a case study
What is Rheumatoid Arthritis (RA)
Rheumatoid Arthritis is an autoimmune disease in which the body’s immune system
attacks cells and tissues of the joints. It is expressed mostly in the joints of the toes
and fingers, the palms and feet, the knees, wrists and sometimes other joints. The
disease is characterized by severe pain, swelling of the joints and sensitivity to touch
and to temperature changes. Joints may develop an inflammatory condition that
include: swelling, redness, fever, pain and limited range of motion. Inflammation may
develop to the point of deformation, changes in the structure of the joint, and in
severe cases it might amount to loss of function and a need for joint replacement.
The disease is quite common and it is found in approximately 1% of the population. A
Higher percentage, up to three times higher, is found in women and it usually tends
to erupt between the ages of 20 to 50, but it can occur at any age.
The joint is a juncture where one bone connects to another. It is wrapped in a
capsule made of connective tissue (tendons and ligaments) and its inner lining is the
synovial membrane that secretes the synovial fluid whose role is to lubricate the joint.
In rheumatoid arthritis cells of the immune system, known as B cells, migrate from
the blood to the synovial membrane tissue of the joints, attack it and cause damage
to the tissue and the cartilage of the joint.
In addition to pain, tenderness and redness in the joints, the symptoms of the
disease include the following:
- Fatigue, weakness and body temperature that is slightly higher than normal
and lasts for long periods of time;
- A feeling of stiffness and difficulty in moving the joints in the morning;
- The inflammation is expressed symmetrically for example: both knees will be affected and not just one;
- Structural changes in the joint itself that can be detected on x ray.
Patients with rheumatoid arthritis differ from each other in terms of the number of
joints afflicted, their type, the development rate of the infection, the symptoms and
specific medications that are beneficial in their case. The disease has direct and
immediate effects on daily activities, ranging from opening the lid of a jar to walking
and making the transition from sitting to standing up. All those symptoms depend on
the severity of the infection.
We can distinguish between periods of flare-up of the disease, during which the pain,
swelling and sensitivity are aggravated and one feels pain and weakness in the
whole body, and quiet periods of recession, in which the range of movement is still
limited but is moderate, the pain and sensitivity decrease significantly, the overall
feeling is better and the daily functioning is easier and they feel more comfortable.
The cause of the disease is still unknown. Some of the literature claims that there is a
hereditary factor. Some assume that environmental factors such as smoking, stress,
and so on affect this condition.
As part of coping with the chronic condition, it is recommended for patients suffering
from RA to foster a beneficial and balanced lifestyle that includes a healthy diet and
The practice of yoga is a beneficial exercise that answers the need of moderation.
Tamara is a woman in her 50s, married with two adult children, works full time, and
maintains a complete daily routine. She has been suffering from rheumatoid arthritis
for 15 years. The root of her disease is probably genetic: her father suffered from
arthritis, and also her sister was diagnosed with rheumatoid arthritis, though of a
Tamara is treated with medication – she receives a transfusion every year or two,
and during acute periods she takes painkillers. In cases of local flare-up of the
inflammation she is treated by steroid injections into the inflamed joint. The overall
quality of Tamara’s life when the inflammation is in recess is good and she can lead
a normal daily active routine.
In addition to the arthritis Tamara has asthma which is almost completely dormant
and some allergies. She suffered for years from periods of low back pain and a
sense of strain in her shoulder girdle. These phenomena have lessened considerably
over the years of yoga practice. Apart from that she enjoys good health.
Tamara’s arthritis affects mainly the knees and wrist bones – in these joints the range
of motion is limited i.e., narrower than normal, and when the infection flares-up the
pain is centered mainly in these joints. Symptoms are also found in her feet – in the
joints of the toes, in the right hip joint – where the range of motion in rotating the hip
inwardly is limited, and also in the fingers of both hands.
We have been meeting for a private yoga class once a week for the past seven years
When I first met Tamara she had a history of eight years of dealing with the disease.
Over the years she recognized the progress route of the inflammation and the
symptoms, and the disease has been stabilized by medication. It should be noted
that finding the right medication to the patient often involves a process of trial and
error, since different patients respond differently to the same drugs despite the
It should also be noted that Tamara arrived to my classes with a rich experience of
working with the body, especially the Feldenkrais practice.
I find it important to mention these two factors as they eased for us the beginning of
our work together, contributed greatly and continue to contribute to Tamara’s ability
to deepen her practice of yoga and persevere.
Tamara’s limitations in the beginning of our work seven years ago were the following:
- Limited range of motion and a limited ability to carry weight at certain angles in the afflicted joints.
- A relative weakness in the muscles of the front thighs and shoulder girdle, that to my opinion were due to the limited range of motion of the knees and wrists;
- Chronic pain in the joints;
- Lower back pain that at times disable her completely.
Tamara’s Vijnana Yoga practice
A General structure of a lesson
- Practicing Pranayama;
- Gentle warm-up, mostly lying on the back – one of the symptoms of arthritis is a feeling of stiffness and contraction in the body and in the muscles. I find that a gentle warm-up with soft and slow movements helps the body to relax and unwind and is an excellent preparation for asana practice.
- Standing poses – this is the warm-up and preparation for the essential part of the class that consists of forward bends, backbends, strengthening of the shoulder girdle or deepening into the standing poses. These poses replace the Sun Salutation that Tamara does not perform due to the sensitivity in her knees and wrists.
- The center of the lesson – forward bends, backbends, shoulder girdle strengthening and deepening into the standing poses.
- towards the end of the lesson – calming and relaxing poses such as:
o Supta Padangusthasana – leg stretches – using a belt or with feet on the wall,
o Sarvangasana – with modification on the wall,
o Viparita Karani – a blanket or a pillow under the pelvis and legs on a wall or on a chair,
o Sitting – Sukhasana or Baddha Konasana.
- Savasana – relaxation was often done with bolsters under the knees and ankles to deepen the sense of rest and relaxation of the legs and the lower back. We can get a sense of the importance of the bolster to her practice from the fact that Tamara calls it “the man’s best friend.”
Like the process of a regular practice we began with basic standing poses:
- Tadasana and Virabhadrasana I – Warrior pose I,
- Virabhadrasana II – Warrior pose II,
- Trikonasana – triangle pose,
- Uttanasana – Standing Forward Bend.
- Prasarita Padottanasana – Standing in a wide stance and bending forward.
We moved to the next poses:
- Vriksasana – Tree pose
- Parivritta Trikonasana – twisted Triangle Pose
- Parsvakonasana – one side of the body extended in lateral bend,
- Parsvottanasana – sides of the body extended in forward bend
- Utkatasana – Chair Pose.
Gradually we started to connect the postures to form sequences – Tamara greatly
enjoys the flow of the movements – and then we added the more challenging poses
in terms of posture, flexibility strength and balancing:
- Ardha Chandrasana – Half-moon pose
- Parivritta Ardha Chandrasana – twisted half-moon pose
- Virabhadrasana III – Warrior pose III,
- Parivritta Parsvakonasana – extended sides of the body in forward bend, twisted.
1) during the first period we worked with legs in small spread: for a comfortable
balance, to make it easier on the knees, especially in poses where one knee is bent,
and to improve the effectiveness of learning and creating a foundation of an effective
posture that does not burden the lower back, an area that caused Tamara pain.
2) Using aids for complex poses in terms of balancing: such as Ardha Chandrasana,
Parivritta Ardha Chandrasana and Virabhadrasana III. For some time we used thick
rectangular blocks made of sponge, but it turned out that they were not stable
enough. Today we use a chair to rest one hand or two on it, yet the emphasis is
always on rooting and placing the weight on the leg and not on the hand resting on
3) Instead of Utthita Hasta Padangusthasana – hand to the toe of the outstretched leg, which is the last position of the Virabhadrasana I sequence. Tamara ends the sequence with a standing twist with one foot on a chair, and the direction of the twist is to the bent leg resting on the chair.
4) The dancer pose – Tamara practices it next to the wall facing it; one hand touching the wall to help balancing, and the other holds a belt bound around the back of the
foot that is bent backwards. Similarly, one can practice the dancer pose lying on their side. In these poses we elongate the front leg muscles, in addition to working on
balancing, caring for the center of the body and maintaining a quiet back. This practice is important for Tamara, since she does not practice Virasana and Vajrasana.
5) After she felt established and happy in Utkatasana, which is her favorite pose, Tamara began practicing the position of the feet in Garudasna. Here too, facing the wall so that one hand can touch it, but not lean, just to help with balance.
Tamara practices fully these sitting poses – Sukhasana and Baddha Konasana.
Due to the restriction of the knees she cannot practice Virasana, Vajrasana and
Ardha Padmasana – Half Lotus. Therefore, we found the following modification:
1) Virasana with one leg, sitting on a chair – sitting close to the right side of the seat and sending the back of the right foot on the ground, towards the right rear leg of the chair. The same with the left foot. In this way she gets an extension of the front thigh and calf muscles and flexibility of the back of the foot. It should be noted that Virasana or Vajrasana with elevation on blocks, are not possible for Tamara.
2) Half-lotus, with one leg, sitting on a chair – sitting on the edge of the seat so that the back is not supported by the back rest. The left foot on the ground (left heel under left
knee) and the external ankle of the right leg resting on the left thigh near the knee. In this way we get an opening of the right hip and extension of the muscles of the buttocks and part of the thigh muscles.
Since the Inflammation damaged the wrist bones, weight bearing in certain positions
is not possible for her because there is no range of motion or 90 degrees flexion.
Therefore, handstands, Bakasanas, and Vasisthasana, are not practiced.
Tamara practices the following poses to strengthen the shoulder girdle, arms and
Downward facing dog – usually Tamara practices this posture gradually. First with
hands in fists against the wall and an angle of about 90 degrees between the hips and the pelvis.
Then, with the outstretched palms resting on the edge of the chair seat and the angle between the hips and pelvis is less than 90 degrees.
In preparation for a full pose of downward facing dog she practices with palms
placed on hard sponge blocks adjacent to the wall.
Tamara enters the full pose of downward facing dog from Uttanasana, while
progressing forward on her fingertips, until her palms are placed on the mat spread in
an angle that is possible for her wrists. Coming back from the Dog pose is done by
transferring the weight back to Uttanasana, or by resting the knees and forearms on
the floor for a few moments, in a sort of an embryo pose, and then transferring to
sitting or lying down.
Dog pose on forearms – Tamara practices a variation of this pose standing with her forearms against the wall with the elbows, forearms and hands rooted into the wall at 90 degrees angels between the forearms and the arms and between the arms and the rib cage.
The next step is dog pose on the forearms with the elbows, forearms and hands rooted to the chair seat.
Here we strive to have an angle bigger than 90 degrees between the arms and ribs and between the arms and forearms. It is also possible to practice with elevation by blocks adjacent to the wall as a more challenging stage after the practice with a chair.
Tamara practices basic backbend poses – Salabhasanas. For a long time she did not practice those poses because of the pain and sensitivity in the lower back, that were aggravated by the backbends and benefited continuously from forward bends. During the recess from practicing these poses Tamara’s practice deepened in terms of relaxation, rooting and connecting. Slowly she learned to relax further and further the lower back, the buttocks and tail bone area, so that the position of the anterior pelvic tilt was moderated, the legs became stronger and posture improved so there was less and less strain on the sensitive area in the back. Recently Tamara began to practice Salabhasana and she implements the same understanding of relaxation, rooting and connecting that she acquired in the standing poses, in poses lying prone ,and with great success . In these poses there is no restriction in terms of arthritis.
In backbends such as Setu Bandha (small bridge pose), Urdhva Mukha Svanasana (Upward-Facing Dog), Ustrasana (Camel Pose) Dhanurasana (the bow), and Urdhva Dhanurasana (Bridge), the restriction of movement of the knees and wrist is reflected, and we do not practice them.
However, Tamara practices the moderate back bend that is part of certain poses such as Virabhadrasana I, the preparation for Parsvottanasana, with the hands behind the back, and also in the practice of a kind of a Cobra pose, standing against the wall or sitting on a chair.
Forward bends while sitting
From the selection of forward bends while sitting Tamara practices those that do not
involve deep knee bending:
- Janu Sirsasana
- Parivritta Janu Sirsasana
- Upavistha Konasana
- Baddha Konasana
The two inversions that Tamara practices are:
Partial Sarvangasana through mounting with the legs on the wall, and without placing
the full weight of the pelvis on the hands.
Another pose is Viparita Karani – the pelvis is elevated on a bolster or on blankets, and the feet are on a wall or on a chair.
Supta Padangusthasana – during acute periods of inflammation of the knee Tamara
practices this pose with a straight leg from the start, i.e. without the stage of
straightening the bent knee.
Variations of Navasana – Boat pose – Eka Pada Ardha Navasana, Navasana with
one leg straightening up the weight of the upper body on the elbows and forearms.
Aids & accessories for support and for resting poses
Accessories such as a chair, blankets, blocks, belts, and bolsters – assist in various
ways in the active asanas and also serve as a good support for deepening the
relaxation in the passive and restorative poses. Rest is important in dealing with
arthritis, especially during the acute periods and the accessories help the body to
relax, rest and regain strength.
Practicing yoga when dealing with arthritis requires a moderate training pace, during
which the practitioner can be aware of body sensations in movement and in resting
periods within the poses. This pace allows noticing the presence of pain or its relief
and maintaining ranges of motion where there is no over burdening of the joints.
Working at a moderate pace builds a sense of confidence in terms of balance, it
facilitates the understanding of the directions of body movement in space, and in
general it allows a continuous presence of the mind with the body and breath.
Working with the principles from the perspective of Vijnana
In Vijnana Yoga the seven principles constitute the core of practice: practicing
Relaxation, Quieting the mind, clear Intent, Breathing awareness, discovering
Rooting and Connecting and developing the capacity of Expanding into Elongation
and Widening, without losing the Rooting and Connection. These principles are the
basis for organizing and guiding the mind, body and breath in the practice of each
asana. The same principles are also the guidelines in finding the appropriate
modification of classical asanas according to the limitations of the practitioner. This is
the importance of finding the middle the mental and physical center, and
consequently a quiet and strain-less back in all poses will follow, even in the complex
poses. It is less important to me to perform, for example, Virabhadrasana III fully and
without support under the arms, if this overloads the joints of the standing leg, weighs
on the back and shoulder girdle and puts the whole body under stress. We can use
support under both palms using a chair or blocks, and in this mode direct the rooting
of the standing leg that will bare more and more weight, develop Intent and rooting
backwards of the leg in the air, learn Elongation between the tail bone and the head
that keeps the back quiet, and then experiment in detaching one hand and sending it
forward with awareness to Rooting and Connecting in the whole body.
In my experience, the ability to move forward in terms of Rooting, Connecting,
Extending, finding balance in the poses, especially the complex ones, increases if we
work in a gradual way, advancing slowly.
I found out that there is efficiency and gain, in terms of focusing the mind, using a
controlled effort and having a good sense of self, in a practice that has a relaxed
sense in the poses as a starting point from which we will meet the challenge. In this
way every now and then a new ability arises and becomes accessible, presents itself
– it cannot be forced. This happens to us all even in a regular practice, and in
working with limitations this requires an even greater creativity, that will help to
moderate and make the complex advancement gradual and thus support the
practitioner in points of difficulty.
Over the years Tamara deepened the practice, both in terms of the complex poses
she practices and in terms of the quality and depth of her practice from the
perspective of working with the principles. With the help of Connecting and Rooting
her posture is more effective also in large ranges of motion, both in widening the
stance in standing poses and in terms Elongating into space. I suppose that, due to a
more balanced weight bearing and a more efficient flow throughout the skeleton, the
load on the joints is more moderate and balanced.
The ability to let go of unnecessary effort during movement and during staying in
poses also contributes to reducing the strain on the joints and lower back. Transitions
between poses in sequences, which were a challenge in themselves, particularly
transitions into the complex poses in terms of balance, became smoother and more
efficient with the deepening of practice.
The legs got stronger, a present “body center” and a quiet back were established,
Rooting and Connecting to the furthest edges from earth evolved into Expansion and
Elongation. The flexibility of the muscles of the legs, back and shoulder girdle is
maintained and even increases.
Today, after seven years of practice, Tamara practices the sequences of standing
poses almost fully: Downward-Facing Dog without pausing on the knees (on the way
up, basic backbends – Salabhasanas, seated forward bends and poses lying on the
back such as Supta Padangusthasana and abdominal poses. One inverted pose that
we practice is a version of Sarvangasana next to the wall. That is, the practice is
done while lying on the back, the stomach or on the side, sitting on the ground and
on a chair, standing on both feet and a four point stance. We almost completely
refrain from a six point stance due to the damage of inflammation in the knees, and
also from hand balances due to the damage in the wrist. Strengthening the shoulder
girdle and arms is done through Downward facing Dog and a dog pose on forearms
Tamara reports that her hip muscles are strengthening; a feeling that is supported by
her routine medical tests. This strengthening supports the knee joints. She feels that
the range of motion in her wrist bones is maintained, and even increased, due to the practice of Namaste and Downward facing dog with variations. The lower back pain
is almost completely gone, and the range of motion in the shoulders has increased.
Tamara feels that the practice of Pranayama helps keep the asthma in a quiet state,
and she can pass through winters without colds and severe flus. It helps her during
physical effort as climbing stairs and even as a tool for relaxation and calm when she
experiences stress, tension or nervousness.
Moreover, the practice of yoga eased the pain that she felt four years ago when she
went through a severe flare of the disease. During a few weeks, while Tamara was
waiting for an approval of the health authorities for a drug that will help her in treating
the inflammation, she suffered severe pain throughout the body, and the painkillers
that she took did not ease her pain sufficiently. During this time she turned to practice
yoga at home on her own since she felt that the practice of Yoga has a very relieving
effect on the pain; a relief that lasts a few hours after the end of practice. She
reported that the relief that she felt following the practice was general, not just in a
particular joint, but a general feeling throughout the body. The practice filled the
space that the painkillers could not satisfy and helped her get through a few more
hours a day with reduced pain.
Tamara’s feels, and so do I, that when yoga is practiced with a simultaneous recruit
of mind, body and breath, into a joint focus provides an additional advantage to our
general feeling, body and soul, that is experienced as calm, relaxation, a center, as a
sense of relaxed and beneficial being within.
Such practice is discovered to ease the pain; it helps people who live with the
constant presence of physical pain to deal with it and with the unexpected
appearance of pain along the way.
I find that a soft approach towards ourselves in the practice, searching for pleasant
ranges of motion and staying in the ones that feel good – and not in those that
arouse pain – cultivate a sense of calm and confidence and of having the ability to be
in motion and action without pain. This is a significant and encouraging state for
someone that is used to the almost constant presence of pain.
This approach dictates a moderate work pace that is very attentive to the body in
each and every practice. It also allows long-term processes in which strength,
flexibility and a physical and mental stability evolve and are established. The
Principles – Relaxation, Quieting, Intent, Breathing, Rooting, Connecting, Elongation
and Expansion – are the tools for such practice.
I would like to emphasize that the work with Tamara is done in a joint and constant
search for the useful and beneficial practice – by questions like – does it evoke pain?
Eases pain? Doesn’t increase pain, yet doesn’t ease it? Pleasant? Unpleasant?
Feels like a positive effort or as excessive effort?
Tamara is one of my students among a few with rheumatoid arthritis. The disease
and its accompanying limitations differ from one to the other. There are differences in
the nature of inflammation, pain intensity, frequency of exacerbations (flare-ups), and
the effects of medication. These differences are reflected in various joints in the
body. For example, poses that are possible and benevolent for Tamara like prolonged practice of standing poses are painful for another student due to painful inflammation in the feet. This other student can stay relatively comfortably on a six point stance and the child pose, while Tamara is unable to practice them due to the limitations in the knees.
My work with students that have physical limitations due to rheumatoid arthritis show
that they will be limited in the training and practice of yoga, but there are there are no
built sequences and no uniform answers for how to practice. Practicing yoga we
endeavor, while applying the seven principles of Vijnanas Yoga, to have an
encounter of a joint investigation that will yield a beneficial long-term practice.
About the author
Hilla Arnon, a senior yoga teacher, with a background in dance studies, movement
analysis and anatomy. She teaches group yoga classes since 2002 and individual
classes of therapeutic yoga since 2006. Lives and works in the greater Tel Aviv area.
For more information and contact please visit her yoga site.