Research in Retinal Disease The Foundation Fighting Blindness Invests 2 1 Million in Seven New Research Efforts

As I continually search the web for interesting news about new technologies for treating retinal diseases, I came across this news from the Foundation Fighting Blindness’ website  yesterday afternoon. It relates to some of the annual grants to researchers that the FFB will be funding this year. It includes better ways of looking at retinal cells (via use of the adaptive optics laser scanning ophthalmoscope) and several projects involving gene therapy, along with a couple looking at ways of, hopefully, stopping the progression of dry AMD.

The following write up is reprinted with permission of the FFB.

The Foundation Invests $2.1 Million in Seven New Research Efforts

The Foundation Fighting Blindness

August 15, 2013

The Foundation's Scientific Advisory Board (SAB) recently completed its annual grants review process, leading to the allocation of $2.1 million in funding for seven new research projects, including those for identifying new disease-causing gene mutations, developing cross-cutting gene therapies and advancing potential treatments for dry age-related macular degeneration. The three-year grants were awarded after the SAB reviewed 117 proposals submitted to the Foundation last October.

"Grants review is a rigorous, multi-step process that takes most of the year to complete," says Stephen Rose, Ph.D., chief research officer, Foundation Fighting Blindness. "Due to revenue limitations, we can only fund a fraction of the high-quality projects we'd like to fund. That makes the selection process even more challenging. We had to leave several excellent proposals on the table."

Here are brief descriptions of the new research projects:

AOSLO: Detecting Retinal Degeneration Before Vision is Lost

The adaptive optics laser scanning ophthalmoscope (AOSLO) is like a powerful microscope that enables retinal researchers to see structural changes in the retina well before vision is lost from a retinal disease. That power can enable researchers to more quickly determine if a treatment is working in a clinical trial. Austin Roorda, Ph.D., of the University of California, Berkeley, is performing studies of AOSLO to correlate changes in the retina (e.g., loss of photoreceptors) with changes in vision.

Enhancing AOSLO for Expanded Clinical Use

Like Dr. Roorda, Stephen Burns, Ph.D., of the University of Indiana, is working with AOSLO to study the correlation between retinal and vision changes. He is also making AOSLO more affordable by using newer camera technology. In addition, he's employing state-of-the-art computing technologies derived from video games to decrease image-processing times and costs. The new technology will make the imaging process more comfortable for the patient by tolerating more head and eye movement.

Figuring Out Why Severity of Vision Loss Varies for People with XLRP

Researchers have reported for many years that the severity of vision loss for people with X-linked retinitis pigmentosa (XLRP) can vary greatly, even for people within the same family. Stephen Daiger, Ph.D., of the University of Texas Health Science Center at Houston, will be looking at the role of a various biological, genetic and environmental factors in vision-loss variability for those with XLRP. The identification of a significant factor that modulates vision-loss severity - perhaps a protective protein - could lead to a potential treatment.

Finding New Genes Linked to ADRP

Researchers have identified almost two dozen genes linked to autosomal dominant retinitis pigmentosa (adRP), but many are yet to be found. Rui Chen, Ph.D., of Baylor College of Medicine, is on the hunt for those remaining adRP genes. With DNA from 118 adRP families, including 18 families with at least nine affected members, Dr. Chen is well positioned to identify additional genes linked to adRP. Finding the new genes will provide researchers with targets for treatments and cures.

Developing Neuroprotective Gene Therapies to Preserve Vision

John Ash, Ph.D., is developing gene therapies that have the potential to preserve vision in people affected by a broad range of retinal diseases. Unlike corrective gene therapies, which work only for conditions caused by a specific gene, Dr. Ash's proposed treatments are designed to keep the retina healthy independent of the underlying disease-causing gene. He also believes the proteins delivered by his treatments - PIM-1 and STAT3 - will be less likely to cause damaging inflammatory side effects than some previously investigated neuroprotective proteins.

Targeting Inflammation to Halt AMD

Thanks to previous Foundation-funded genetic studies, researchers have strong evidence that the progression of age-related macular degeneration is associated with an over-active immune system. This ultimately leads to inflammation and cell death in the retinal pigment epithelium (RPE), a layer of cells that provides critical waste and nutritional support to photoreceptors. Loss of the RPE subsequently leads to loss of photoreceptors and vision. Jayakrishna Ambati, M.D., of the University of Kentucky, is developing a gene therapy that preserves the RPE by preventing the harmful sequence of immune-system events.

Boosting Cells' Energy Supplies to Save Vision in AMD

Based on prior research, Deborah Ferrington, M.D., of the University of Minnesota, believes that mitochondrial dysfunction in the RPE plays a significant role in the development of AMD. Mitochondria are like miniature organs (organelles) within all cells that provide energy. When not working properly in retinal cells, they can lead to cell death and vision loss. Dr. Ferrington is evaluating compounds that help protect mitochondrial function in the RPE.

Iluvien Update 2 New Safety and Efficacy Data Presented at ARVO

In July 2010, I wrote a comprehensive report about Iluvien and its potential in the treatment of diabetic macula edema (DME) (Iluvien and the Future of Ophthalmic Drug Delivery Systems). It was anticipated at that time that the company would obtain marketing approval for its sustained release treatment of DME by the end of that year. However, as I wrote in early January, the company received a CRL (complete response letter) from the FDA instead, that requested additional information before approval could be granted. (Iluvien Update: FDA Marketing Approval Delayed).

Earlier this week, Alimera Sciences and pSivida Corporation jointly announced that one of the FAME Study investigators had presented on a subset of the FAME Study data at the ARVO Meeting in Fort Lauderdale, and that the company (Alimera) plans to submit this new subgroup data to the FDA in support of its New Drug Application. Iluvien is licensed by pSivida to Alimera Sciences, Inc.

Here are the details:

Alimera's New 36-Month Safety and Efficacy Results From the Phase 3 Fame Study of Iluvien in Patients With Diabetic Macular Edema Presented at the 2011 Arvo Annual Meeting

Alimera Plans to Submit This New Data to the FDA in Support of Its Pending New Drug Application

Alimera Sciences, Inc. announced that positive new data from the completed FAME Study of Iluvien were presented at the 2011 Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting. The new data showed that 33.6% of patients in Trial A (p<0.001) and 42.4% of patients in Trial B (p<0.001) were observed achieving best corrected visual acuity (BCVA) improvement of 15 letters or more from baseline at month 30 in the identifiable subgroup of patients diagnosed with diabetic macular edema (DME) for three years or more at baseline. The new data were presented by Dr. Andrew N. Antoszyk, one of the FAME investigators and a practicing retina specialist at Charlotte Eye, Ear, Nose and Throat Associates in Charlotte, N.C.

The new data, presented by Dr. Andrew N. Antoszyk, analyzed the subgroup of patients who had been diagnosed with DME for three or more years at entry of the FAME Study (which comprises over 50% of patients in the Study).

The FAME Study consisted of two three-year, Phase 3 pivotal clinical trials (Trial A and Trial B) to assess the safety and efficacy of Iluvien in the treatment of DME. The 956 patients in the trials were randomized to receive either high dose Iluvien, low dose Iluvien or control treatment. The primary endpoint for efficacy in the trials was the difference in the percentage of patients whose BCVA improved by 15 or more letters from baseline on the Early Treatment Diabetic Retinopathy Study (ETDRS) eye chart at month 24 between the treatment and control groups.

As previously reported, the pre-specified primary endpoint for the FAME Study was met for the low dose Iluvien in both Trial A and Trial B. Based on these data, Alimera submitted a New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) on June 29, 2010 for approval of the low dose Iluvien. Therefore, only the low dose data is presented and discussed here.

In February 2011, Alimera presented positive results from the full patient population at month 36 of the FAME Study in Trial A (28.4%) and Trial B (29.0%) with demonstrated improvement in BCVA of 15 letters from baseline. Statistical significance was seen in both trials as late as month 33 with Trial A at 28.4% (p=0.042) and Trial B at 29.6% (p=0.046).

Dr. Antoszyk's ARVO presentation on May 3rd included additional data from a subgroup of study patients that was identifiable prior to administration of Iluvien. This subgroup reflected the duration of DME at baseline and across all patients randomized, with a median duration of DME at baseline of three years.

In the data reported for this subgroup at 36 months in Trial A, 31.8% of patients treated with Iluvien experienced an improvement in best corrected visual acuity (BCVA) of 15 or more letters from baseline compared with 13.6% of those in the control group (p=0.010), for a net benefit of Iluvien versus control of 18.2%.  In Trial B, 36.4% of Iluvien patients in this subgroup experienced improvement of 15 or more letters compared to 13.2% of control patients (p= 0.004), for a net benefit of Iluvien versus control of 23.2%.  On a combined basis for both Trials A and B, at three years the net benefit of Iluvien compared to control reported for patients in the subgroup was  20.6%, more than double that seen for the full patient population (9.8%).

In the subgroup, peak efficacy was seen at month 30, with 33.6% of Iluvien treated patients in Trial A gaining 15 or more letters in BCVA compared to 10.2 % of control (p < 0.001) and 42.4% of Iluvien treated patients in Trial B gaining 15 or more letters in BCVA Trial B compared to 11.3% of control (p< 0.001).

Consistent with the full patient population in the FAME Study, approximately 75% of the patients in this subgroup treated with Iluvien were reported to have received only one Iluvien insert over the 36 month study.

There was no statistically significant difference in BCVA improvement in the subgroup of patients with less than three years' duration of DME at entry compared to control.

"Throughout the FAME Study, Iluvien has shown significant potential for patients suffering with DME. This new data is particularly exciting with 34% of patients who've had DME for three years or more gaining three lines of vision after therapy," said Dr. Antoszyk. "If regulatory approval of Iluvien is obtained, we will be able to offer an additional option in the form of a long-term treatment to our patients who are dealing with this devastating disease."

Data for the subgroup was gathered from 536 patients who had been diagnosed with DME for three years or more and 416 patients who had been diagnosed with DME for less than three years. Alimera will provide these additional data in its response to the Complete Response Letter issued by the FDA in December 2010.

Safety was assessed among those patients within the subgroup who were treated with Iluvien in the study. Intraocular pressure (IOP) increases to 30 millimeters of mercury (mmHg) or greater at any time point were seen in 14.8% of these patients by month 36, compared to 18.3% in the full Iluvien treated patient population. By month 36, 5.3% of these patients had undergone an incisional surgical procedure to reduce elevated IOP, compared to 4.8% in the full patient population. The incidence of cataracts among patients with a natural lens in their eye at the start of the study was 86% at month 36, with 85% undergoing a cataract operation, compared to 80% and 74.9%, respectively, in the full patient population.

"We are pleased that this identifiable subgroup shows even greater benefit to risk than the full patient population through month 36 of the study, thereby further improving Iluvien's profile," said Dan Myers, Alimera's president and CEO. "This data spotlights the benefit that Iluvien, if approved, could bring to the patient population that retinal specialists are targeting for its use. We believe this data will be very valuable to the treatment of DME going forward."

Paul Ashton, president and chief executive officer of pSivida, said, "We are very pleased with the efficacy and safety results through month 36 in patients with chronic DME.  This subgroup comprised a majority of patients in the FAME Study.  We look forward to Alimera's filing of this data with the FDA in connection with the NDA for Iluvien."


About the FAME Study

Alimera conducted two 36-month, Phase 3 pivotal clinical trials (collectively known as the FAME Study) for Iluvien involving 956 patients in sites across the United States, Canada, Europe and India to assess the efficacy and safety of Iluvien with two doses of the corticosteroid fluocinolone acetonide (FAc), a high and low dose, for the treatment of DME. The primary efficacy endpoint for the FAME Study was the difference in the percentage of patients whose best corrected visual acuity improved by 15 or more letters from baseline on the ETDRS eye chart at month 24 between the treatment and control groups. The study concluded in September 2010 with the final patient visit at the three-year data point.

Following its NDA submission to the FDA, Alimera submitted a Marketing Authorization Application to the Medicines and Healthcare products Regulatory Agency in the United Kingdom. Applications have also been submitted to regulatory agencies in Austria, France, Germany, Italy, Portugal and Spain. Based upon the analysis of the FAME Study, all filings included the 24-month data. The FDA, in a December 2010 Complete Response Letter, requested further information including the month 36 data from the FAME Study.

About DME

DME, the primary cause of vision loss associated with diabetic retinopathy, is a disease affecting the macula, the part of the retina responsible for central vision. When the blood vessel leakage of diabetic retinopathy causes swelling in the macula, the condition is called DME. The onset of DME is painless and may go undetected by the patient until it manifests with the blurring of central vision or acute vision loss. The severity of this blurring may range from mild to profound loss of vision. The Wisconsin Epidemiologic Study of Diabetic Retinopathy found that over a 10-year period approximately 19% of people with diabetes studied were diagnosed with DME. As the population of people with diabetes increases, Alimera expects the annual incidence of diagnosed DME to increase, as well.

Drawing Inside and Quieting Roger Cole on Savasana Part 2 Rerun

Drawing Inside by Melina Meza

Here is the second excerpt from the interview that Leslie Howard did in 2008 with yoga teacher Roger Cole. In this excerpt he talks about his own practice of Savasana, compares seated meditation with Savasana, and gives his recommendations for setting up and practicing the pose. 

 Leslie: Have you had any special experiences with the pose, either in your own practice or with students?  

Roger: Not really. There isn’t one that stands out for me. Restorative asana experiences—Ssavasana being one of them—many times I have had resting poses or Savasana in which I just really feel like this is exactly what I need and what everyone needs—everyone needs to do this sometime. Take the time when you would not ordinarily be sleeping, and lie down and just stop. It is different from seated meditation. Seated mediastion is wonderful in its own way. In Savasana and the other more reclining poses, the brain just shuts off. In the seated pose you are very, very alert. Seated meditation is really good for this deep realization in which you you see the connection between things. In Savasana it is more like you are drawing inside and quieting, and you are observing the quietness. There is a lot less activity in Savasana.  

Leslie: Do you always practice Savasana in your own practice?

Roger: Ideally, yes but in reality no.   

Leslie: When you take the time to do it, what is your preferred method?

Roger: First of all, I am very big on restorative poses and sometimes I will substitute a restorative pose for Savasana. Now ideally Savasana is the last pose because it is the most neutral; no part of the body is elevated over the other, nothing is particularly stretching, especially if you support the arms and stuff. So if I had the ideal Savasana, I would be almost completely neutral, with maybe a little elbow flexion so I could stay longer, maybe padding under the head not to lift the head but to make it not hurt. I personally don’t need padding under the knees but padding under the heels so that the heels don’t hurt. So I make it comfortable. 

The other thing that a lot of people don’t realize about Savasana and other restorative poses is that temperature is extremely important. You get cold. And if you get cold it is just not a relaxing experience. So I am very conscious of the room temperature, and if you need to be covered with a blanket in Savasana and other restorative poses, you need to cover the hands and feet. Don’t just cover the trunk and have the hands and feet sticking out. So in my practice of Savasana ideally it would be the last pose even if I do a lot of other restorative poses. But in reality there is a time limit so if I end up staying in another pose longer well than Savasana gets shortened. Same thing when I am teaching; ideally I would like to put it at the end of every class but sometimes I just run out of time.   

Leslie: Are there any special circumstances or conditions for which you think Savasana is particularly valuable? 

Roger: One of things is that Savasana is the quickest, most generic pose. When it comes time to relax, just lie down. You can do it on a bed, which is actually very important. Bedrooms are set up with a bed so you can lie on them. Of course they have blankets and such, but the availability of having a space to do it is extremely important. If you just lie down on a dirty floor you might not relax, or if its cold or too light or in a traffic area, the bed takes care of all that. Of course, it is a little soft but its there and its available. 

In a yoga class situation, with students that have never done yoga you don’t what to do some strange thing with them in Savasana, maybe with support under the knees because that is very non threatening and it’s very intuitive. So, it’s got a lot of benefit. It doesn’t have a lot of the problems of being uncomfortable or they can’t hold it or their knees hurt or whatever. But if you are going to put people in it a long time, you are going to have to prop them up. So I think it would be particularly valuable for quick relaxation. Also, some kind of relaxation is valuable, but it doesn’t always have to be specifically Savasana. 

You asked me if there were times Savasana should be avoided. So with some kinds of back pain, such as when people have a facet joint injury, it’s too much back bend, but you can modify the pose. Generally it is a pretty easy pose to do. Also if the nose is congested, prop them up and it can be used to drain the nose. 

What about emotionally? Emotionally if someone has had a trauma, like after an earthquake or something like that or a terrorist attack, people are often afraid to close their eyes, to lie there with their eyes closed is very frightening. Also I have had a couple of deaf students and they don’t like to close their eyes because once they close their eyes in Savasana, they don’t know what is going on in the world, although they will do it. They can hear enough through their hearing aid to know when there is shuffling around, but it’s a little tricky. 

So in those instances Savasana with eyes open is a good pose and if their eyes close, apparently they have gotten over it. 

Leslie Howard is an Oakland-based yoga teacher, specializing in all things pelvic. She leads workshops and trainings nationally and internationally, and is the director of the 200 hour Deep Yoga program at Piedmont Yoga. With a state certification in massage, she also practices cranial sacral therapy. To learn more about Leslie, visit: www.lesliehowardyoga.com.  

Roger Cole, Ph.D. is an internationally recognized, certified Iyengar yoga teacher trained  at the Iyengar Yoga Institutes in San Francisco and Pune, India. He is also an accomplished scientist educated at Stanford University and the University of California, with specialties in the science of relaxation, sleep, and circadian rhythms. Roger has taught yoga since 1975. He has authored dozens of articles on yoga teaching, practice, biology and therapeutics, including Yoga Journal's Anatomy Column, Master Class Column and Ask Our Expert Column, Yoga International's Asana Solutions Column, and special feature articles on the prevention of yoga injuries, the physiology of stress, relief from back pain, and the science of keeping your balance. He has trained thousands of yoga teachers and taught yoga as a healing art to physicians, physical therapists, medical students and patients. He offers weekly classes in Del Mar, California, and conducts workshops throughout the U.S. and abroad. His specialties include yoga teacher training, yoga anatomy, yoga physiology, restorative yoga, and promotion of better sleep. See rogercoleyoga.com for more information.

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Video of the Week Downward Facing Dog Pose to High Lunge Version 2

This second version of Downward-Facing Dog pose to High Lunge presents the second easiest way to make this transition, allowing you to step your first foot as far forward as it can go without forcing it all the way between your hands. (Version 1 from last week showed the easiest way to make this transition.)

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Featured Pose Warrior 2 Pose Revisited

by Baxter

We wrote about Warrior 2 pose (Virabhadrasana 2), a staple of modern yoga asana practice quite a long while ago (October 20th, 2011, on our first month of the blog), but it is such a valuable pose I felt it was worth revisiting and updating, especially as we have some ideas for useful variations that we never described.

Warrior 2 is one of the most commonly taught and practiced yoga poses in our modern era, and is often one of the first standing poses taught to beginners. This is probably because you are mostly upright and therefore not to far away from the home base of Mountain pose. It is a pose that fosters both strength and flexibility, especially in the legs and shoulders, and begins to introduce just a bit of rotation or twist to the spine. Specifically, it will strengthen the hip flexors of the front leg, the knee extenders of the back leg, the muscles that help to keep the arms parallel to the floor, such as the deltoids, upper trapezius, and supraspinatus, to name just a few. It encourages lengthening of your inner thigh muscles of both legs in slightly different areas, as well as your back leg calf muscles.

Your spine rotates a bit in this pose, as your pelvis turns slightly towards your front foot, your thoracic spine turns toward the long axis of your mat, and your neck and head turn towards your front hand, so the pose is also a mild twist. Because you step the feet apart and one foot turns out and other turns in, it is one of the first balancing poses you are likely to meet if you are new to yoga. And if you step carefully in and out of the pose, or move from the starting position in and out with our breath (see Warrior 1 and 2 Mini Vinyasas), this pose also cultivates agility.

I prescribe this pose for:

• General strengthening 
• General stretching 
• Osteoporosis. The pose is weight bearing for the lower body, so strengths lower body bones. It also provides isometric work of the shoulders and upper back so it can improve the thoracic spine bone health.
• Improving balance and agility
• Improving mental focus (when held for longer periods of time)
• Improved overall muscular endurance (when held for longer periods of time)
• Anxiety (the pose burns off excess energy and is “grounding”) 
• Fatigue, sluggishness, or depression (standing poses can stimulate your nervous system) 

Cautions: For those with uncontrolled blood pressure or a history of heart disease, I recommend that you don’t hold the pose for more than a few breaths, as it can cause an increase in blood pressure and the workload of the heart. For those with balance issues, I recommend that you work with your back to a wall or start with the chair version shown below. If you have knee problems, don’t bend your front knee quite as deeply. Make sure it stops just shy of being over the front ankle.

Classic Version

Step your feet wide apart (about the length of your legs). Turn your right foot and leg out 90 degrees. Then turn your left foot in slightly, so the lateral edge of your back foot lines up with the short edge of your yoga mat, or even in a bit more than that. 

Inhale and extend your arms out to your sides, parallel with your shoulders. Then, exhale and bend your right knee toward 90 degrees (but not further), making sure your right knee is aligned with your middle right toe and positioned over the right ankle. 

Allow your hips to rotate around the vertical axis of your spine a bit towards your front foot. At the same time, rotate your chest towards the long axis of your mat. If it’s comfortable for you, turn your head to gaze over your right hand.

You can hold the pose for a few breaths initially, and gradually add more time in the pose as you feel ready, eventually up two minutes.

To come out, straighten your front leg, turn your feet parallel and relax your arms to your sides. Repeat on the second side.

First Variation: Feet Closer Together, Hands on Hips

Working with your feet slightly closer together and keeping your hands on your hips is a good variations for people newer to yoga, those with tight inner thigh muscles and connective tissue, and those with shoulder issues such as rotator cuff injury that make taking your arms to sides challenging or painful. It is also less challenging for balance then the first variation, so is a good place to start for those with balance challenges.

Instead of stepping the feet as wide as classic Warrior 2, step your feet only about three feet apart. Then adjust your front and back foot as in classic Warrior 2, but keep the hands on the hips, with the shoulder blades relaxed on the back chest.

From here, the rotations of the spine are as with the full version.

Second Variation: Warrior 2 with Chair

This variation of Warrior 2 is particularly helpful for those with balance issues, with other health issues that compromise endurance, or with injuries that could affect safely standing without pain, such as knee, hip and ankle injuries or arthritis. But it is also beneficial for people who have no restrictions, and you might find that it actually creates more sense of stretch to the muscles and connective tissue of the inner thighs.

Sit on the front edge of a chair. If you are taller or have long legs, you may need to use a blanket or lift under your front leg, so your thighs are not lower than your knees.

Swivel to your right, bringing your right sitting bone and the back of your right thigh along the front edge of the chair seat. Your left sitting bone may actually be slightly off the chair seat.

Bend your right knee so that the right knee is right above the ankle with the right foot turned out 90 degrees.

Slide your left leg back away from the right until you can fully straighten your left knee with the sole of your left foot on the floor. Note that your left leg will likely not stretch straight back as in the full pose, but will probably need to come towards the right long edge of the mat a few inches. From here, your arms and spinal movements are the same as the classic pose. 

Stay for several breaths, and gradually work up to 90-120 seconds with practice.

To come out of the pose, lower your arms, bend your back knee and swing both legs forward so you sit evenly on the front edge of the chair. Then repeat on the second side.

Third Variation: Reverse Warrior 2 (aka Exalted Warrior)

This variation challenges the stability of your legs and also adds some stretch and lengthening for your chest and arms on the front leg side. It will also add more challenge to your balance.

Come into classic Warrior 2 as described above.

Maintaining the alignment of your front knee, inhale and bring your right arm up towards the ceiling as you reach your left hand down toward the outer left thigh.

Keeping your right knee firm and steady, slowly slide your left hand further down your left leg as you side bend your torso over your left leg and continue to reach your right arm up and back. Stop when your body signals significant tightness. 

Lynda Bailo

Lynda Barrow

Your gaze can remain straight ahead, or for more challenge to your balance, you can carefully gaze up towards your top hand. Stay for just few breaths at first, working towards longer holds over time. 

To come out, start by tipping back into classic Warrior 2, then exit as described above. Then repeat on the second side.

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When to Transition to a Gentler Practice Part 2

by Nina

Hidden Waterfall by Brad Gibson

"At ninety-three, he could still perform difficult asanas--including variations on the headstand many younger "masters" could not. When he was ninety-five, however, he fell and broke his hip. Because of the reputation of Krishnamacharya, several leading surgeons offered to operate—but he would have none of it. Instead, he rigged up pulleys and ropes by his bed and began to experiment with new Yogic techniques for his own rehabilitation. Within two months he was able to walk, but the loss of full freedom of movement depressed him." —from Health, Healing and Beyond by T.K.V. Desikachar (about his father Krishnamacharya)

In Baxter’s post yesterday When to Transition to a Gentler Practice, he quoted a letter we received from a reader asking for advice about when to transition to a gentler asana practice. This is not the first time we’ve received such a question; in fact, this is probably the most frequent question we get here on Yoga for Healthy Aging. I suspect that most people with this question are hoping for some kind of formula from us, saying for example, if you can no longer do x, y, and z poses, it is time for your transition or most people should make the transition by age 65. But as I said to Baxter, I really feel that if you are asking the question, it’s not time yet. Because when the time comes, you will know it. Maybe you will be like Krishnamacharya, who had to change when he was 95. Or maybe you will need to transition much earlier, the way I did.

In my forties I had a rather strong, what I like to call “semi-fancy” asana practice. I took an advanced yoga class, did challenging poses like arm balances, full Lotus, advanced backbends, etc., practiced about two hours a day, and did long inversions almost every day (including a ten-minute headstand with variations and a ten minute Shoulderstand). I quite enjoyed the athleticism of my practice, and the feeling of strength and physical wellbeing it brought to me. By my fifties, however, I developed certain physical problems, probably brought on by menopause, which forced me to change my practice. Mild arthritis in my right hip meant that I could no longer do Lotus or even half Lotus and that I had to start using props in certain other poses. And two rounds of frozen shoulder (who knew you could get it more than once?) temporarily restricted my range of motion in my shoulder so that I was very limited in what I could do with my upper body, and after the frozen shoulders abated, I was never able to get my full range of motion back (though I’m still flexible in that area, compared to some).

I practiced asana throughout all these difficulties, adapting my practice as my restrictions increased and then decreased. While my shoulder was frozen, I couldn’t even do Downward-Facing Dog pose, much less Headstand, Handstand, or Upward Bow pose. So my practice was by nature very gentle. After I got better, I began to gradually ease my way back into the poses I couldn’t do with my temporary injury, and I’m still working on getting back to where I was (realizing, of course, that I may never get there).

When I was able to do Headstand again, I made a conscious decision not to do it as often or as long as I used to. I felt that it was a pose I enjoyed so much, I didn’t want to risk losing it again, and I knew that both Headstand and Shoulderstand would be pretty hard on my neck. So I decided to practice it only about twice a week and only for about 5 minutes each time, instead of the way I used to practice it. I had absolutely no scientific evidence that this was a good idea, and it was not suggested to me by any of my teachers, it was just a feeling I decided to follow. And it can’t hurt to be cautious, right? Removing the long inversions from my practice also made it shorter, so now my practice is more in the 1 1/2 hour range (and sometimes shorter, if I’m tired). As it happens, I never had to leave my regular (intermediate) yoga class. That’s partly because I know how to make modifications to my poses (or do alternatives) when there is something I can’t do. But it’s also because my teacher has been very supportive and understanding. (Once he said something about me—thank you, Donald—that I’ll never forget: “Nina never gives up!”)

The point is, my transition has been a very organic process, in which I’ve responded to signals from my body (some rather loud, others perhaps not) and made adaptations along the way. It hasn’t all been a one-way process, either. During times of difficulty, my practice was very gentle, and when I was more able, I returned to a stronger practice. And I also know, the transition process is not over yet. Who knows what the future holds. Will I be still be doing Headstand at 95 like Krishnamacharya? Or will I have to give it up much earlier?

Baxter, too, has gone through a similar process, with physical problems (including a touch of hip arthritis) prompting him to modify his practice. And that’s how I think it will turn out for most of you, dear readers. Perhaps you will have an injury or illness that forces you to change your practice, either temporarily or permanently. Or perhaps you will simply reach a point (who knows at what age?) when you can just no longer do the poses you used to be able to do or get through an entire class the way you used to, and you’ll know deep down inside that now is that time for a change. Like the future, this process is both inevitable and completely unpredictable. But it is your own body that will guide you through it.

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