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Podcast

Yoga is a Philosophy, Not Just an Exercise: Demystifying Yoga for Arthritis with Dr. Steffany Moonaz 

January 4, 2023
50 min read
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Summary:

If you have a chronic illness you’ve likely heard the question: “Have you tried yoga?” In this episode, yoga therapist and researcher Dr. Steffany Moonaz and host Cheryl Crow discuss the many benefits of yoga for people with inflammatory arthritis. They also bust common myths and misconceptions about yoga, including that it’s just an exercise or series of physical poses. 

Dr. Moonaz shares her best tips for patients newly diagnosed with arthritis and explains how the philosophy of yoga can help people with arthritis fully embrace the present moment and improve overall wellbeing. Dr. Moonaz is the founder of Yoga for Arthritis, which aims to bring evidence-informed and heart-centered yoga practices to people living with arthritis and chronic pain worldwide. 

Video

Episode at a glance:

  • Yoga meaning and philosophy: The union of mind and body through movement, breath, and mindfulness – not just poses and exercise!
  • What makes Yoga Therapists different than Yoga Teachers: Yoga therapists have further training in understanding of health conditions to help patients manage chronic illness or imbalances through yoga.
  • The power of movement for mental health: After experiencing improvements in her own mental health through dance and exercise, Dr. Moonaz realized her purpose of reducing suffering for people through mindful movement. She focuses on arthritis due in part to it being a leading cause of disability. 
  • Research on Yoga for Arthritis: It is considered integrative medicine with improvements for overall quality of life. This is due to relief of pain and stiffness, increase in physical function through balance, strength, and flexibility, and mindfulness for stress reduction
  • Beginner Tips: Ask your rheumatologist if there are positions you should avoid, search for a Yoga Therapist who has experience with accessible / adaptive yoga through the International Association of Yoga Therapists, private lessons can be beneficial for added safety and personalized / targeted symptom management
  • Advice for newly diagnosed patients: find “RA Thrivers” and listen to their stories, use social media as a resource for building connections, and join Rheum to THRIVE for education and support!

Medical disclaimer: 

All content found on Arthritis Life public channels was created for generalized informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

Episode Sponsor

Rheum to THRIVE, an empowerment program Cheryl created to help people with rheumatic disease go from overwhelmed, confused and alone to confident, supported and connected. Learn more here! 

Speaker Bios:

Dr. Steffany Moonaz is a yoga therapist and researcher outside of Philadelphia. She serves as the Associate Research Director at Southern California University of Health Sciences and Adjunct Professor at Maryland University of Integrative Health. She is the founder and director of Yoga for Arthritis, which aims to bring evidence-informed and heart-centered yoga practices to people living with arthritis and chronic pain worldwide.

Cheryl Crow

Cheryl is an occupational therapist who has lived with rheumatoid arthritis for nineteen years. Her life passion is helping others with rheumatoid arthritis figure out how to live a full life despite arthritis, by developing tools to navigate physical, emotional and social challenges. She formed the educational company Arthritis Life in 2019 after seeing a huge need for more engaging, accessible, and (dare I say) FUN patient education and self-management resources.

Episode links:

  • Links to research on Yoga and Arthritis:
    • Original RCT at Hopkins: Moonaz, S. H., Bingham, C. O., 3rd, Wissow, L., & Bartlett, S. J. (2015). Yoga in Sedentary Adults with Arthritis: Effects of a Randomized Controlled Pragmatic Trial. The Journal of rheumatology, 42(7), 1194–1202. https://doi.org/10.3899/jrheum.141129
    • Replication for Underserved Patients: Middleton, K. R., Ward, M. M., Haaz Moonaz, S., Magaña López, M., Tataw-Ayuketah, G., Yang, L., Acevedo, A. T., Brandon, Z., & Wallen, G. R. (2018). Feasibility and assessment of outcome measures for yoga as self-care for minorities with arthritis: a pilot study. Pilot and feasibility studies, 4, 53. https://doi.org/10.1186/s40814-018-0248-x
    • RCTs: Cramer, H., Ward, L., Saper, R., Fishbein, D., Dobos, G., & Lauche, R. (2015). The Safety of Yoga: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. American journal of epidemiology, 182(4), 281–293. https://doi.org/10.1093/aje/kwv071
    • OBSERVATIONAL STUDIES: Cramer, H., Ostermann, T., & Dobos, G. (2018). Injuries and other adverse events associated with yoga practice: A systematic review of epidemiological studies. Journal of science and medicine in sport, 21(2), 147–154. https://doi.org/10.1016/j.jsams.2017.08.026

Full Episode Transcript:

Cheryl:  

I’m so happy to have Dr. Steffany Moonaz here on The Arthritis Life podcast today. Welcome!

Dr. Steffany:  

Hi! I’m so happy to be here. Glad we can do this.

Cheryl:  

We just had — you’re one of the first people from the podcast that I’ve actually met in person, because we were both at the American College of Rheumatology Conference recently in Philadelphia. So, that was really fun. But yeah, can you just give the listeners a quick introduction to you, like where you live, and what is your relationship to arthritis?

Dr. Steffany:  

Sure. So, I live in the suburbs of Philadelphia. It’s about an hour north of the city in an area called Bucks County, very bucolic area. My university — I’m a research professor — and my university is actually in Southern California. I’m the Associate Research Director at Southern California University of Health Sciences, and adjunct professor at Maryland University of Integrative Health, which is outside of Baltimore. My relationship to arthritis is that I am a career researcher, I have a PhD in public health, and I am a yoga therapist, and a health coach. And in all of those professional areas, the focus of my work is the non-pharmacological management of arthritis and rheumatic conditions, primarily using behavioral interventions, and specifically mind-body practices such as yoga as an adjunct to standard care. So, what can people do beyond what they are working on with their medical management with their doctor, their rheumatologist, their orthopedist, depending on the type of arthritis they have and how its treated; what can they do in their own lives? And we can get into what that means, what that looks like. But I study how that works from a research perspective. And I also help people to execute it in their own lives, both with groups and individuals. And then, I also train yoga teachers and yoga therapists to work safely, appropriately, inclusively, effectively with people who are living with arthritis and chronic pain. And so, I can stop there, or I can tell you how I ended up doing that, which probably is your next question.

Cheryl:  

Yeah, you’re a psychic. Well, first of all, I’m thrilled to have you on here because I do think there, you know, there are a lot of people out there who are interested in yoga, but not many of them have such a rigorous research background like you. And like, I don’t want to be a snob or something, but I think it matters to be able to really like disentangle correlation from causation and in the kind of, I don’t want to call yoga alternative medicine because it’s — yeah, you mentioned non-pharmacological management, there can be a whole bunch of, you know, claims made and you’re gonna be helping us today — us, me and the people listening — you know, kind of understand what does the research say about the benefits of, of yoga and other mind-body practices, as you so eloquently said. But before we get to how you came to specialize in yoga for arthritis, can you tell me if there’s a difference between a yoga teacher and a yoga therapist?

Dr. Steffany:  

Great question, Cheryl. I’m so glad you asked.

Cheryl:  

I actually don’t know. I know that they’re different. I don’t know the actual answer to that. 

Dr. Steffany:  

Yeah, and most people don’t. So, I’m glad that you asked this question for your listeners as well. A yoga teacher teaches, right. They are, their primary role is as an educator. It is their job to teach you the practices of yoga. The minimum standard qualification to become a yoga teacher is 200 hours of training that consists of things like basic anatomy and physiology, what the poses are, how to teach them, breathing practices, a little bit of philosophy, et cetera. They are learning how to teach you yoga. A yoga therapist is a yoga teacher first. So, a requirement to enter into a yoga therapy training program is that you already are a yoga teacher and have experienced teaching yoga. Yoga therapy is focused on the application of yoga practices to the management of imbalances or health challenges from a whole person perspective. So, when you go into a yoga class, the yoga teacher has a plan for what they’re going to teach. And they’re going to basically teach that regardless of who comes in. They may adapt the practice, and they should to make sure that you’re safe and that it’s accessible to you. But they are not going to design the class for you, Cheryl, who’s walking in the door. That is exactly what a yoga therapist does. 


So, a yoga therapist, one, is trained a whole lot more in understanding of variety of physical, and mental, emotional health concerns; and how the tools of yoga may be applied appropriately for those concerns. For example, if you have hypermobility disorder, doing a lot of stretching is not going to be therapeutic. Whereas if you have, if you have a lot of stability and not a lot of mobility, then that may be just what is called for. And so, a yoga therapist will do an assessment and design a plan of care that is going to serve your needs, you know. It’s co-created between the client and therapist in prioritizing what matters most to the individual, and also what is called for based on where the imbalances might be. 


So, a yoga therapist is going to, already on the basis of their training, know more about arthritis and rheumatic diseases. But yoga teachers can also get a whole bunch of continuing education, and become skilled and equipped to work with people who are living with arthritis. But sometimes, people who are living with arthritis just want the practices of yoga to be accessible to them. They don’t necessarily want to use yoga as a therapy to manage their disease, right. So, whether you want a yoga teacher or a yoga therapist depends on what are you trying to experience, accomplish, achieve; what is the purpose of your yoga practice. And that can change you know where you are with your disease and in your life.

Cheryl:  

That makes a lot of sense that it kind of reminds me of this idea of like, using an activity as a means versus an end. Like, you know, if I want to go to a yoga class because I just like the feeling of doing a yoga class, I like getting out of the house. And I like, yeah, I have this association that yes, this is something that kind of promotes my health, but I’m not having like a really specific goal with it. But it’s more of the yoga teacher style versus the yoga therapy is like I’m using yoga as a modality to like, achieve a really specific goal. And yeah, just to make life more confusing, like from my background as an occupational therapist, you know, we were taught we could use things like, you know, really simple, you know, we’d have like the, for pediatrics, like yoga dice, you know, like dice where we would do — and that’s not really the full practice of yoga. It’s just using the literal, you know, poses as ways to stretch and get kids to improve their mobility of their body.

Dr. Steffany:  

Cheryl, it might help to pause and explain what yoga —

Cheryl:

And define yoga? 

Dr. Steffany:

What’s yoga, yeah. 

Cheryl:  

Yeah, okay. Yeah. Yeah, that’s probably a good idea. Let’s do that too, while we’re at it.

Dr. Steffany:  

Okay, awesome. Because you know what you said, that those dice are not the fullness of yoga. Many people don’t know that, especially in the Western world. There is a predominance of what we call modern postural yoga, which is basically taking the poses of yoga, extracting them from the entire context of yoga philosophy and practices more broadly, and using them like a physical exercise routine, right. So, it looks like yoga, you’re making the shapes of a yoga practice, but it could be argued that’s not even yoga, because the root word of ‘yoga’ means ‘yoke’, like how oxen are yoked together, or you could translate it as ‘union’. And that can be the union of the mind and body, the union of the individual and the collective whole. It can be movement with breath. There are lots of ways to think about that union. But it does include, first and foremost, philosophy. There are basic tenets to yoga, like the first one being non-harming. If you’re not doing that, that’s the foundation that all other yoga is built on. 


So, for example, if you go to a yoga practice, and you’re doing poses that hurt you, you could say, well, that’s not yoga, because it’s not in alignment with that foundational concept of non-harming. But the practices of yoga emerged over time in an effort to achieve a state of union. A state of, you know, perfect peace, equanimity. And so, all of these practices, the breathing, the meditation, mindfulness, relaxation, postures, movement, all of that originally had the purpose of helping the individual to come into balance and achieve a state of union. As it turns out, there are also a whole bunch of other good reasons to do those things aside from, you know, achieving eternal inner peace, like having more stability and mobility, for example. And so, it’s fine to use these practices toward those ends. But it’s not — it’s important to recognize that you’re extracting a practice from a toolbox, and that when we’re studying the effects of yoga, or we’re trying to optimize the effectiveness of yoga in helping someone to achieve whole person well-being, we’re talking about a whole toolbox, we’re not just talking about a hammer.

Cheryl:  

Wow, that’s super helpful. I mean, I was literally, as an occupational therapist, I was just thinking of an analogy of like, you know, let’s say enhanced therapy when you’re rehabbing from, you know, a surgery, let’s say carpal tunnel release or something. And like, you’re teaching someone to put their palms together. Like, they’re not praying. That’s what most people do when they’re praying. But, you know, it’s definitely — like yoga, unfortunately, I think, in the Western world and in the United States, it definitely has become this kind of like, to some people a synonym with just fitness or, you know, just taking your body through a series of poses. I love everything you said, it was so eloquent, you know. I wrote down little notes as you’re talking about, you know, union, and gosh, like, what — when do you need a union between the mind and body more than when you’re in pain, you know. Actually pain, to me, makes me want to dis-unionize myself and my body, to not be in union with it. Literally, when I was in the worst pain I’ve had, I remember having this really vivid image of like, I just want someone to take my head and implant it on another body. Like, I want to just to get out of this body, you know, so the idea of achieving a union with your body and union of your movement with the breath and all those things, it’s a very — it’s a very interesting, or it’s an interesting, what’s that — proposition, that was the word I was looking for.

Dr. Steffany:  

Yeah. Yeah, it starts with a willingness to pay attention. And I would say, I mean, there’s so much in the yoga toolbox, so to speak, that serves life with arthritis. The ability to pay attention to whatever is happening in the moment, right, that’s mindfulness practice. And there is a tendency to not want to do that because what you might discover when you pay attention is unpleasant. And however, if you don’t pay attention, there are consequences to that. Very real consequences, like not recognizing that you’re in a flare until it’s full blown, versus paying attention to those maybe like subtle, very individual kinds of cues that you get of like, “Oh, something maybe is a little bit off,” and being able to pay attention to how is my energy? What am I up for today? How do my knees feel? Should I do a little more or a little less? All of this starts with paying attention before you can make wise choices from the information that you’re getting. But can you do that without getting caught up in a story about, “Well, the last time my knees hurt, this is what happened. And if I do, why is my life like this? And it’s not fair. And so-and-so is able to and this is where I’m going to be when —” right, all of the story that starts to happen, which in yoga, we call [14:37 Word], they’re, you know, ruminations of the mind. Can we just observe and then make choices based on what we’re observing without attachment or aversion to what we notice?

Cheryl:  

Yeah, it’s really a fascinating practice when you’re guided through it by an expert guide. I would say this definitely it overlaps with some of the Acceptance and Commitment Therapy mindfulness aspect of that which I was taught by a therapist who is really good at kind of helping me disentangle that difference between like, sensation, the sensation versus, you said, the story. And I mean, the story is not about finding the right story or the wrong, identifying the wrong story. It’s just about understanding that like, the sensation is, you know, what it is, and it actually reminds me of something that my — who said this? I forget. I think it actually might have been in my OT training. The difference between pain and suffering. 

Dr. Steffany:

Yes. Yes. 

Cheryl:

You know, the pain is the sensation — now, it’s obviously, that is more complicated than that, right. Pain is like psychological as well. But suffering is like, from the meaning we attach to the pain, you know. So, yeah, but I’m just curious in your — or what led you to specialize in arthritis? You do have an amazing website, yoga for arthritis. It’s arthritis.yoga. It’s literally — I love that you got that URL. It’s like so straightforward. Just arthritis.yoga, not even —

Dr. Steffany:  

Arthritis.yoga. That’s it. Yep. Yeah. Oftentimes, when I tell people the website, they say, “Wait, that’s it? Arthritis.yoga?” Yeah, that’s it. Okay, my backstory. So, I was a dancer, my mother was a dance teacher. I started dancing when I was a toddler, I actually have a Master of Fine Arts in dance and am a certified movement analysts. That’s my before-kids life. So, I was very serious about dance. And I would go to the dance studio after school every day, my mother’s best friend owns the yoga studio. And I was on a, you know, competitive dance company, all of that. So, there was a day in middle school, when I got to dance in a bad mood. I could not tell you what that bad mood was about now, but I think it was probably something, you know, angsty and interpersonal. And I remember, like, I remember stomping up the stairs to — the studio was on the second floor — and I remember just like, feeling, being miserable. And for anyone who’s familiar with dance classes, like ballet, or jazz, or modern, there’s a point in the class, oftentimes, when you travel across the floor. So, you know, everybody starts on one side of the room, and one-by-one or two-by-two, you do a movement sequence that travels across the floor, and you wait for your turn to go across the floor. Well, we were doing that. And I was waiting on the side of the room to go across the floor. And I was leaning on the bar and looking out the window. And I had this epiphany that I was not upset anymore. I was totally unconcerned with whatever it was that had happened. But nothing was different. Like, nothing about the situation had changed, except that I had danced. And I realized that this was magic. And that there were people in the world who were suffering far more than I have ever suffered. And they don’t know that this is possible. They don’t know that they could change their lives in an instant, without actually changing anything in their lives. 

And so, I decided that it was — and I don’t know that I necessarily in that moment realized this. But like, that was the beginning of what in yoga, we call my dharma, my path, which is to reduce suffering through mindful movement, which is what dance is, right. The reason why I wasn’t upset anymore is because I was completely immersed in the present moment of my body in motion, and the breath, and the attention, and the emotion, and all of that experience of dancing. And so, I intended to study neuroscience, because I figured whatever this is, it’s happening in my brain. And then, I quickly discovered that, you know, studying brains wasn’t going to actually change the world. I wanted to change the world. So, I went into public health, because public health is how you change the world. So, that’s exactly what I do, is I help people to reduce suffering by changing not necessarily anything about their external circumstance, but the way that they are in that circumstance.

Cheryl:  

It’s so fascinating. And I’ve definitely had that experience with dance as well. I don’t think I would have been able to articulate it as a middle schooler, that’s really advanced. But I love it. I love that. And I think when you add music to it, there is something so primal about music, for me, at least. And I do — the only style of dance that I am proficient at is the Lindy Hop and it’s a very —


Dr. Steffany:

Oh, wow. 

Cheryl:

Yeah, that’s how I met my husband. Like, I taught swing dance and Lindy Hop for years and yeah, and I feel like — they call Lindy Hop the happy dance.

Dr. Steffany:

Mm, I can see that. 

Cheryl:

Like, it’s that music from Charleston from the 20’s and 30’s, you know, swing music just has a da-dee-da, it just brings a smile to your face, you know, regardless of whether you’re physically capable of dancing in the moment. So, anyway, I was just thinking about all my happy memories dancing. It’s been a little bit about difficult thing for me, like just psychologically right now with COVID and exposures. And, you know, dancing is probably one of the highest exposure activities. It’s indoors, you’re changing partners constantly, breathing hard ’cause you’re exercising. So, I haven’t done it as much. But anyway, but back to your story. So, but why arthritis? I feel like I’m the Zoolander, where he said, “But why male models?”

Dr. Steffany:  

Well, I mean — [laughs] in retrospect, I can say arthritis is the leading cause of disability. If I wanted to do something that was going to have an impact on a major scale, reduce suffering, you know, worldwide, that’s a great place to do it. It wasn’t that intentional. And —

Cheryl:  

That’s how I feel about Arthritis Life for me. So, that’s actually really funny. Parts of it were very well thought out. But if you told me three years ago, when I started Arthritis Life, like what it would be now, like, some of it is like, whoa, I mean, I didn’t anticipate many things. But anyway, so.

Dr. Steffany:  

I don’t know, you know, what your worldview or spiritual orientation is, but this isn’t — this is the honest truth of what happened. I was doing — and I had studied biology, I was pre-med, I was doing a summer internship looking at herbs and culture with cancer cells led by a gastroenterologist, okay. None of this has anything to do with anything. And I was in that internship, and I was in my office and the gastroenterologist came into the office and said, “You’re a dancer. You should write a paper on how movement can help people with rheumatoid arthritis,” out of the absolute clear, blue sky. And I knew nothing about rheumatoid arthritis. But she was my boss. And I wrote a review paper, there were literally six manuscripts on this topic at the time. There were two papers on dance, two on yoga, and two on Tai Chi. They were all absolutely tiny, tiny, you know, not federally funded, like probably 15, 20 people in a group. But I wrote what there was. And I found that on my computer months later, and just on a whim, sent it to the rheumatology department at Johns Hopkins, which is where I had been doing this internship. And it turns out that the person who would become my research mentor had just started taking yoga. I, by the way, was already a yoga teacher. And she called me. I said, “I just want to know if this review is worth it. I don’t know anything about rheumatoid arthritis.” And she said, “Well, I’m interested in studying how yoga might help people with rheumatoid arthritis. Do you want a job?”

Cheryl:  

Oh, my gosh. What an amazing meant-to-be. Yeah.

Dr. Steffany:  

Exactly. So, you know, I kind of feel like I had the intention of what I wanted my life — what I wanted the purpose of my life’s work to be, and the Universe answered and like dropped this work and all of the tools that I needed to follow it right into my lap. So, I just, I think, Oprah said, like, you know, “Luck is opportunity being met by preparation,” like I had, I was doing the work that I needed to do on my journey, and I just walked through the open doors.

Cheryl:  

Yeah, and that’s actually really important because I can be really stubborn sometimes. Like, I’m not saying that it’s a good or a bad thing because stubbornness is a really good quality when you want to, like, pursue a goal and never give up. But sometimes, if you’re so stubborn about like, I’m making this path. I actually initially didn’t want to do a podcast because I didn’t like the sound of my voice. Like, most people don’t like the sound of their voice, right. I wasn’t like, “I’m hideous,” I was just like —

Dr. Steffany:  

It sounds different inside your head than outside of it.

Cheryl:  

Totally. And I was just like, I’m better on video. I think my energy translates on video better. I think objectively, that’s true. But the same time, you know, eventually it was like, I had to open my blinders to be like your podcast — I could take the same content I was doing on video, especially with the pandemic, not — my initial vision was to — sorry, I’m going on about myself — but was to do this as a talk show where I was in person.


Dr. Steffany:

Oh, fun. 

Cheryl:

You can see like, my first three or four videos, or like, my first three or four podcasts are the people I met with at their house or at their clinic. And then, pretty soon the pandemic happened. And I was like, okay, let’s do virtual. And then, but well, as long as it’s just a recording, I could just do that as a podcast. So, that we have to be open to those doors and not so stubbornly like, this is what, I’m only doing this.

Dr. Steffany:  

I mean, you can say that, Cheryl. So, in yoga, we talk about taking the practice off the mat. So, there are things, there are things that you practice in your yoga practice that hopefully will carry out into your life just naturally. Like, if you learn deep breathing on the mat, you will start breathing more deeply in the rest of your life, because it’s a skill of habit, a pattern that you’ve developed. Well, what you’re talking about, and I love finding metaphors in yoga practice, when you talk about the idea of like, noticing when there’s an opportunity and not resisting it and not pushing and trying too hard, that translates to yoga practice, too. When we’re in a pose or in a movement, where is the opportunity? Where can we make an adjustment to bring more ease, to find more flow, to stop fighting, or forcing, or resisting? And when you can practice these things, sometimes on a gross level, like in the physical body, it starts to change the way that those things happen energetically, mentally, emotionally, you know, in our lives.

Cheryl:  

I love that. I love that. 

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And so, you mentioned that you did a paper or you did like a review paper on the dance and rheumatoid arthritis. But so, this was perfect segue after my little side tangent-ish that about what the research says about the benefits. I know that, you know, it’s listed often in the list of evidence-based, you know, tools for your toolbox for rheumatoid arthritis specifically. What are some of the highlights you think people should know about the research for yoga?

Dr. Steffany:  

Yeah. So, oftentimes, when I tell people what I do, and I say, “I study the effects of yoga for people with arthritis and chronic pain,” they say, “Well?” I say, “Well, it works.” I mean, that’s the bottom line, it works. So, depending on the study that you’re looking at, because there are a bunch of them out there, there are slightly different effects from one study to the next. But generally speaking, you tend to see effects in a variety of areas. We could kind of break them down and say there’s like, arthritis symptoms, you know, so things like pain and stiffness. There are things, there’s that general area of function. So, strain, mobility, balance. And then, there are more the psycho-emotional challenges that come with life with arthritis, like mood and depressive symptoms. And then, you could put those all together and say, well, they all affect quality of life, right? So, we have a higher quality of life when all of those things are going better. And you see improvements in all of those areas. Now, how big of an improvement, and which measures change how much from one study to the next varies a little. And I will say, when it comes to underlying disease activity, you know, our sed rate, and CRP, and IL-6, are those things changing? Not enough studies have looked at that. There are studies that have shown changes in underlying disease activity. But I think that it’s too early to say much about whether or not those are changing. But it’s not too early to say, across the board, what we call the patient-reported outcomes, the things that people tell us that they’re feeling improved dramatically. As an example, in our research, we’re looking at like 30% reduction in pain, which is similar to some medications.

Cheryl:  

Wow. Oh, wait, did you just say 40%? Sorry. 

Dr. Steffany:

30%, 30% reduction in pain. Yeah.

Cheryl:

That’s incredible. Yeah. Yeah. And I think, at the end of the day, patient reported outcomes is, yeah, is what we’re looking to improve because so often, the sed rate and CRP don’t tell the whole story of what your subjective experience is anyway. Even my own doctor, she doesn’t go off of my bloodwork as much as even — and I am, you know, I do have seropositive rheumatoid arthritis, but she’s like, you know, I really trust more your feeling. You know what that inflammation feels like. For me, it starts feeling like someone’s squeezing my joints, it’s like giving me a handshake from the inside out. Like, when I can start feeling that, that more of that tenderness in the morning, like, those things don’t always show up in the bloodwork. But if I’m noticing them, that’s what’s important for her. Obviously, more than just those symptoms. I love how you broke it down, the symptom relief, the function, the psycho-emotional, all of those things contribute to the quality of life. And so, yeah, that’s what we’re all looking to do, right? Just doing better with arthritis.

Dr. Steffany:  

Right. Exactly. That’s — and as you said, you know, yoga is not alternative medicine, because it’s not an alternative. It’s a complement, or it’s integrated with; it’s something that we doing in addition to the, you know, what you’re working on with your doctor, in terms of your medication management, et cetera. If you’re, let’s say, you’re using medication that does improve your pain, well, let’s go above and beyond that, and let’s see what else we can do with changes in your lifestyle that can take it even further. And when people come to me, it’s because they want to be able to get on the floor and play with their grandkids, they want to be able to, you know, do swing dance, whatever it is. They want that quality of life. And sometimes you need to reduce pain and improve physical function in order to have that improved quality of life.

Cheryl:  

A hundred percent. And I’m curious, because a lot of people with rheumatoid arthritis also have osteo, not as much, vice versa. But, you know, does the research change a bit? Depending on, I would imagine it would change a little bit if you’re looking at like, osteoarthritis versus rheumatoid, or if you’re looking at lower body osteoarthritis. 

Dr. Steffany:

Right, yeah.

Cheryl:

You know, yeah, I’m sure it starts getting complicated. But — 

Dr. Steffany:  

Yeah. So, we’ve actually done studies that have had people with RA and OA together in the same yoga class because their needs are similar in terms of how the yoga practices should be adapted and modified, whether, you know, if you’re experiencing arthritis in your hands, whether it’s RA or OA, you’re going to want yoga practices that don’t put weight in your hands or that use a proper, you know, as an occupational therapist, there are all kinds of things we can do, and their needs are similar. And so, dynamics are really interesting when you have people with RA and OA in the same room who have some similarities and some differences. But there are a whole lot of research studies that look at those populations separately. And to your point that specifically sometimes look at lower extremity osteoarthritis, so knee and hip which tend to be the most common; there are some studies of osteoarthritis of the hands, but not as many. And so, of course, with osteoarthritis, we’re not looking at disease markers in the way that we might with rheumatoid arthritis. But, and also, I would say that the comorbid psychosocial challenges are different, like comorbid depressive symptoms are more a feature of rheumatoid arthritis than they might be of osteoarthritis, although you could be depressed with OA for different reasons.

Cheryl:  

Don’t feel like — you’re not a freak if you are. 

Dr. Stefanny:

Yeah, right. 

Cheryl:

It’s just a little more common in RA.

Dr. Steffany:  

So, the changes that I just outlined for you, right, those buckets of symptoms, physical function, psychosocial changes, all of that being quality of life, I would say, that is also true in OA. It’s just in OA, there is more of an emphasis on pain, they’re less — they’re dealing less with fatigue, right, which is something that we care a lot about in RA. But they care about pain, and they care about physical function. Those are kind of the two main concerns for OA, and those also improve from yoga practice. You know, interestingly, like a lot of the reason why people think yoga can be good for people with arthritis is because they think, well, yoga is exercise. Exercise is good for people with arthritis. So, yoga is good for people with arthritis. 

And I want to emphasize that when we offer yoga to people with arthritis, it is a comprehensive yoga practice that includes breathing, mindfulness, meditation, relaxation, applied philosophy — and I think that that’s a critical ingredient — and poses, and movement. And you could make an argument for how each of those improves arthritis through different pathways. So, it’s really a black box. We can’t say, “Well, what if you just did the poses and you didn’t breathe deeply?” or, “What if you just practice mindfulness and you didn’t —” and there are studies that look at those things independently. Turns out those also a benefit, right. Like, you can have improvements in pain just from meditating. We’re doing all of these things together. So, I think that there is something synergistic about combining all of these practices and having them as an arthritis management toolbox that’s particularly useful.

Cheryl:  

I’m already thinking of an alternate title for this episode, “It’s not just exercise.” Yeah. That’s a huge — I mean, yeah, you’re totally preaching to the choir of like, what is important to me, like, as a patient, but also as like a patient, a self-appointed patient, occupational therapist/patient. And like, I think that’s so crucial to understand that this is not just, not only exercise, although exercise, yeah, is very evidence based. I tend, when I think about exercise, I put exercise into three, well, in terms of types of exercise for rheumatoid, I put it into the three pillars of like, cardiovascular, right. Cardiovascular — regardless of strengthening and stretching — cardio, getting your heart rate up. And then, there’s strengthening, supporting the muscles around the joints. And then, there’s stretching. Like, and so those are three different distinct needs that you have. Like, if you’re living.

Dr. Steffany:  

I would add balance to that, Cheryl.

Cheryl:  

Oh, yeah. Oh, yeah. I have excellent balance. So, I was like, it’s like a blind spot.

Dr. Steffany:  

Not even something you have to think about.

Cheryl:  

No. No, actually, it’s kind of true. Like, I haven’t actually slipped — I’m totally tempting fate right now. But I slipped on some ice and like, caught myself on my foot. And I was like, I am amazing. It’s all that swing dancing. 

Dr. Steffany:

Yeah, I’m sure.

Cheryl:

But you’re right. You’re right. But it’s like, the point is that like, a lot of times people just think exercise is one thing, right. It has to be running a marathon, you know, it has to be one or one thing or the other. And so, with yoga, it does seem like on a, you know, you’re getting at least three of those four bullet points in terms of, you know, you’re getting for sure stretching.

Dr. Steffany:  

Strengthening. I mean, it depends on the yoga, to be honest, Cheryl. Because for example, you could be in a yin class, which is a lot of stretching and not a lot of strengthening. You could be in a restorative class. That’s not really a whole lot of physical activity at all. You could be in a hot power class that is very cardiovascular.

Cheryl

Oh, I have — I did do that.

Dr. Steffany:

Or it could be in a general chair class that is, you know, not cardiovascular at all. So, that’s important to note, that not all yoga does all of those things. And it’s important to find the right one.

Cheryl:  

Okay, so that perfectly leads to my next question, which is, first, people who are listening to this where like, “I want to get started, sign me up,” what are some tips for beginners to guide, to figure out like, what is a good fit? Like, should I do Bikram yoga in a 100-degree room and like bounce around? Should I, yeah, how do you sort through the options?

Dr. Steffany:  

Yeah. So, first of all, if we’re talking about RA, ask your rheumatologist. Ask your rheumatologist, tell your rheumatologist, “Hey, I’ve been thinking about doing yoga.” Not, “Should I do yoga?” because most rheumatologists don’t really know what that is and don’t really know how to guide you. So, a rheumatologist might say, “Oh yeah, I’ve heard yoga could help. Go for it,” or, “No, yoga is a terrible idea,” neither of which may be an informed decision. What you really want to know from your rheumatologist is what should I avoid? What should I be careful about? There is no one who can’t practice yoga. If you have a body and a mind, you can practice yoga. You could be laying in your bed paralyzed from the neck down and you can practice yoga, because yoga is also a mental practice, it’s also breathing practice, it’s also a philosophical practice. But it’s a matter of what are the appropriate yoga practices for you. So, getting guidance from your rheumatologist about anything especially movement or positions because your rheumatologist is going to know about the particulars of your disease activity, any fusions that you have, any areas of involvement that shouldn’t be weight bearing, that shouldn’t be in extreme flexion, for example, that’s going to be important guidance for you to have. 

And then, contact — well, I will say that a yoga therapist is going to have more of a — is in general going to know more about rheumatoid arthritis than the average yoga teacher. And so, if you really want an individualized plan, if you want some individual guidance to start with, look for a yoga therapist, the best place to find them is through the International Association of Yoga Therapists, iayt.org. But there aren’t a whole lot of yoga therapists, so there might not be one near you. And if you don’t want to do this virtually, you can also shop around for a yoga teacher who knows something about arthritis, or who has worked with people with limited mobility, or chronic conditions, joint disease, pain, et cetera. Even if it’s not RA in particular, there are yoga teachers who have training in what you might call accessible yoga, or gentle yoga, right, yoga that is adapted. And even if you find a teacher who is capable of doing that, not every class lends itself to that. So, for example, if it’s a hot vinyasa flow class, you’re moving very quickly from one thing to the next, to the next; there’s not a whole lot of opportunity to offer a bunch of different variations, which is what somebody with RA is going to need. 

So, you can call a yoga studio and say, “I have rheumatoid arthritis. I’m looking for a class that’s going to allow me to modify the poses as needed, and an instructor who’s capable of doing that.” You can also go to a yoga therapist or a qualified yoga teacher for a couple of private sessions just to learn how to modify things for yourself. And then, once you know, then you can go to any yoga class and you know, okay, instead of putting my hands down on the mat, I’m going to put my forearms on blocks, or whatever it is for you. Once you have those strategies, then you can use them in any environment.

Cheryl:  

That’s super, super helpful. And even just that phrase ‘accessible yoga’, a lot of people don’t know what that means. Like, accessibility sometimes, to the average person, like if I wasn’t an OT, I would think accessibility just means like, there’s a wheelchair ramp, or like, there’s a wide doorway for a wheelchair, which is totally a huge part of accessibility. 

Dr. Steffany:  

Yeah. It’s whatever makes it possible for you to be able to do the things that you’re trying to do, right? 

Cheryl:

Yeah. 

Dr. Steffany:

Which may be getting into the building. But it also may be, you know, participating in the class. 

Cheryl:

Accessing the class.

Dr. Steffany:

Yeah, exactly. Right.

Cheryl:  

Yeah. And then, we’ve already cleared up some misconceptions about yoga, you know, that it’s not just exercise. It’s not, it’s the philosophy, and the breathing, it’s in mindfulness. It’s not just a series of physical poses. Are there any other common misconceptions — and I just want to first acknowledge that I have actually used this before — there’s a saying in the chronic illness world that I didn’t really think about contemplatively when I used it before, where people get tired of being asked, “Have you tried this? Have you tried that?” And a lot of the kind of catch all for this has become, “Have you tried yoga?” as like, a signifier of the kind of random stuff people ask us, even though it’s not a good idea what to use, because yoga is so evidence-based, right? So, yeah, how does that make you feel, first of all? Yeah, tell me.

Dr. Steffany:  

I am familiar with that, Cheryl. And I absolutely simply sympathize with the plight of the person with chronic illness who is tired of being told what they should try. I mean, my eyes roll. And I know, I mean, I have, I’ve worked with thousands of people with arthritis and chronic pain conditions, broadly speaking. And I have seen such profound transformation in entire lives, not just like, “Oh, I couldn’t touch my toes before. And now I can”, “I couldn’t bring my palms together. And now I can,” like, all of that is lovely. “I couldn’t walk, you know, five blocks, and now I can,” wonderful. And I mean, like, absolute transformation in the way that someone thinks about their body, their disease, their purpose in life, the relationships they have with other people. Like, huge, profound changes that are — I have a book. You should read the book. Some of the stories are in it. 

Cheryl

Oh, yes. Of course. 

Dr. Steffany:

But so, I don’t want to discount by any means how profound the transformation of engaging in yoga practice can be, especially over the long-term. That being said, when someone says, “Have you tried yoga,” usually, it’s said in the vein of, “Well, if you would just do this thing, then, you know, like, rheumatoid arthritis is no big deal. Just go do some yoga,” or, you know, “You don’t need all of those toxic medications. Just do yoga,” or, “I have a friend who had low back pain and she did yoga and now she’s fine.” It’s like, you know, this simple, easy, no big deal, magic bullet kind of thing that suggests a lack of understanding of what it is like to live with these conditions and how complex it is to manage these conditions from day to day to day, let alone over the course of a lifetime. So, I think that oftentimes it’s said in a way that is diminishing the lived experience of the person who is bearing the burden of life with that disease.

Cheryl:  

The other thing I was going to add is I had on someone of South Asian descent, and she’s brought a perspective I hadn’t thought of, which is, you know, it’s definitely, it can be very culturally insensitive to kind of say, “Oh, yoga is just this other practice,” you know, and so, there’s a lot of, again, that it’s a saying of like solidarity between chronic illness warriors, like a shorthand of, “Oh, gosh, we get tired of all these questions.” But really, it’s not about yoga, it’s about unsolicited advice, and people diminishing your lived experiences.

Dr. Steffany:  

It’s also, let’s be honest, it is cultural appropriation to like, diminish this, like, ancient tradition with a whole bunch of ways of living and being in the world, and pulling out some physical postures, and saying, like, “Hey, why don’t you try this thing? That feels really good,” right. And so, I mean, I recognize that as an a white American woman — by the way, also one with thin privilege, and ability privilege, and all of those things that I am a champion of this practice, that I hope I am able to somehow do justice through presenting it as whole of a practice as I can, having come into it in adulthood, not having grown up in the tradition. I do feel like it is my path, my life purpose to offer this work. And I think that perhaps the package that I come in makes it more accessible to some people who share a cultural background with me and might not have access to these tools otherwise. But it is, it is loaded and complicated. So, I think it’s important to recognize that. 

Cheryl:  

Yeah, I think you’re a wonderful steward, you know, for yoga, but yeah, I appreciate you, yeah, clarifying the cultural aspect of it. And I just wanted to clarify, the one who I was referring to was Sukhjeen from @chronicallybrown, which we had on the podcast. It’s a great non-profit she started to empower disabled South Asians through education and support. And that’s, you know, she’s the one who spoke previously on the podcast about how she finds that very culturally insensitive to just say — and also, you know, I’m a huge proponent, or just not proponent, I’m a — I try to, as a patient educator, clarify to patients that are really concerned or hesitant about Western medicine, like I try to help inform them about the wealth of evidence of the effectiveness of Western medicine, and the dangers of some of the alternative practices. Again, not to go there, but actual people posing ‘You don’t need these scary Western meds, you need to take my supplement’. But she also pointed out to me that, you know, sometimes saying, oh, like, kind of lumping everything together like herbs and like, ‘weird remedies’. Oh, I should, that’s very insensitive way of putting it. Like, these are things that other people have been using for a long time. So, there’s a whole other aspect, but we have just a few minutes left. So, I just want to make sure did you, was there anything else that you wanted to just say?

Dr. Steffany:  

Yeah. So, I do want to say, Cheryl, because you bring up an important point about kind of the dangers of some of those things. There are dangers in all of those things, right. There are dangers in the Western medicine, and there are dangers in the integrative health practices, and there are dangers in the yoga practices, too. So, when we say, “Oh, just try yoga,” I think it’s really important to recognize that not all yoga is safe or appropriate for everyone. For example, a hot vinyasa flow class may not be a good fit for a person who is having an RA flare. And there’s some really interesting research that has looked at — so, a systematic review, I know you’re familiar with it, but for your listeners, it looks at a whole body of research on a particular topic. And so, there’s a systematic review that was done looking at the safety of yoga in randomized controlled trials. A randomized controlled trial being we recruit a bunch of people and we give some of them yoga, and we give some of them something else, and we compare on how they are the same or different after that, Yoga, in randomized controlled trials, is incredibly safe. In fact, it is, according to the systematic review, as safe as usual care. In other words, doing yoga is as safe as not doing yoga. There is no health risk. 

However, there is also a systematic review of observational studies. So, these are people who are doing yoga out in the world, wherever they do yoga, at the Y, in their basement, you know, with their friends. And it turns out that in observational studies, there is a very real risk, first and foremost, of musculoskeletal injury. Which, if you’re somebody who’s living with arthritis, musculoskeletal injury is an important consideration. And so, the kind of yoga that happens in a randomized controlled trial, where it is closely supervised, it’s highly individually designed for a specific population, there’s really tight control over who participates and who doesn’t participate. So, when it’s optimized for the population, it’s incredibly safe. And when you go out into the world, it’s a mixed bag, and it may not be safe if it’s not a good fit, and it’s not appropriate for you as an individual.

Cheryl:  

That’s such an important distinction because a lot of people think well, randomized control trials are the gold standard. But by definition, if you want to get something — and as I’m not as much of a researcher as you are, obviously — but if you want to get something through an IRB, like the review board, you have to, it has to be safe, first and foremost. So, you’re already — it’s not the same as what is out in the real world, the Wild West. And so, that’s really fascinating to compare what’s actually being done. And there’s risks if you’re doing your own home exercise program, you know, just on your own. And so, I think that that’s a really important — and there’s also, I would just say, just one last point on rheumatoid arthritis, there’s a risk in doing nothing.

Dr. Steffany:  

Yes, yes. Very good point. It’s true.

Cheryl:  

It’s true. Yeah. I mean, I think this is where people really miss the forest for the tree again. And sorry, I feel like I’m like on my soapbox again. But it’s like, if you do nothing, like if you do no medicine, no, you just decide to kind of put your head in the sand and like, “This is gonna go away on its own,” it is a by definition, a progressive disease. It will get worse unless you’re one of the lucky people which there have been since the dawn of people knowing what rheumatoid arthritis is, there’s a certain small group that just goes into remission and no one knows why. It’s more likely if you had juvenile arthritis, but to go into long term remission.

Dr. Steffany:  

And then maybe come out of it.

Cheryl:  

And then maybe coming out. I know. But it’s like, so, like, that’s what’s — like, we’re not comparing it to nothing, you know? But that’s really, really hard for people to conceptualize.

Dr. Steffany:  

What’s the risk of doing this —

Cheryl:

The risk of inaction.

Dr. Steffany:

Compared to the risk of, yes, exactly.

Cheryl:  

Inaction is an action. 

Dr. Steffany:

Yes. 

Cheryl:

Doo-doo-doo-doo. But okay, so much, but I know you have another meeting. So, is there anything else you wanted to say, or any advice that — my other favorite question, if you want to end on this one, is best advice for newly diagnosed patients? Although that could be its whole episode.

Dr. Steffany:  

Oh, Cheryl. Yeah. My best advice for someone who’s newly diagnosed is as soon as possible after you have that like, very scary conversation with the rheumatologist where the information is just like, you know, too much to absorb and totally overwhelming, find a thriver. Find a person with RA who is living their best possible life with RA, and listen to their story, because there are so many people who are thriving with RA. And I think that when you initially get that diagnosis — and also, you’re like, in the worst shape that you’re ever going to be in quite possibly, right. Like, you’re unmanaged because you haven’t even started treatment yet. And you think that this is what the rest of your life is going to look like. And even I don’t have RA, but I have been fortunate enough to have early conversations with some people who are newly diagnosed, and just being able to share stories and give glimpses of what your life can look like with this disease, I think, one, is very inspiring, it can get you out of the doom and gloom and also set you on a path toward finding what that’s going to look like for you. 

Cheryl:  

Oh, my gosh. I love that. You’re like, literally give me chills. Did you know my program is called Rheum to THRIVE? 

Dr. Steffany:

Oh, I love this.

Cheryl:

Synergy. Synergy, it’s perfect. I love it. And I think that’s, just to tie it into social media, but that’s one of the best, that’s one of the biggest benefits of social media is access to those. You get access to doom and gloom stories and access to the positive and the plethora of what it could look like. Your life could look a lot of different ways.

Dr. Steffany:  

Well, the doom and gloom is important too, because you get to feel that you’re not alone and see your struggles in the lives of other people, too. So, it’s important to have both reflected back. Yeah.

Cheryl:  

Yeah, a hundred percent. Well, I really, really appreciate what you said, we could just talk for hours. But I really appreciate your time and just, you’re very articulate in like, taking these very complex concepts and distilling them into you know, manageable sentences, which I struggle with. So, thank you so, so much. And I’ll put all of your social media links and your arthritis.yoga, and also a link to the arthritis.yoga/book for your book too because that’s, the more people understand this, the better. So, thank you.

Dr. Steffany:  

Absolutely, Cheryl, it’s such a pleasure. And I’m so glad that you’re doing the work that you are in the world because it brightens my day when I see you in my social media feed. So, I know it’s having that effect for lots of people.

Cheryl:  

I love it. I love your tagline, ‘Get up and live your joy’. I love that. I love that. And the pictures are amazing and videos that you have. So, she has a YouTube channel, everything, so, you know, yeah, that’s a good place to get started if someone wants to just — well, hello. Hello. Someone who’s just got started with yoga, you have a website, so they could do that too.

Dr. Steffany:  

Yeah. 

Cheryl:

Okay, well, thank you.

Dr. Steffany:

Yeah, I also have a directory of teachers, Cheryl, so people can find teachers on my website, too. So, I’ll give you links to all of that.

Cheryl:  

There’s more. Yeah. Thank you. Okay. Thank you so much. Bye-bye for now. 

Dr. Steffany:

Bye.