time, the human heart loses mass and elasticity, which increases the risk of heart failure. But here at SFA, we emphasize that it is never too late to get going and reap worthwhile physiological and psychosocial benefits.

At the annual meeting of the
American College of Cardiology in April, 2011, Dr. Bhella discussed his research team’s findings. They compared the hearts of subjects over age 65 who had exercised different amounts (if at all) during their lives with the hearts of subjects under 35 who, while healthy, were physically inactive. MRI results showed that youthful heart mass was maintained in the older adults who had habitually exercised four or five times per week. Better still, exercising six or seven times per week not only preserved mass, but also promoted new mass – exceeding that of youngsters (ages 25 to 34) who didn’t exercise. Similar outcomes were observed regarding heart elasticity.

For the study’s purposes, “exercise” was defined as aerobic activity, such as walking or cycling, generally performed for more than 20 minutes per session. Importantly, a “lifelong” commitment to exercise did not necessarily mean uninterrupted physical activity since childhood – or even since high school. Most of the senior citizens with notably desirable heart mass and elasticity levels had been physically active for about 20 to 25 years. That suggests that middle-aged and older persons can gain greatly by embarking on a regular program of physical exercise.


Exercise Cuts Older Adult Health Costs

Friday, May 6th, 2011 by American Senior Fitness Association   View This Issue of Experience!

While most senior health-fitness professionals already advocate insurance coverage of structured physical exercise programming for older adults, the following news release strongly reinforces that position:

Structured exercise and physical activity programs should be covered by insurance as a way to promote health and reduce health care costs, especially among high health-risk populations such as those who have diabetes.

So says Marco Pahor, M.D., director of the University of Florida Institute on Aging, in an editorial Wednesday, May 4, in the Journal of the American Medical Association. Pahor’s paper accompanies an analysis of multiple clinical trials that examined the effect of exercise and physical activity on the control of blood glucose levels.

“Cumulative work over the past few decades provides solid evidence for public policymakers to consider structured physical activity and exercise programs as worthy of insurance reimbursement,” Pahor said.

A host of studies have linked exercise programs with improved health measures related to blood pressure, lipid levels — including cholesterol and triglycerides — cardiovascular events, cognition, physical performance, premature death and quality of life. People who take part in programs that contain both aerobic and resistance training are likely to get the greatest benefit, compared with people who do only resistance exercises.

The study that Pahor’s editorial accompanied, conducted by Daniel Umpierre, M.Sc., of the Hospital de Clinicas de Porto Alegre, Brazil, and colleagues, compared the association between physical activity advice and structured exercise programs, respectively, and markers of diabetes.

Analyses of interventions to promote physical exercise in adults have found that compared with no intervention, exercise programs are cost-effective and have the potential to improve survival rates and health-related quality of life.

Some insurance providers already include a fitness benefit for members, such as monthly membership at certain fitness centers or access to personal trainers or exercise classes at reduced cost. Use of such health plan-sponsored club benefits by older adults has been linked to slower increases in total health care costs.

In one study, older adults who visited a health club two or more times a week over two years incurred $1,252 less in health care costs in the second year than those who visited a health club less than once a week. Programs among people with lower incomes can also pay off, because people in that group are otherwise more likely to forego health-promoting physical activity because of economic constraints or safety concerns.

“People are willing to invest in improved health, but if you have a fixed amount of resources then you want to choose where you get the most health for the dollar,” said Erik Groessl, an assistant professor of family and preventive medicine at the University of California, San Diego, and director of the UCSD Health Services Research Center. Groessl was not involved in the current analysis.

Group training or walking programs, for example, can be cost-effective, sustainable forms of physical activity that don’t require expensive health care professionals or equipment. But more costly interventions that yield dramatic results might also be worth the expense.

With respect to type 2 diabetes, Medicare reimburses for approved self-management education and medical nutrition therapy programs. But no specific reimbursement is given for any physical activity or exercise program, despite evidence that such programs can help improve health and cut costs.

Questions remain as to what format reimbursable exercise and physical activity programs should take, what population group should be targeted, and at what stage of life or health status would a lifestyle intervention be most cost-effective to implement.

Various studies, including the UF Institute on Aging Lifestyle Interventions and Independence for Elders, or LIFE study, are aimed at answering those questions through randomized controlled trials that can provide data about the efficacy and cost-effectiveness of structured activity programs with respect to a range of health outcomes. Funded by the National Institute on Aging, the LIFE study is the largest of its kind to examine physical activity and health education as a way to prevent mobility disability among older adults, and accounts for the largest federal award to the University of Florida.

The institute will break ground on May 26 for a 40,000-square-foot complex within UF’s new $45 million, 120,000-square-foot Clinical and Translational Research Building, which will serve as headquarters for this research and others aimed at speeding scientific discoveries to patients.

“There is a lot of evidence that physical activity works, and I think it’s time to start putting it into practice more widely,” Groessl said.



Thursday, March 24th, 2011 by American Senior Fitness Association   View This Issue of Experience!

Recent comments on the Brain Fitness for Older Adults professional education program:

  • "I could not put the materials back down because it was so fascinating. I loved the video. Very informative." Margaret, Tennessee
  • "I liked the suggested plans for brain fitness projects, and covering just enough historical and physiological content. Good mix of reading and video content. Very good program." Lori, Virginia
  • "I liked the variety of material — practical and theoretical. The references were excellent, and the additional resources were helpful." Suzanne, Oklahoma
  • "Material presented well. Amount of material is a bit overwhelming." Mary, Pennsylvania
  • "I liked the simplicity of materials and instruction sheet suggestions to complete class." Leslie, California
  • "Very easy to understand — even technical terms made sense." Betty, Illinois
  • "Extremely educational, comprehensive, and practical! Thank you so much for making this unique course available!! It will be invaluable for helping my clients maintain and improve their quality of life!" Hope, Florida
  • Recent comments on the Long Term Care Fitness Leader professional education program:

  • "As an activity coordinator in LTC facilities for the past 12 years, I’ve thoroughly enjoyed studying for this course — Part One and Two! Plan to take more courses from SFA. Will share much of what I’ve learned with the staff at my ALF workplace. Very informative!" Elise, Florida
  • "Great information. Very useful material that can actually be applied to real life situations. Truly enjoyed this applicable material. I was refreshed by the material and I also learned a few new techniques and ideas. Material is very helpful whether as a beginner or a refreshment course. Very good!" Jose, New Mexico
  • "What I liked most about the course — Everything!! I enjoyed all the materials and videos. I liked the way these were organized and boxed in sets for future reference. I liked the wide range of topics covered. I especially enjoyed the in-depth coverage on arthritis, as well as the overview of commonly prescribed medications and their effects on exercise." Mary, Illinois
  • "I liked the conversational, practical writing style. Helpful information." Cathy, Maryland
  • "All great! I liked the information flow and the in-depth info. Great info." Debra, Ohio
  • "I loved all the terrific activity ideas that my frail elderly fitness participants can take part in both safely and successfully. These workouts and activties are fun, beneficial, and easy to conduct. They have my participants smiling, laughing, moving, and engaging with each other. Thanks a million, SFA!!! " Sharie, Florida
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    Thursday, March 24th, 2011 by American Senior Fitness Association   View This Issue of Experience!

    Recent comments on the Senior Fitness Instructor professional education program:

  • "I am glad I chose your organization for this course! Great materials! Lots of great information that I can use for reference over and over again! I liked the materials included. I like that you
    had everything to work with. The manual is very good and useful as a reference." Pauline, Washington
  • "I enjoyed having my eyes opened to some very important matters concerning critical areas for seniors." Randall, Texas
  • "Terms I have encountered in my [organization name omitted] exam materials, which weren’t fully explained, were clarified much better with SFA materials. And I like that the course is specifically dealing with seniors and not the whole population." Joan, California
  • "I liked the exercises displayed with each section. It will be helpful in class planning." Cindy, Missouri
  • "I wish more [organization name omitted] credit courses (by other companies) were as well laid out and knowledgeable in their subjects. I have been [organization name omitted] certified for 15 years and this is one of the best correspondence courses! Extremely well organized and, most importantly, the questions and content are useful for this subject area." Rachel, Washington
  • "Thank you for this wonderful program. Though it has taken me a while to complete, it was well worth it. I found both courses (Part One and Two) to be informative and thorough. I look forward to helping others and being a positive role model for the American Senior Fitness Association. Great material! Very informative relative to senior safety during exercise. Enjoyed all aspects… I enjoyed the study of specific exercises and programs for senior adults — also, information regarding nutrition. I would also like to mention the professionalism of the staff at SFA, particularly Grant. He is always kind, polite and able to answer my questions. Thank you!" Sydney, Michigan
  • "I love this course! I like your open book approach. I learned so much. Once I opened the book I could not put it down. I love the exercise plans as well as the motivation chapter. Thanks! I liked all the information about risk factors and senior nutrition. I learned a lot. Thanks for this opportunity to become a senior fitness instructor. Although persons aged 65 and older comprise only about 12 percent of the U.S. population, I see my future as a senior fitness instructor wide open." Graziella, New Hampshire
  • "This is one of the best manuals for older adults that I have found in my studies! Many thanks to Janie Clark! The content of the course is excellent and most useful. It was especially helpful having the exercises pictured along with the ‘instructor-to-client’ information and the ‘teaching tips and ideas.’" Mary, Florida
  • "Great review and reinforcement of what I’ve been teaching for years!! I am an RN and have been a group fitness instructor for over 25 years! Thanks for all." Rebecca, North Carolina
  • "Interesting, very informative, very practical and can use right away. The variety offered for different types of health situations and training for many types of clients who want to exercise and get in shape is appreciated." Laurie, Massachusetts
  • "Great program. Will add to my current training schedule for older clients. Enjoyed the reading material. Nicely written, easy to follow." Kathryn, California
  • "The information content was interesting and easy to understand. The staff is excellent and very accessible." Linda, Nevada
  • "I liked the content. Good course!" Jane, New York
  • "I gained a better understanding of the benefits of exercise for the older adult population." Sylvia, Tennessee
  • "I liked the organization of material. Great course!" Sophia, Massachusetts
  • "I liked the simplicity." Adam, Minnesota
  • "The detail on the exercise routines — excellent! And the pictures were very helpful. I appreciate the workbooks for future reference. Very comprehensive." Beth, California
  • "Instantly useable information. Extremely in-depth. Very informative." Melissa, Ohio
  • "Very thorough and organized by subject areas." Juliana, Colorado
  • "Well organized, easy to understand, no trick questions on test [happy face symbol]." Kathryn, Massachusetts
  • "I could go at my own pace. I could fill out the exam as I studied. Thanks!!" Laura, North Carolina
  • "Easy to follow." Elaine, Florida
  • "Very thorough and organized presentation." Juliana, Colorado
  • "Wonderful programming ideas, clearly presented. Lots of creative ideas for teaching seniors. DVDs were very enjoyable." Mary, Illinois
  • "Great course. I liked the organization of the information." Nikki, South Carolina
  • "Challenging. I liked the fitness tips I could use right away." Carma, Washington
  • "Very comprehensive. Thoroughly addresses all the aspects of instructing senior fitness classes." Denise, Colorado
  • "I liked the DVDs that show
  • "I liked the overall education principles of senior fitness. I learned about training and teaching older adults and the health risks to consider." Tracy, Texas
  • "Keep up the great work! It was very complete!" Robert, Hawaii
  • "I liked the variety of topics and the depth they were covered, including info on medications. I liked all of the background information about older adults." Jennifer, California
  • "I appreciated the practical tips on setting up classes." Kelly, Nebraska
  • "Appreciated that it was so clear and concise. Made the material more enjoyable to read." Margaret, California
  • "Format, presentation — good." Grace, Illinois
  • "Great reference material." Leslie, Georgia
  • "Very easy to follow. Great study material." Megan, Washington
  • "Well thought out. Very thorough!" Eric, Washington
  • Recent comments on the Senior Personal Trainer professional education program:

  • "I liked the progression of content. Challenging and exciting even though I have a BS in physical education. The program is age-specific which is why I enrolled. I am energized and looking forward to taking more of your courses. Very courteous staff. Material well presented in a clear, concise manner and with systematic logical order." Barbara, New Hampshire
  • "I will recommend this course to others. Useful information." Nancy, New York
  • "I am looking forward to applying all study materials to my new career in senior personal training and to my own personal fitness program as a ‘senior’ myself! Thank you! I like all of the detailed information from start to finish. Very thorough and applicable to trainer and clients! I found value in the explanation of the seven fitness assessment tests, training goals, and implementation of functional fitness training. Thank you for the valuable work you do to assist trainers and clients to achieve healthy lifestyles as seniors!" Cathy, Louisiana
  • "It was very informative. I was able to apply it immediately." Mike, Oregon
  • "I liked all the great hands-on ideas, as well as the client handout sheets and functional fitness emphasis. The materials were well organized." Mary Ann, Illinois
  • "The course not only covered subject matter regarding the actual job of senior personal trainer, but also marketing and acquiring clients. I liked the anatomical details and explanations." Phillip, Arizona
  • "I personally enjoyed the ‘Contemporary Reading’ manual. I learned quite a bit about the most important psychological dynamics involved with the aging adult. I hope to put much of this into practice. I thought all the material was very well organized. The language and text were most understandable and applicable." Rebecca, New York
  • "The ‘Special Population Imperatives’ section was very educational and helpful. The information was easy to understand and was organized well." Daniel, Colorado
  • "The glossary of terms was very helpful. I learned a lot. Great, updated, current, well organized information." Ann, North Carolina
  • "The subject matter was interesting. I liked the information about fibromyalgia and the high blood pressure basics. I would like the design of the certificate to show more about the content completed." Elizabeth, Virginia
  • "I liked all of the handouts, forms on wellness, and questionnaires; the related lifestyles information; the goal-specific sections; and the examples of exercises and sample training forms." Renee, Nevada
  • "Important, practical, concise information that is immediately useful. Presented in an effective, retainable format. I liked the use of specific client and training examples. Great resource. Overall, good to excellent." Kimberly, Oregon
  • "I liked that the learning pace was my choice! I also found the information easy to follow but, at the same time, I learned a lot." Caitlin, Pennsylvania
  • "Terrific course! Though I have over 30 years experience as a personal trainer, the information gleaned from your course materials has further increased my confidence and comfort level for working with seniors in a one on one setting. Thank you again for this wonderful program! It will truly be an asset in my quest to be one of the most reputable senior fitness businesses in the state of Michigan. I learned so much with these tools!" Sydney, Michigan
  • "I liked the exercise promotion and suggestions for increasing the use of lower body exercise." Tim, California
  • "I felt it was all very informative. I especially liked the part on how to market yourself to older populations and all of the sample questions and handouts." Pamela, California
  • "Interesting, meaningful. I liked the range and depth of info." Debra, Ohio
  • "The knowledge of the material was excellent! It is very well written and easy to understand." Patricia, Iowa
  • "I liked the value of the information as it pertains to older adults, and that it focused specifically on older adults." Rick, Idaho
  • "Clear, concise. Info easy to follow." Juliana, Colorado
  • "Very easy to follow and well written." Whitney, New York
  • "The content was easy to read and gave me ideas I had forgotten about." Tracy, Texas
  • "Excellent course." Susan, Texas
  • "I especially liked Part III of ‘Contemporary Readings in Senior Personal Training,’ specifically ‘Exercise Psychology and the Aging Adult.’ Also especially liked chapter two of ‘Physiology and Health Promotion for Senior Fitness Professionals,’ specifically ‘Practical Exercise Science: Key Facts and Definitions.’" Carlo, Texas
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    Hip Hip Hooray!

    Thursday, March 3rd, 2011 by American Senior Fitness Association   View This Issue of Experience!

    Today we celebrate an outstanding leader in the field of older adult fitness and take a revealing look at his most recent book-length publication, which is entitled the Healthy Hips Handbook: Exercises for Treating and Preventing Common Hip Joint Injuries. In the book’s introduction, author Karl Knopf states that it "is designed to help prevent a hip problem for some and, for those of you with existing hip problems, provide post-rehabilitation exercises that you and your health-care provider can select to best meet your needs."


    Who’s Who in Senior Fitness

    Thursday, March 3rd, 2011 by American Senior Fitness Association   View This Issue of Experience!

    Karl G. Knopf, Ed.D., is a long-time member of the American Senior Fitness Association (SFA) National Advisory Board. "Dr. Karl" — as his students affectionately call him — has been involved in the health and fitness area for the disabled and for mature adults for more than 30 years. Currently he is the coordinator of the Adaptive Fitness Therapy Program at Foothill College in Los Altos Hills, California.

    In the past Dr. Knopf has been a consultant for numerous grants, including National Institutes of Health grants. He is a frequent guest on the PBS "Sit and Be Fit" television series; has served as advisor to the State of California on fitness for the disabled; and has been featured in the LA Times, the Wall Street Journal, and other major publications discussing the benefits of physical activity for older adults.

    Dr. Knopf is the author of more than 10 books, including the following titles published by Ulysses Press: Stretching for 50 Plus, Weights for 50 Plus, and Sports Conditioning for 50 Plus. His latest book is the Healthy Hips Handbook (2010), which is also published by Ulysses Press.

    Dr. Knopf can be reached via email at


    The Healthy Hips Handbook

    Thursday, March 3rd, 2011 by American Senior Fitness Association   View This Issue of Experience!

    SFA president Janie Clark has this to say about Karl Knopf as an older adult fitness author: "I have always loved Karl’s style because it is so clear, so practical, and so to-the-point. This is very true of his newest contribution, the Healthy Hips Handbook, which I am delighted to recommend for both senior fitness professionals and mature adult laypersons alike."

    The book, released in 2010 by Ulysses Press, is a reader-friendly manual that outlines causes and solutions for common hip problems. The publisher notes that millions of people suffer from debilitating hip conditions each year and that Knopf’s book offers easy-to-follow exercises to:

    Build strength,

    Improve flexibility,

    Hasten recovery, and

    Avoid future injury.

    It also features specially designed programs to help prevent common hip issues and to condition the body for successful participation in everyday activities, as well as in popular sports activities.

    The Healthy Hips Handbook begins with an overview and an illustrated discussion of the anatomy and functions of the hip joint. It moves on to describe the symptoms, usual causes, and treatment options regarding a number of prevalent hip-related concerns, including:

  • Groin strain,
  • Bursitis,
  • Snapping hip,
  • Iliotibial band fascitis,
  • Sciatic pain,
  • Hip dislocation,
  • Hip pointers,
  • Osteitis pubis,
  • Degenerative joint disease, and
  • Pelvic girdle fractures.
  • One useful and interesting provision in the manual is its section on self-massage. The author explains that massage can relax a muscle or, in some cases, invigorate it. Often massage will increase blood flow to the area and can release tension, prepare a joint for motion, or provide relief following an exercise/therapy session.

    The physical exercises presented by the handbook are divided into six categories, as follows:

  • Stretches
  • Standing activities,
  • Seated activities,
  • Floor activities,
  • Ball activities, and
  • Sports-ready activities.
  • There are more than 300 excellent step-by-step photographs of the exercises, all of which are accompanied by clear and concise written instructions. The physical exercise recommendations are augmented by helpful discussions of pertinent subjects, such as:

  • Hip replacement,
  • Micro versus macro trauma injuries,
  • Healthy hips lifestyle tips,
  • Healthy hips training tips, and a
  • Proper posture checklist.
  • Dr. Knopf is singularly qualified to provide exercise guidance to older adults and disabled persons. SFA president Janie Clark says, "In addition to his impressive academic credentials and professional achievements, Karl also has life experience that enhances and distinguishes his work." Once a college
    wrestler and triathlete, Dr. Knopf subsequently injured his back while lifting a patient out of a wheelchair. At that point, he adjusted his exercise routine to revolve around swimming and the use of a recumbent bicycle.

    "I learned from this experience what it is like to live with daily pain," he has said, adding with a touch of humor: "I think this makes me a better teacher because I feel worse than most of my students. I also know that if I don’t exercise I’ll feel even worse!" Indeed, he hasn’t let the injury slow him down very much, but has always remained active in every sense of the word.

    Regarding his work with older adult fitness participants, Dr. Knopf told SFA many years ago: "My philosophy is that I like for people to set themselves up to win." This approach shines through in the following short excerpt from the Healthy Hips Handbook. In the author’s own words:

    "It helps to know the areas of the body that are vulnerable to injury. Besides the hips, the knees, neck, low back, shoulders, and ankles are high-risk. Pay special attention when performing exercises that involve these areas, and follow these rules:

  • "Don’t allow your legs to spread too wide or too far forward or back.
  • "Always perform exercises with proper execution.
  • "Don’t neglect the small supporting actors of your hip joint (most of us focus on the ‘show’ muscles and forget the importance of these smaller muscles).
  • "Pay attention to how your head, upper back, and legs are positioned during activities of daily living and in the workplace."
  • The Healthy Hips Handbook contains 135 pages and retails for $14.95. Retail orders are shipped free of charge. California residents must include sales tax. For further information or to order the book, here’s how to contact the publisher:

  • Call 800-377-2542 or 510-601-8301,
  • Fax 510-601-8307,
  • Email, or
  • Write to Ulysses Press, P.O. Box 3440, Berkeley CA 94703.
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    Yoga for Older Adults

    Monday, October 18th, 2010 by American Senior Fitness Association   View This Issue of Experience!

    The American Senior Fitness Association is pleased to present the following in-depth article addressing the safe instruction of yoga to mature fitness participants. It is reprinted with permission from The Journal of Alternative and Complementary Medicine August 2010: 899-905, published by Mary Ann Liebert, Inc., publishers:


    Teaching Yoga to Seniors: Essential Considerations to Enhance Safety and Reduce Risk in a Uniquely Vulnerable Age Group

    Monday, October 18th, 2010 by American Senior Fitness Association   View This Issue of Experience!

    Carol Krucoff, E-RYT,1 Kimberly Carson, MPH, E-RYT,2 Matthew Peterson, PhD,3 Kathy Shipp, PT, MHS, PhD,4 and Mitchell Krucoff, MD, FACC, FAHA5

    1Duke Integrative Medicine, Duke University, Durham, NC., 2Oregon Health & Science University, Portland, OR., 3Geriatrics Department, Duke University, Durham, NC., 4Physical Therapy Department, Duke University, Durham, NC. 5Department of Cardiology, Duke University, Durham, NC.


    Background: Seniors age 65 and older represent the fastest-growing sector of the population and, like many Americans, are increasingly drawn to yoga. This presents both an extraordinary opportunity and a serious challenge for yoga instructors who must be both a resource and guardians of safety for this uniquely vulnerable group. A typical class of seniors is likely to represent the most diverse mix of abilities of any age group. While some may be exceedingly healthy, most fit the profile of the average older adult in America, 80% of whom have at least one chronic health condition and 50% of whom have at least two.

    Objectives: This article discusses the Therapeutic Yoga for Seniors program, offered since 2007 at Duke Integrative Medicine to fill a critical need to help yoga instructors work safely and effectively with the increasing number of older adults coming to yoga classes, and explores three areas that pose the greatest risk of compromise to older adult students: sedentary lifestyle, cardiovascular disease, and osteoporosis. To provide a skillful framework for teaching yoga to seniors, we have developed specific Principles of Practice that integrate the knowledge gained from Western medicine with yogic teachings.


    We are in the midst of one of the greatest sociological shifts in history: Global aging. While the entire world is graying—developed countries are leading the way.1 In the United States, seniors age 65 and older represent the fastest growing sector of the population.2 This group is expected to more than double to over 80 million by the year 2050—with nearly one quarter 85 and older.3

    Like many Americans, older adults are increasingly drawn to yoga. This presents both an extraordinary opportunity and a serious challenge for yoga instructors, who must be both a resource and guardians of safety for this uniquely vulnerable group. A typical class of seniors, which we define as “over age 65,” is likely to represent the most diverse mix of abilities of any age group. Today’s seniors may be extremely healthy and fit—able to run marathons, do headstands, and compete in masters athletic events. However, much more common are seniors who fit the profile of an “average” older adult in America, 80% of whom have at least one chronic health condition4 and 50% of whom have at least two.5 Most seniors face a broad array of health challenges, ranging from arthritis and incontinence to hip and knee replacement, heart disease, and cancer. Consider the health statistics for people over 65.6

  • 52% of men and 54% of women have high blood pressure.
  • 43% of men and 54% of women have arthritis.
  • 37% of men and 26% of women have heart disease.
  • 24% of men and 19% of women have cancer.
  • 19% of men and 17% of women have diabetes.
  • 11% of men and 10% of women have chronic bronchitis or emphysema.
  • 10% of men and 8% of women have had a stroke.
  • 11% of men and 17% of women have clinically relevant depressive symptoms.
  • More than half of all adults over age 65 have a disability and more than a third have severe disability.7 More than 87% of seniors take at least one prescription drug and nearly 60% take three or more.8 The average 75-year-old has three chronic conditions and uses five prescription drugs.9 Several classes of medications commonly taken by seniors—including antihypertensives, antianxiety drugs, and antidepressants—are associated with dizziness, in particular postural dizziness, so it is not surprising that prevalence rates for dizziness in the older adult population may be as high as 38%.10 This is of particular concern, since falls are the leading cause of injury deaths and the most common cause of injuries and hospital admissions for trauma in this age group.11

    These sobering statistics present a tremendous opportunity for yoga teachers and yoga therapists to help senior students improve their strength and enhance their balance to reduce their risk of falls, add comfort and control to breathing, and contribute to vitality, mood and alertness. These data also highlight the potential for harm that could occur if yoga instructors do not create a safe environment and class structure geared appropriately to older adults.

    Another vital fact is that an estimated 30% of postmenopausal women have osteoporosis,12 a disorder of impaired bone strength that results in skeletal fragility and increased fracture risk. One (1) of every 2 women over age 50 will have an osteoporosis-related fracture in their lifetime, with risk of fracture increasing with age. Each year an estimated 1.5 million people suffer an osteoporotic-related fracture, an event that often leads to a downward spiral in physical and mental health. In fact, 20% of seniors who suffer a hip fracture die within 1 year.13 Osteoporosis is considered a “silent disease,” since people who have this condition are often unaware of the problem until they suffer a fracture. This means it is quite likely that older adult yoga students, particularly females, will have osteoporosis and be at risk of fracture, but not know this—and, of course, will not be able to inform their yoga instructor that they need modified programs.

    In addition to being at greater risk for osteoporotic fracture, older adults are also at greater risk for numerous other potentially life-threatening ailments, including heart attack and stroke. Finally, seniors are also far more likely than younger groups to have health challenges that affect their participation in a yoga class—ranging from hearing and vision loss to tremors, dementia, and incontinence.

    Like the reality society faces with an historical proportion of our population living to more advanced ages than ever before with a very broad range of functional capacities and needs, yoga teachers of older adults are—in many ways—navigating uncharted territory. The great sages who originated the yogic practices thousands of years ago had never encountered artificial joints, canisters of supplemental oxygen, or prosthetic heart valves in large numbers of people who have reached extremely advanced age. As recently as 1900, the average life expectancy in the United States was 46.3 for men and 48.3 for women. In 2005 that number had jumped to 75.2 for men and 80.4 for women.14

    Training yoga teachers who work with seniors—like all practice of healing arts—represents a blend of scientific knowledge and research, philosophy, and opinion based on direct experience. It is our belief that, in service of ahimsa and the imperative to “first do no harm,” yoga teachers working with seniors should recognize the importance of adapting the practice to senior bodies, minds, and spirits.

    The Therapeutic Yoga for Seniors Program at Duke Integrative Medicine: A Brief Background

    Western medical science offers a wealth of knowledge in the arena of aging and disease, but many yoga teachers have limited access to this valuable input. The Therapeutic Yoga for Seniors program was created to fill a critical need to help yoga instructors work safely and effectively with the increasing number of older adults coming to yoga classes and was launched in 2007 when Duke University Health System opened its integrative medicine facility. The goal is to combine the best of modern, evidence-based medicine with the ancient wisdom, experience, and tradition of yogic teachings. It has evolved from a 3-day workshop to its current format as an 8-day teacher training with a mentored practicum, held twice annually at Duke Integrative Medicine ( The curriculum involves a balance of lectures, movement and meditation practices, small group work and discussions, and features presentations by a variety of Duke University faculty including physicians, exercise physiologists, physical therapists, and health psychologists. The program covers health conditions common to seniors, such as heart disease, pulmonary disease, arthritis, and osteoporosis, and also addresses special issues in teaching seniors including pain management, spirituality and aging, and end-of-life issues.

    Creating a safe environment for older adult students is of paramount importance. Equally essential is ensuring that this imperative of safety does not translate into establishing a fearful or limiting tone, but rather invites the empowering recognition of yoga’s highest teachings that our true nature is already whole. To this end, yoga teachers are encouraged to fully welcome older adult students as they are, rather than being attached to expectations of how things should be, including how a body should move. To provide a skillful framework for teaching yoga to seniors, specific Principles of Practice were developed, which integrate knowledge gained from Western medicine with yogic teachings (Table 1). At the heart of these Principles of Practice is the recognition that how yoga is taught to seniors is as important as what is taught. For example, the principle of honoring Feeling Over Form suggests a teaching style that focuses on inviting students to move with a specific intention of a posture, exploring their own sensations and letting how the pose feels guide their movements. This is in contrast to telling students specifically what their body should look like in a pose. Another principle, Emphasize Fluidity, is particularly important as the body tends to become rigid with age and the circulation is more sensitive to fluctuations during the respiratory inhale/exhale cycle.

    While the training covers many of the medical concerns common to seniors, for the purposes of this article, we have chosen to focus on three that pose the greatest risk of compromise to senior students: sedentary lifestyle, cardiovascular disease, and osteoporosis.

    Effects of Aging and the Impact of Physical Activity

    Some physical decline is inevitable with aging. While healthy lifestyle habits—including activity such as yoga practice, proper nutrition and social contact—can help slow the aging process, the reality is that eventually flesh weakens and everyone born must die. In general, as humans grow older, systems become slower to react and recover, the heart and blood vessels becomes stiffer, lung capacity decreases, the kidneys’ filtering capacity is reduced, bones weaken, and muscle mass declines. Sleep disturbances become more common, and older adults often sleep less deeply, wake up more often throughout the night, and have more trouble falling asleep.15 Hearing is often compromised, with 35% of women and 48% of men over age 65 reporting trouble hearing.6

    Table 1.

    Carson–Krucoff Principles of Practice a

    1. First, Do No Harm. Join with our physician colleagues in making this our primary intention.
    2. Create a Safe Environment. Cultivate ahimsa (non harming) by encouraging students to honor their own personal journey and explore their full potential, with compassion and integrity.
    3. Encourage Yogic Balance. Sthira sukham asanam—A yoga pose is, by Patanjali’s definition, stable and comfortable. Invite students to challenge themselves, but never strain.
    4. Meet People Where They Are. Honor individual abilities and limitations by offering accessible and appropriate modifications that reflect the intention and function of traditional postures.
    5. Emphasize Feeling Over Form. Let go of ideas of how a pose should look. Focus instead on how a pose feels. Teach students to discriminate between discomfort, which may be welcomed as an inherent part of the growth process, and pain, which is to be avoided.
    6. Honor the Inner Teacher. Don’t assume you know what’s going on with someone, even if you’ve asked. Consider yourself a guide, helping students explore what works best for them.
    7. Encourage Gratitude and Joy. Create an environment that celebrates what students can do.
    8. Emphasize Fluidity. The Tao’s teaching that “those who are soft and supple are disciples of life” is particularly important as the body becomes rigid with age. Minimize static “holdings.”
    9. Use Skillful Language. Encourage and invite rather than direct and demand.
    10. Respect Our Scope of Practice. Recognize that what we do as yoga teachers is only part of the integrative health care landscape. Do only what we are trained to do and refer to other practitioners when necessary.
    11. Be a Guardian of Safety. Get CPR/AED training and keep your certification current.
    12. Teach People, Not Poses or Conditions. While acknowledging the inevitable changes inherent in life, it is essential to recognize the unchanging spirit at the heart of all beings.
    a From Therapeutic Yoga for Seniors, Teacher Training Manual, Copyright 2008 Kimberly Carson and Carol Krucoff.

    CPR, cardiopulmonary resuscitation; AED, automated external defibrillator.

    Despite the inevitable declines, a growing body of research suggests that the way in which older adults spend their final years—either frail in a nursing home, or vital and living independently—may be greatly influenced by their physical activity habits, throughout their lifetime and in their later years. “Current evidence clearly indicates that participation in a regular exercise program is an effective way to reduce and/or prevent a number of the functional declines associated with aging,” according to the American College of Sports Medicine’s (ACSM) statement on Exercise and the Older Adult.16 As mounting scientific evidence supports the myriad health benefits of regular physical activity, public health officials have launched campaigns to encourage people to become more active. The sad fact is that less than one quarter of all adults exercise regularly and “physical inactivity is second only to tobacco use as a cause of death in the United States, responsible for an estimated 400,000 deaths per year.”17 In 2008, the U.S. Department of Health and Human Services issued their first-ever Physical Activity Guidelines for Americans, which noted: Most health benefits occur with at least 150 minutes a week (the equivalent of five, 30-minute sessions) of moderate intensity physical activity, such as brisk walking. Additional benefits occur with more physical activity.18

    A key feature of these new guidelines is a section devoted to older adults (defined as age 65 and older), who are not only the least physically active of any age group, but also generate the highest expenditures for medical care. The guidelines advise older adults to avoid inactivity, participate in regular aerobic activity, do muscle-strengthening activities, and do exercise that maintains or improvesbalance.19

    Flexibility exercises are recommended in a similar set of guidelines, jointly released by the American Heart Association and the American College of Sports Medicine in 2007.20 These guidelines recommended use of a Perceived Exertion scale to determine an appropriate level of exercise intensity. This 10-point scale defines “sitting” as “0″ and “all-out effort” as “10″—with moderate-intensity activity in the “5″ or “6″ range (Table 2). Rather than gauge intensity by an external device such as a heart rate monitor, this Perceived Exertion scale invites each individual to determine how effortful something feels. Since people’s abilities and fitness levels vary, the perception of “moderate intensity” effort will vary—with some reporting that climbing several flights of stairs is a moderate intensity activity, while others saying that moderate-intensity activity is getting up off the couch to answer the door.

    While the yoga practice is clearly more than a “workout,” it certainly fits into the public health mandate encouraging regular movement. In fact, many of the activities currently being promoted for older adults—such as balance training and flexibility exercise—are integral parts of most yoga classes. And yoga teachers will likely recognize the Western “Perceived Exertion” scale as a subjective measure of intensity, quite similar to yogic teachings that advise practitioners to find their own comfortable and stable seat in each posture.

    Table 2. Perceived Exertion: 10-Point Effort Scale

    0 Sitting—no movement
    1–2 Very light activity
    3–4 Light activity
    5–6 Moderate-intensity effort
    7–8 High-intensity effort
    10 All-out effort

    Cardiovascular Disorders and Seniors

    Age is one of the most significant risk factors for all cardiovascular ailments. This includes coronary artery disease (CAD), which is the number one cause of death and disability for both men and women in the United States,21 as well as numerous other chronic and potentially life threatening cardiovascular conditions such as hypertension, congestive heart failure, arrhythmias, valvular disorders, and stroke. With advancing age, the elastic elements of the blood vessels are progressively replaced by more leathery, fibrous tissue. In addition, progressive deposition of cholesterol plaque—known as atherosclerosis, or hardening of the arteries—in the inner walls of the arteries can also compromise blood flow to vital organs such as the brain, kidneys, and the heart itself. Loss of elasticity in the heart muscle itself can lead to symptoms of heart failure. Wear and tear on the blood vessels over time can lead to aneurysms and clots, while wear and tear on the heart valves can lead to narrowing and leaking. The most catastrophic of clinical cardiovascular outcomes—death, stroke, heart attack, heart failure, blood vessel rupture, sudden loss of consciousness—all occur more frequently just by virtue of advancing age.

    The risk for the most common form of heart disease, CAD, increases in midlife—beginning at age 45 for men and age 55 for women. The narrowing or blockage of arteries characteristic of CAD can lead to a variety of ailments including the following:

  • Angina, which consists of pain, pressure, or burning symptoms in the neck, chest, or arm, often associated with exertion or stress
  • Irregular heart rhythms, ranging from minor to life threatening
  • Fast or slow heart rate
  • Breathlessness, easy fatigability, dizziness, and loss of tolerance for exertion
  • Congestive heart failure
  • Heart attack, with irreversible heart muscle damage caused by sustained interruption in the blood supply to the heart.
  • Each year, about 1.2 million Americans will have a first or recurrent heart attack, and about 452,000 of them will die—nearly three fourths of whom die in the emergency department or before reaching a hospital.22 Surprisingly, an estimated 50% of men and 64% of women who died suddenly of CAD had no previous symptoms of this disease.23 Like osteoporosis and hypertension, CAD can be a “silent disease,” because there are often no symptoms until the disease reaches a critical point. It is highly recommended that anyone working with seniors—including yoga instructors—be certified in cardiopulmonary resuscitation, CPR, a potentially lifesaving technique taught around the world by organizations such as the Red Cross and the American Heart Association. Today, most CPR classes also include instruction in using the automated external defibrillator (AED), a portable electronic device that automatically diagnoses potentially life-threatening cardiac arrhythmias. AEDs are now generally available in most public places—including community centers, airports, and schools—and it is also advisable for anyone teaching seniors to know the location of the nearest AED. Yoga studios might consider purchasing AEDs, which are as commercially available as fire extinguishers.

    Aging is associated with loss of blood vessel elasticity, and seniors frequently have chronic hypertension, often treated with medicines that affect blood vessel tone and circulating blood volume. Loss of elastic resilience in the blood vessels with age also makes seniors more susceptible to both sudden elevation of blood pressure and to dizziness from low blood pressure related to sudden changes in posture, breath holding, and heavy lifting.

    Yoga instructors who work with seniors do not need to become cardiologists, nor should they try to be. If a senior student becomes suddenly uncomfortable, dizzy, or ill with a sense of nausea, chest pain, or short windedness, calling 911 for professional assistance is the immediate next step. On the other hand, cardiovascular knowledge and awareness is a critical educational element for anyone working with seniors.

    Another key dimension of cardiovascular awareness and yoga for seniors is in the mind–body–spirit milieu, which fits well in the most ancient yogic traditions and to which modern Western cardiology has begun to gain insight.24 Seniors, like all people with cardiovascular disorders, face immediate and penetrating questions of personal mortality. Personal styles and social forces that often affect seniors in Western civilization—social isolation, depression, loneliness, hostility—have all been shown to significantly affect both quality and length of life in people with heart disease. While specific mechanisms are still under study, a growing body of evidence suggests that certain brain–heart signals can be influenced by intangible factors that are typically part of the yoga practice, such as relaxation, mindfulness, prayerfulness, meditation, and group support.25

    For yoga instructors working with older adults, these and related findings should shed light on the potential impact of wisdom-based yogic instruction for modern seniors. As the most vulnerable humans to both physiologic and spiritual “loss of heart” in Western society, seniors are perhaps the yoga students with both the most to lose and the most to gain from yoga practice.

    To ensure the safety of senior yoga students as well as reduce the personal liability of the yoga instructor/therapist, it is highly recommended that a very short, simple clinical history be documented before joining classes. Is there any history of heart disease, high blood pressure, or stroke? Has any surgery or procedure ever been performed on any blood vessel, heart valve, or pacemaker? Are any prescription medicines being taken for blood pressure, heart disease, to thin the blood, or for prevention of stroke? If the answer to any of these questions is yes in a student 65 years of age or older, ask permission to partner with their physician so you can seek guidance in creating a safe and effective yoga practice. If you are ever uncertain as to whether or not a specific posture or practice is safe, avoid it. Observe the safety-first principle—when in doubt, do not do it.


    The word osteoporosis means porous bones and is a disorder of impaired bone strength due to a combination of low bone mass and poor bone quality, which results in skeletal fragility and increased fracture risk.26 In the United States, 10 million people have osteoporosis and 34 million more have low bone mass—or osteopenia—placing them at increased risk for further bone loss resulting in osteoporosis.27 While losing bone is a natural part of the aging process, osteoporosis is preventable or, at least, can be delayed. The disorder is caused by an imbalance between the natural processes of bone breakdown and bone formation, which occurs in women after menopause and in both men and women with aging. Certain characteristics put people at greater risk of osteoporosis, including gender—women after menopause are three times more likely to develop the disorder than men28—small body size, and age. The longer you live, the greater your likelihood of developing osteoporosis. While not every older person gets the disease, the number increases from about 15% of women in their fifties to half of all women in their 80s.29 Due to the aging of the population, the prevalence of osteoporosis is expected to increase, so that, by 2020, 1 in 2 Americans over age 50 is expected to have or to be at risk of developing osteoporosis of the hip; even more will be at risk of developing osteoporosis at any site in the skeleton.30

    The “gold standard” for diagnosis is a bone mineral density (BMD) measurement at the hip and spine, using dual-energy X-ray absorptiometry. The World Health Organization definition of osteoporosis is BMD of 2.5 standard deviations below that of an average young adult, and Tscore at or below –2.5.31 Osteopenia (low bone mass) is defined as a BMD between 1 and 2.5 standard deviations below this same mean, and T score of –1 to –2.5. The United States Preventive Services Task Force recommends that BMD testing is appropriate for all women over age 65 and for women under age 65 who are postmenopausal and have risk factors for osteoporosis. Similarly, BMD testing is recommended for all men over age 70 and for men under age 70 if they have risk factors. Testing also is appropriate for younger people who have diseases or use medications that cause bone loss.

    While it is recommended that people who are diagnosed with osteoporosis receive education about fracture prevention, it is our experience that few people diagnosed with osteoporosis have been told—or understand—how to reduce their risk of fracture. Indeed, we have encountered numerous seniors who are unsure whether or not they have osteoporosis—even if they are taking prescription medications specifically for this condition—and often confuse the condition with osteoarthritis or osteopenia. It is also critical to recognize that a significant number of people with this “silent disease” of osteoporosis are undiagnosed and unaware that they are at increased risk of fracture.

    The most common bones that break as a result of osteoporosis are the hip, wrist, and verterbral bodies of the spine. Surprisingly, two thirds of vertebral fractures do not come to clinical attention, which means that people with osteoporosis may suffer this kind of fracture either without pain, or with pain that is not recognized as originating from a vertebral fracture. A previous fracture is the strongest risk factor for having another fracture, so asking students if they have had fractures—particularly minimally traumatic ones—since age 50 will help yoga teachers identify students who are at high risk of having a new fracture. In addition, yoga teachers can observe two characteristics that are strongly suggestive of previous vertebral fractures:

  • Loss of two or more inches in height (compared to maximum adult height)
  • Fixed kyphosis (a forward curve of the spine that cannot be corrected by cuing the student to stand or sit more erectly).
  • If a student presents with either or both of these factors, it would be prudent to assume that he or she has had vertebral fractures and modify the yoga practice accordingly.

    While many yoga postures and practices can be extremely beneficial in maintaining or improving muscle strength, restoring function and relieving pain in this population, certain common yoga poses should be relatively contraindicated for people with actual or suspected osteoporosis as they have the potential for significant harm32—something not typically recognized in the yoga community. Spinal flexion (forward bending) and rotation of the spine (twisting) can place large and compromising loads on the anterior vertebral bodies33 and are often implicated when a fracture of a vertebral body occurs.34 Indeed, the National Osteoporosis Foundation warns that “many exercises and activities such as yoga, Pilates, tennis, and golf may need to be avoided or adjusted because they often involve twisting and bending motions.”35 They recommend that people diagnosed with osteoporosis:

  • Avoid bending forward from the waist
  • Avoid twisting of the spine to a point of strain
  • Avoid twisting the trunk and bending forward when doing activities such as coughing, sneezing, vacuuming, or lifting.
  • Avoid sit-ups, abdominal crunches, or toe-touches.
  • These precautions are important to consider in adapting yoga postures appropriately, since it is critical to avoid teaching movements that can cause fractures. Another important factor to consider in modifying postures is the concept of a loaded spine, which refers to the amount of pressure on the spine and represents a combination of the weight of the head and upper body as well as the pull and tug of muscles and ligaments on the vertebral bodies. When the vertebral bodies are under high load, the addition of flexion or rotation movements significantly increases the risk of vertebral fracture.

    Different body positions result in differing amounts of load on the spine. These loads are independent of the addition of positioning related to asana. Below is a list of positions and their relative load on the spine.

    Activities with increasing amount of load:36

  • Lying supine
  • Erect standing
  • Walking
  • Sitting
  • Standing, lifting a 20-kg weight with back straight and knees bent
  • Slouched sitting
  • Standing, flexed forward from the waist
  • Sitting, flexed forward and rotated while lifting 20 kg.
  • Taking into consideration the significant and inalterable risk presented by certain postures, as well as the actual physical abilities of most students who begin yoga for the first time in their 60s or 70s, we have opted to take a conservative approach in the postures we suggest in the Therapeutic Yoga for Seniors teacher training. As a result, we have eliminated seated forward bends and end-range twists from our recommended repertoire of postures, substituting safer variations, such as supine knees-to-chest pose and gentle supine, sidelying, and standing twists. Due to the risk associated with high spine loads, we also advise against head or shoulder stands and extreme spine flexion in any position.


    Balancing Risks and Rewards

    Teaching yoga to seniors presents both significant risks as well as extraordinary rewards. Older adults can be extremely receptive to the profound benefits offered on all levels— physical, emotional, mental, and spiritual. Unlike younger practitioners, who can become distracted by the desire for a shapelier body, older adults typically have a ripeness for the experience of ease and union, which provides an amazing opportunity for yoga teachers.

    Yet with the increased physical vulnerabilities present in an aging population, it is imperative for yoga instructors to be guardians of safety. This requires a solid understanding of common medical conditions and their associated risks, as well as an ability to use this knowledge as a foundation for creating a safe and effective yoga practice. Creating a truly safe environment may often require letting go of preconceived and commonly held notions of what a yoga practice entails in order to open to the joyful creativity and vast potential inherent in the experience of yoga.

    It is a great honor and responsibility to meet our elders where they are, as they are, and to celebrate however they can join us in the practice of yoga—with great love and integrity.

    Disclosure Statement

    No competing financial interests exist.


    1. Hatcher BJ. Center for Learning and Global Public Health. Global Aging: Impact of Human Resources for Health. Online document at: Accessed June 24, 2010.
    2. Day JC. National Population Projections. 2001. U.S. Census Bureau. Online document at: Accessed June 24, 2010.
    3. Wan H, Sengupta M, Velkoff VA, DeBarros KA. U.S. Census Bureau, Current Population Reports, P23-209, 65þ in the United States: 2005. Washington, DC: U.S. Government Printing Office, 2005.
    4. Centers for Disease Control and Prevention and the Merck Company Foundation. The State of Aging and Health in America 2007: Executive Summary. Whitehouse Station, NJ: The Merck Foundation, 2007.
    5. Centers for Disease Control and Prevention. Public health and aging: Trends in aging. United States and worldwide. Morbid Mortal Weekly Rep 2003;52:101–106.
    6. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2008: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics. Washington, DC: U.S. Government Printing Office, 2008.
    7. Brault MW. Current Population Reports: Americans with Disabilities. 2005, Washington, DC: U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau, 2008.
    8. Table 98. In: National Center for Health Statistics. Health, United States, 2008: A Report of the Department of Health and Human Services, Hyattsville, MD: National Center for Health Statistics, 2009.
    9. Merck Institute on Aging and Health. The State of Aging and Health in America, 2004. Online document at: Accessed June 24, 2010.
    10. Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation, 2007.
    11. Centers for Disease Control and Prevention. Falls Among Older Adults. Online document at: // Accessed June 24, 2010.
    12. Melton LJ III. How many women have osteoporosis now? J Bone Miner Res 1995;10:175–177.
    13. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: Office of the Surgeon General, U.S. Department of Health and Human Services, 2004.
    14. National Center for Health Statistics. Health, United States, 2008: A Report of the Department of Health and Human Services. Hyattsville, MD: National Center for Health Statistics, 2009.
    15. National Institute on Aging, Sleep and Aging. NIH Seniors Health. Online document at: Accessed June 24, 2010.
    16. Mazzeo RS. Exercise and the Older Adult: American College of Sports Medicine, ACSM Current Comment, 2007. Online document at: Accessed June 24, 2010.
    17. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General, Atlanta, GA: U.S. Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1996.
    18. Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. Online document at: Accessed June 24, 2010.
    19. Active Older Adults. In: Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services, 2008. Online document at: Accessed June 24, 2010.
    20. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1435–1445.
    21. Coronary Artery Disease Fact Sheet. Medline Plus, National Library of Medicine. National Heart, Lung and Blood Institute. Online document at: Accessed June 24, 2010.
    22. Know the Facts, Get the Stats. The American Heart Association. Online document at: Accessed June 24, 2010.
    23. Rosamond W, Flegal K, Furie K, et al., for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. AHA Statistical Update: Heart Disease and Stroke Statistics—2008 Update. A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25–c146. Online document at: Accessed June 24, 2010.
    24. Vogel J, Krucoff M. Integrative Cardiology. New York: McGraw-Hill Medical, 2007.
    25. Vogel J, Krucoff. ACC CAM Consensus Statement. J Am Coll Cardiol 2005;46:184–221.
    26. NIH Consensus Development Panel on Osteoporosis Prevention. Osteoporosis prevention, diagnosis and therapy. JAMA 2001;285:785–795.
    27. 27. National Osteoporosis Foundation. America’s Bone Health: The State of Osteoporosis and Low Bone Mass in Our Nation. Washington, DC: National Osteoporosis Foundation, 2002.
    28. Genant HK, Cooper C, Poor G, et al. Interim Report and Recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporosis Int 1999;10: 259–264.
    29. Praemer A, Furner S, Rice DP. Musculoskeletal Conditions in the United States. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1999:182.
    30. U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: Office of the Surgeon General, U.S. Department of Health and Human Services, 2004.
    31. Kanis JA, Melton LJ III, Christiansen C, et al. The diagnosis of osteoporosis. J Bone Miner Res 1994;9:1137–1141.
    32. Bouxsein ML, Myers ER, Haways WC. Biomechanics of agerelated fractures. In: Marcus R, Feldman D, Kelsey J, eds. Osteoporosis. New York: Academic Press, 1996:373–393.
    33. Schultz AB, Andersson GBJ, Hadersperk K, et al. Analysis and measurement of lumbar trunk loads in tasks involving bends and twists. J Biomech 1982;15:669–675.
    34. Melton LJ, Chao EYS, Iane J. Biomechanical aspects of fractures. In: Riggs BJ, Melton Lj, eds. Osteoporosis: Etiology, Diagnosis, and Management. New York: Raven Press, 1998;119–122.
    35. Bone Basics, Moving Safely. The National Osteoporosis Foundation. Online document at: Accessed June 24, 2010.
    36. Nachemson A. Towards a better understanding of low-back pain: A review of the mechanics of the lumbar disc. Rheum Rehabil 1975;14:129–143.

    Address correspondence to:

    Carol Krucoff, E-RYT
    Duke Integrative Medicine
    Duke University
    3475 Erwin Road
    Durham, NC 27705