Yoga, Vertebral Fractures, and Osteoporosis: Research and Recommendations

Abstract

Background:
Osteoporosis is characterized by decreased bone density that leaves bones fragile and highly susceptible to fracture. Globally, 1 in 3 women and 1 in 5 men older than 50 will suffer from an osteoporotic fracture, and those individuals will experience a considerably higher risk of postfracture mortality than will the general population. Gentle, weight-bearing exercises such as yoga can help prevent or cease the progression of osteoporosis; however, there is insufficient data regarding which yoga poses present the least risk and are most beneficial to individuals with reduced bone density.

Objectives:
Review the extant literature about the risks and benefits to the spine of particular forms of movement and consider recommendations relative to the practice of yoga.

Methods:
A review of the PubMed, Medline, and Cochrane databases was conducted that identified manuscripts published between 1966 and 2011 about topics related to osteoporosis and spinal movement.

Conclusions:
Movements involving spinal flexion can increase risk for vertebral compression fractures; however, a combination of mild spinal flexion and extension may prove beneficial. Moderate, weight-bearing activities that strengthen the muscles supporting the spinal column, promote balance, improve posture, and enhance quality of life appear to be of greatest benefit. Ample evidence supports the importance of varied spinal movement for preserving the health and strength of the vertebral bodies. Exercise modifications suitable for high-risk individuals may be counterproductive for those at low risk for vertebral fractures. Yoga therapists are cautioned to not apply a one-size-fits-all approach when working with this population. Well-designed empirical studies are needed to further our understanding of which yoga poses present the least risk and are of greatest benefit to individuals with osteoporosis.

Full text

Abstract
Background: Osteoporosis is characterized by decreased bone
density that leaves bones fragile and highly susceptible to frac-
ture. Globally, 1 in 3 women and 1 in 5 men older than 50 will
suffer from an osteoporotic fracture, and those individuals will
experience a considerably higher risk of postfracture mortality
than will the general population. Gentle, weight-bearing exer-
cises such as yoga can help prevent or cease the progression of
o s teoporo s is; howeve r, the re is insu f fi c i e n t data re g ard i ng
which yoga poses present the least risk and are most beneficial
to individuals with reduced bone density. Objectives: Review
the extant literature about the risks and benefits to the spine of
particular forms of movement and consider recommendations
relative to the practice of yoga. Methods: A review of the
PubMed, Medline, and Cochrane databases was conducted that
identified manuscripts published between 1966 and 2011 about
topics related to osteoporo s is and spi n al move m e nt .
Conclusions: Movements involving spinal flexion can increase
risk for vertebral compression fractures; however, a combina-
tion of mild spinal flexion and extension may prove beneficial.
Moderate, weight-bearing activities that strengthen the muscles
supporting the spinal column, promote balance, improve pos-
ture, and enhance quality of life appear to be of greatest benefit.
Ample evi d e nce supports the importance of vari ed spi nal
movement for preserving the health and strength of the verte-
bral bodies. Exercise modifications suitable for high-risk indi-
viduals may be counterproductive for those at low risk for ver-
tebral fractures. Yoga therapists are cautioned to not apply a
one-size-fits-all approach when working with this population.
Well-designed empirical s tudies are needed to further our
understanding of which yoga poses present the least risk and
are of greatest benefit to individuals with osteoporosis.
Key Words: yoga, osteoporosis, yoga therapy, vertebral frac-
tures, safe movements for the spine, yoga and osteoporosis
Corresponding author: Eva Norlyk Smith, PhD,
evanorlyksmith@gmail.com
Osteoporosis is characterized by excessive loss of bone protein
and mineral content, particularly calcium, that leads to decre-
ments in bone mass and strength. As bones weaken the y
become fragile, brittle, and highly susceptible to fracture. In the
case of severe osteoporosis, the event precipitating a fracture is
often unknown (National Osteoporosis Foundation, 2008).
Osteoporosis represents a considerable public health prob-
lem, with 44 million people in the United States being at risk for
developing the disease. Globally, 1 in 3 women and 1 in 5 men
older than age 50 will eventually experience an osteoporotic
fracture. The risk of fracture increases with age, with 3 of 4 frac-
tures of the hip, spine, or wrist occurring in people age 65 and
older (International Osteoporosis Foundation). In the United
States, 50% of the 1.35 million fractures reported annually are
ve rtebr a l compre s s i on fr a c tu res (Longo, Loppi n i , De naro,
Maffulli, & Denaro, 2011). Osteoporotic fractures of the hip
and spine have been linke d to higher mortality rates, but it
remains unclear whether this is an independent effect or a func-
tion of comorbid illness and poor he alth status commonly
found in elderly persons with osteoporosis (Teng, Curtis, &
Saag, 2008).
Osteoporotic fractures of the hip and wrist are most com-
monly prec i pitated by tr au m a, su c h as a fall (Ng u ye n ,
Pongchaiyakul, Center, Eisman, & Nguyen, 2005). In contrast,
the vertebral bodies of individuals with osteoporosis are very
fragile, such that even a nontraumatic event, such as a sneeze,
can result in a vertebral compression or wedge fracture. The
risk of fracture is even greater for those who have incurred pre-
vious vertebral fractures (Briggs, Greig, & Wark, 2007).
Gentle, weight-bearing exercise can help prevent or cease
the progression of oste oporosis (Sinaki, Fitzpatrick, Ritchie,
Montesano, & Wahner, 1998). Weight-bearing and strength-
building activities stimulate new bone growth and help improve
posture, bal ance, and range of motion. There is considerable
controversy as to which exercises are beneficial and which con-
stitute a risk for injury, however. Individuals with osteoporosis
are often instructed to avoid flexion or twisting of the sp ine
during exercise, and even in activities of daily living. Because
spinal flexion and tw isting commonly occur in yoga classes,
there is a pressing need for yoga therapists and yoga teachers to
understand which types of movements are safe for people with
osteoporosis and osteopenia and to communicate this knowl-
edge to their students.
The goals of this literature review were to (a) review the lit-
erature about the risks and benefits to the spine of particular
forms of movement, (b) examine the importance of spinal
movement for health, and (c) present an overview of recom-
mendations for exercises targeting spinal movement for indi-
viduals with osteoporosis and osteopenia.
Literature Review
Spinal Movement, Posture, and Risk for Vertebral Fracture
We used the Pub M ed, Medl i ne, and Coch r ane databases to
c o ndu ct a comprehe ns ive search for pe r ti ne n t manusc r ipt s
publ ished be t ween 1966 and 2011. Publ i cati o ns in wh i ch var-
i o us combi nati ons of the key words osteoporosis, ve r tebral
compression fractures, axial rotation, f le x ion , twisting, torque ,
e x te n sion , back exte n sors, ve r tebral loading, trabec ular bone ,
International Journal of Yoga Therapy — No. 23 (1) | 2013 17
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Yoga, Vertebral Fractures, and Osteoporosis:
Research and Recommendations
Eva Norlyk Smith, PhD, RYT-500,1Anita Boser, LMP, CHP, RYT2,3
1. YogaUOnline.com, 2. Vital Self, Inc., 3. Essential Yoga Therapy
ARTICLE

e xe r c ise, and rehabilitation we re cons i d e red. All rel e v ant arti-
cles we re exam i ned and their bibl i o g r aphies we re searched for
a d d iti ona l re fe re n c e s .
T h is inve sti g a ti o n reveal ed that the majority of osteoporo-
s is re s earch has focused on drug inte r ve nti ons inte nd ed to
reve rse or preve n t the loss of bone mass. Su rgi c al inte r ve n -
ti o ns, su ch as ky phoplasty and ve r te plasty, wh i ch are ofte n
used to treat pain re sulti ng from ve rtebr al compre ss i on fr a c-
tu res, have also been wi d ely stu d i ed. In additi on, the role of
e xe rc ise relative to bu i l d i ng bone mass or preve nti ng bone loss
has rec e i ved atte n ti on.
Relative to the overall literature, very little research has
been conducted to examine the effectiveness of physical reha-
bilitation measures designed specifically to prevent spinal frac-
tures for individuals with osteoporosis. The majority of pro-
posed exercise strategies have been designed to elicit a sufficient
weight-bearing load on the bones to stimulate growth without
creating excessive strain or risk for fracture (Sinaki, 2007).
Although physical activity is recognized as central to maintain-
ing musculoskeletal health, strong bones, and balance among
those with osteoporosis, a great deal remains to be learned
about which types of spinal movement constitute a risk for frac-
ture and which provide the greatest benefit (Pratelli, Cinotti, &
Pasquetti, 2010).
In this review of the literature we report what is kno wn
regarding the safety of various types of spinal movements (i.e.,
flexion, extension, axial rotation, lateral side bending) for indi-
viduals with osteoporosis.
Spinal flexion. Before the mid-1980s, spinal flexion exer-
cises were often recommended to alleviate back pain related to
vertebral fractures (Sinaki, 2007). Flexio n of th e spine was
thought to be useful to relieve contractions of the paraspinal
muscles that surround the vertebral bodies. This belief was
challenged by a study that demonstrated that flexion exercises
( e. g ., forw ard be n d i ng with a rou nd e d spi n e, abd om i n al
crunches f rom a su pine position) were associated with an
increased incidence of vertebral fractures (Sinaki & Mikkelsen,
1984). In the study, 59 women age 49 to 60 years with osteo-
porosis of the sp ine and back pain were divided into four
groups. The first group performed spinal extension exercises,
the second engaged in spinal flexion exercises, the third con-
ducted a combination of spinal extension and flexion exercises,
and the fourth was a no-exercise group who received heat and
massage. C omparison of pre- and postexercise radiographs
revealed a statistically significant between-groups difference in
the number of spinal fractures. In the flexion-only group, 89%
of participants incurred new fractures, compared with 67% of
participants in the no-exercise group, 53% in the combined
extension and f lexion group, and 16% in the extension-only
group (Sinaki & Mikkelsen, 1984). These findings suggest that
an exercise regimen characterized exclusively by flexion exer-
cises increases the risk for development of spinal f ractures for
women with osteoporosis.
The morphology of vertebrae helps explain this finding.
Spinal flexion increases anterior vertebral compression; studies
have shown that the anterior structure of a vertebra is weak rel-
ative to the overall vertebral body, making it vulnerable to com-
pre ss i on fr a c tu res (Papa d akis, Sapk a s, Papa d o poulos, &
Katonis, 2011). Spinal flexion also leads to increased pressure in
the vertebral discs, which can be translated to the anterior por-
tion of the vertebral bodies, thus increasing the risk of wedging
and fracture in people with osteoporosis (Sinaki, 2007). These
biomechanical properties of the vertebrae may cause move-
ments that involve spinal flexion to increase the risk of vertebral
fractures (Duan, Seeman, & Turner, 2001).
There is some evidence that older adults with reduced bone
density may be vulnerable to spinal fracture during yoga poses
that involve spinal flexion. In a recent case study, 3 healthy indi-
viduals age 61, 70, and 87 with reduced bone mass who report-
ed yoga-induced pain or vertebral compression fractures were
assessed. All practiced Halasana (plow pose), during which the
weight of the lower extremities and pelvis wa s distributed
toward a flexed thoracic spine and neck. The author concluded
that reduced bone mineral density could account for less than
50% of fracture risk, with the remaining risk being associated
with posture, degenerative changes of the spine, torque of the
spine, muscle weakness, and falls (Sinaki, 2012).
Spi n a l ex ten sion . Spi ne exte n sor muscle stre n g th is
important for retaining healthy posture and normal s pinal
cu r ves (Si naki, Itoi, Ro ge rs, Be rg s tr a lh, & Wah ne r, 1996).
Strong back extensor muscles provide extrinsic support for the
spine, and there is evidence that strengthening the back exten-
sors may decrease the long-term risk of vertebral fractures
(Sinaki et al., 2002). Excessive thoracic kyphosis may also be
l i n ked to weake n i ng of spi n al exte nsor muscles (Mik a ,
Unnithan, & Mika, 2005). Several studies provide evidence that
strengthening the spinal extensor muscles is asso ciated with
decreased thoracic kyphosis, which can be an independent risk
factor for fractures (Itoi & Sinaki, 1994; Sinaki et al., 2002).
Spi nal exte nsor muscles te nd to be comprom ised in
women with osteoporosis, suggesting that weakness of back
extensors may precede and/or contribute to compression frac-
tu res of the spi ne (Si n aki, Kho s la, Li mbu r g, Ro g e r s, &
Murtaugh, 1993). Strong spinal extensor muscles have been
shown to be a significant contributor to spinal range of motion
(Miyakoshi et al., 2005). Lo w-intensity, back-strengthening
exercises are associated with reported quality of life improve-
ment for people with osteoporosis (Hongo et al., 2005), with
higher quality of life being related to stronger spinal extensor
muscles and inceased range of motion.
Most important, strengthening the back extensors may
provide long-term protection against vertebral fractures, inde-
pendent of bone mineral density. Sinaki et al. (2002) examined
the effects of a back-strengthening program on bone mineral
density fo r a group of healthy, Caucasian, postmenopausal
women. Although no significant differences in bone mineral
density were detected for those who exercised and those who
did not during the initial 2-year study, data obtained during an
8-year follow-up, when the women were between ages 58 and
75, revealed that those in the back-strengthening group had
fewer fractures tha n did those in th e control group (Sinaki,
2007). At the 8-year mark, individuals in the no-exercise con-
trol group evidenced 3 times the rate of vertebral compression
fractures than did those in the exercise group. As a result, inves-
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tigators posited that bone mineral density might not be the only
predictor of vertebral fractures, and that the strength of the
muscles supporting the spine may be another significant con-
tributing factor.
Rotation and lateral side bending. Very little data exist
about specific types of exercise that might be most beneficial for
individuals wit h compromised bone density (Pratelli et al.,
2010). This lack of empirical evidence is most pronounced with
regard to effects and safety of axial rotation and lateral flexion
of the spine.
Studies designed to assess the effects of axial rotation on
intervertebral discs have linked axial rotation to an increased
risk of low back strain or intervertebral disc injury, particularly
when combined with flexion and weight bearing, for example
while bending over and lifting combined with spinal rotation
(Kumar, 2004; Kumar & Narayan, 2006).
Professionals in the yoga or fitness community who work
with individuals with osteoporosis often strongly advise against
axial rotation, even to the point of avoiding it in daily activities
(Hathaway, 2012; Meeks, 2012). However, although axial rota-
tion has been shown to increase the risk of low back strain or
intervertebral disc injury, there is no empirical evidence of a
link between axial rotation performed during exercise and the
risk for vertebral fractures. Tangentially, one case study found a
potential link between the sudden twist of a golf swing and frac-
ture risk (Ekin & Sinaki, 1993), but the biomechanics of golfing
are vastly different than those used in yoga or other exercises
involving axial rotation.
Researchers conducting an ongoing study of the effects of
yoga practice for individuals with osteoporosis are examining
weight-bearing yoga postures that involve axial rotation. The
sample includes more than 500 registered participants with
more than 30,000 cumulative practice hours. To date, no verte-
br al fr a ctu r es re s ulti n g from the yoga pr a ctice have bee n
reported (Fishman, 2012).
Postural alignment as an independent risk factor for
spinal fracture. It is important to examine the safety of spinal
movements relative to postural alignment. Postural misalign-
ment can independently exacerbate spinal flexion and increase
the risk for vertebral compression fractures (Keller, Harrison,
Colloca, Harrison, & Janik, 2003).
Many individuals with osteoporosis exhibit increased tho-
racic kyphosis, or hyperkyphosis. This pronounced flexion of
the thoracic spine increases the vertebral compression load and
the risk for compression fractures (Pfeifer et al., 2004). As the
degree of kyphosis increases, the compressive stress on the
anterior portion of the vertebrae is magnified. Kyphosis of 41.7
degrees is associated with a 19% increase in compressive force
and a 40% increase in spinal extensor force at T7/T8 (Papadakis
et al., 2011). Hyperkyphosis was previously thought to be
caused by osteoporotic vertebral fractures; however, it is also
prevalent in people without vertebral fractures, and the condi-
tion is also frequently associated with degenerative disc disease
and muscle weakness (Schneider, von Muhlen, Barrett-Connor,
& Sartoris, 2004).
Hyperkyphosis is an independent risk factor for vertebral
and hip fractures, particularly for elderly women (Katzman,
Wanek, Shepherd, & Sellmeyer, 2010). It is also associated with
reduced breath capacity and increased mortality. There is good
evidence that hyperkyphosis and activities involving spinal flex-
ion are associated with an increased risk for vertebral fractures,
i r re spective of bone loss (Campbell, Robe r t s on, Gard n e r,
Norton, & Buchner, 1999). In individuals with hyperkyphosis,
exercises involving flexion are likely to further intensify the
anterior compression of thoracic vertebrae, yielding an elevated
risk for fractures. As such, postural forces can predispose an
individual to vertebral fractures when the anterior translation
of the upper part of the spine increases the compressive load.
Movement and Spine Health
There is general consensus that frequent, gentle to moderate
weight-bearing activity offers the greatest benefit to individuals
with bone loss (Chan, Anderson, & Lau, 2003). Some have rec-
ommended gentle spinal rotation as an important contributor
to spine health (Fishman & Saltonstall, 2012). The literature
reviewed in the following sections provides evidence that varied
movements of the spine are critical to maintaining overall spine
health and to reducing vertebral fractures.
Activity, bone loss, and regeneration. Bones conform to
the environmental conditions placed upon them. O steoblasts
lay down new bone mate r ial, and osteoclasts reab s or b
unhealthy tissue (Turner, 1999; Turner & Pavalko, 1998). Bone
strength is linked to bone mass and to the internal structure of
trabecular bone. Trabecular bone constitutes the major portion
of the bone and is the inner part that surrounds marrow spaces
(Kreider & Goldstein, 2009). The structure of trabecular bone is
influenced by mechanical stress and is sensitive to the nature
and quality of the forces placed upon it (Barak, Lieberman, &
Hublin, 2011). It is quite porous, not as strong as cortical bone,
and more susceptible to the effects of osteoporosis.
Osteogenic loading refers to the use of impact force to stim-
ulate the de velopment of bone tissue and muscle f iber. It is
highly site specific. In one study of the effects of osteogenic
loading, participants performed weight-lifting exercises on one
side of the body. An increase of 3% to 4% in bone mass of the
wrist a nd hip was found on the weight-lifting side after 12
months, compared with the no-exercise side (Kerr, Morton,
Dick, & Prince, 1996). Site-specific effects of osteogenic loading
on the spine have also been found. Increased lumbar trabecular
bone mineral density was detected for individuals participating
in a 1-year training program for the psoas muscles, compared
with those performing exercises that targeted the deltoids only
( R evel, Mayou x - B e n hamou, Rabou rdin, Baghe r i, & Rou x ,
1993). These results suggest that exercises intended to strength-
en muscles that support the spine may be useful to prevent or
ameliorate the effects of vertebral bone loss.
Wolff’s Law posits that the internal s tructure of bone
adapts commensurate with the form and function of each of the
stressors placed upon it (Frost, 1994). There is evidence that
bone is anisotropic, meaning that its physical strength varies
al ong diffe re nt axes. Inc reased phy s i c al activity places a
mechanical load on bones, which stimulates bone tissue forma-
tion. Conversely, inactivity is associated with bone loss (Frost
Yoga, Vertebral Fractures and Osteoporosis: Research and Recommendations 19
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1997; Takata & Yasui, 2001). The microarchitecture of the tra-
becular bone within the vertebrae is constantly remodeling
based on the demands placed upon it. This remodeling enables
bones to optimally withstand loads associated with habitual use
(Homminga et al., 2004).
According to th e Utah Paradigm of Skeletal Physiology
(Jee, 2000), inactivity leads to reduced bone mass and bone
strength. In the absence of sufficient use, bone remodeling
turns off and disuse-mode remodeling turns on (Frost, 1997).
Immobility has been linked to local b one loss (Alexandre &
Vico, 2011; Saltzstein, Hardin, & Hastings, 1992), which is evi-
denced dramatically in astronauts, for example, who demon-
strate bone loss during long-duration spaceflights. The majori-
ty of astronaut bone loss occurs in heavy load-bearing areas,
such as the hip and spine, which are exposed to the greatest
mechanical stress under the earth’s gravity (Lang et al., 2004;
Zhao et al., 2010).
Muscle strength is also a protective factor against fracture,
with muscle contraction relieving some of the strain of over-
l oa d i ng, thus protecti ng bone from fr a c tu re (Bu rr, 2011).
Studies have found site-specific positive exercise effects in bone
mass density from weighted exercise (Zehnacker & B emis-
Dougherty, 2007), suggesting that weak or atrophied muscles
around the sp ine might leave the vertebrae more vulnerable.
Similarly, low-back extensor strength has been shown to have
an inverse relationship with high bone mass density (Briggs,
Greig, Wark, Fazzalari, & Bennell, 2004). A German study of
237 postmenopausal women with osteoporosis found signifi-
cant associations between trunk muscle strength and reduc-
tions in the Spine Deformity Index, which is a measure of the
number and severity of vertebral fractures (Pfeifer et al., 2001).
In short, there is considerable evidence that load-bearing
activities are essential for bone and spine health. Inactivity and
limited spinal movement are likely to weaken the internal tra-
becular structure of the vertebrae and result in greater risk for
vertebral fractures. Immobility has been linked to localized
bone loss, and lack of trunk muscle strength has been linked to
an increased number of vertebral fractures.
The site-specific nature of bone regeneration, along with
the anisotropic properties of the vertebrae, suggest that limiting
the normal repertoire of spinal movement might weaken the
capacity of vertebrae to withstand movement and make them
more susceptible to fracture.
Movement and intervertebral disc health. Preserving the
health of the intervertebral discs is critical to avoiding common
age-related impairments (Buckwalter, 1995). The loss of integri-
ty of the intervertebral discs can potentially contribute to verte-
bral fracture risk by causing abnormal lo ad distributions in
adjoining vertebrae (Briggs et al., 2004).
As with the bony vertebrae, the intervertebral discs require
motion for optimal health. These discs are the largest avascular
structures in the body, meaning that nutrients and waste prod-
ucts are exchanged through diffusion from the vertebrae rather
than bl ood exchange (An, Masu d a, & Inou e, 2006). This
process is facilitated during sitting or standing load-bearing
activities, during which fluid and molecules are transferred
from the discs into the vertebrae. Fluid and molecules flow back
into the discs in s upine positions. Changes in pressure that
occur between lying down, st anding up, an d sitting create a
dynamic exchange between the vertebral discs and vertebrae.
Discs require varied movement and dynamic loading of the
spine for optimal health. There is evidence that vertebral load-
ing that occurs during activity may improve disc metabolism
(Chan, Ferguson, & Gantebein-Ritter, 2011). Although in vivo
measurement of disc pressure is difficult, preliminary experi-
ments indicate that muscle activity increases disc pressure, and
that frequently changing bodily positions promotes the flow of
fluids to and from discs. In the absence of sufficient pressure or
movement, the nucleus pulposus, or center of the vertebral disc,
loses valuable proteins (Chan et al., 2011). As with bones, inter-
ve r tebr al discs be n e f it the mo st from dynamic, mod e r ate,
weight-bearing exercise.
Trunk flexibility. Most fractures are the result of falls (Bell,
Talbot-Stern, & Hennessy, 2000). There is a higher correlation
between falls and fractures than between low bone density and
fractures, suggesting that the relationship between osteoporosis
and fractures is complex (Jarvinen, Sievanen, Khan, Heinonen,
& Kannus, 2008). Stiffness of the t runk is asso ciated with
reduced postural control, reduced balance, and increased risk
for falls (Reeves, Everding, Cholewicki, & Morrisette, 2006). In
addition, the combined inflexibility of hip and trunk muscles is
related to loss of bal ance (Gruneberg, Bloem, Honegger, &
Allum, 2004).
One factor influencing loss of trunk mobility is lack of
movement, suggesting that activities that benefit hip and trunk
flexibility may improve postural control and balance.
Summary
Spinal mobility is a significant factor in maintaining the health
of the sp ine’s components, including the vertebrae, muscles,
discs, and joints. Spinal articulation is central to reducing the
risk of fractures, and movement of the spine is necessary for
keeping the trunk muscles strong and flexible to maintain bal-
ance and diminish the risk of falls. Movement of the spine is
also important for maintaining functional h e alth, range of
motion, and the ability to perform activities of daily living.
Recommendations for Spinal Movements in Current
Therapeutic Practice
The Canadian Medical Association’s clinical practice guidelines
for people with osteoporosis include resistance training and/or
weight-bearing aerobic exercises, movement to enhance core
stability to counteract the effects of postural abnormalities or
weakness, and exercises that focus on balance control or bal-
ance and gait training (Papaioannou et al., 2010). These recom-
mendations were based partly on a study of physiotherapist-
supervised group exercises that included regular stretching of
the hip flexors, hip extensors, lumbar extensors, and the verte-
bral column, along with strength, posture, and balance exercis-
es (Angin & Erden, 2009). In this study, 43.8% of the women
who had osteoporosis-level bone density at the beginning of the
program had increased bone density to osteopenia levels by the
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end of the 21-week program. Although exercise must be modi-
fied for those with osteoporosis, results of this study suggest
clear benefits of regular movements that emphasize spinal
strength, flexibility, posture, and balance.
On the basis of the literature reviewed, we recommend spe-
cific approaches to exercises and modifications for individuals
with osteopenia or osteoporosis. They are described in the fol-
lowing paragraphs.
There is sufficient evidence to support the contention that
yoga teachers and therapists must exercise caution when work-
ing with individuals with reduced bone density. Movements
emphasizing flexion of the thoracic spine are contraindicated
for people with osteoporosis (Chan et al., 2003; Papaioannou et
al., 2010; Sinaki, 2012; Sinaki & Mikkelsen, 1984). This is par-
ticularly the case for individuals with hyperkyphosis.
Although there are risk factors associated with spinal flex-
ion in standing or seated forward-bending yoga poses, the risk
can be minimized if flexion occurs at the hip joint with the
spine kept straight. One yoga intervention designed for individ-
uals with osteoporosis and osteopenia provides excellent exam-
ples of modified postures in which flexion occurs at the hip
rather than the spine, reducing the potential for vertebral com-
pression fractures (Fishman & Saltonstall, 2012). Because many
individuals do not have the body awareness needed to distin-
guish between forward flexion from the hip versus from the
spine, great care should also be taken to first teach awareness of
the difference between these two movements when working
with at-risk individuals.
It is important to consider that individuals with a severe
hy pe r ky p hotic po s tu r e are in pe r mane n t spi nal fl e x i o n .
Instructions to bend forward from the hip instead of the spine
will not afford the necessary protection for these individuals. At
the same time, postures using hip flexion that stretch the ham-
strings are an important component of preventing hyperkypho-
sis and other postural imbalances, because tight hip extensors
distort the alignment of the pelvis, which often results in a com-
pe nsatory inc rease in ky p ho s i s (Be n ed e t ti, Be r ti, Pre sti,
Frizziero, & Giannini, 2008). The focus should be on supine
poses involving hip flexion, which can better isolate hip flexors
(Shipp, 2012).
Exe rc ise pro g r ams that combi ne spi nal fl e x i on and exte n -
s i o n have been shown to be be ne f i c ial to ind ivi duals with
o steoporo s i s (Si naki & Mikkelsen,1984). This su gge sts that the
relati o nsh ip be t ween move me nt involvi ng spi nal fl e x i on and
fr a ctu re risk is complex, and that more re s earch is need ed to
fully und e rst and the unique and conju nct risks and be ne f its of
the s e move me n ts. The lite r a tu re su gge sts that people with
o steoporo s i s can be ne f it from stre n g the n i ng spi nal exte nsor
muscles, wh i c h may also preve n t hy p e r ky pho s is and its con-
c o m itant risk of ve r tebr a l compre ss i on fr a ctu res. Ge ntle prone
or stand i ng yoga po s tu res involvi ng spi n al exte ns i o n can offe r
a be ne f i c i al we i ght - b eari ng chall e nge for ind ivi duals with
o steoporo s i s and hy p e r ky pho s is.
The literature does not provide sufficient or conclusive evi-
dence regarding the r isks and benefits of spinal movement
involving rotation relative to the risk of vertebral fracture for
individuals with osteoporosis or osteopenia. This suggests that
the most prudent approach for yoga teachers, therapists, and
practitioners is to exercise a considerable degree of ca ution.
Concurrently, it is important to consider extant findings that
inactivity and lack of movement of the spine can contribute to
the ris k of fracture vis-a-vis muscle weakness, lack of spinal
mobility, and compromised balance. The absence of loading of
the spine in certain directions may further weaken the internal
stru c tu re of the ve r tebr a l bodies and comprom i se the i r
strength. As such, varied spinal movement appears to be essen-
tial for spine health and maintenance of the vertebral strength.
Based on this understanding, it is important to consider
that some form of spinal movement is needed to retain verte-
bral strength, trunk flexibility, spinal range of motion, and the
strength of the muscles supporting the vertebrae. People with
lower degrees of fracture risk may be adversely served by rec-
ommendations to avoid movement of the spine (including axial
rotation) that are a part of of daily living (Shipp, 2012).
Conclusions
Shipp (2012) suggests the following criteria to identify individ-
uals wit h higher risk of vertebral fractures. First, individuals
with osteoporosis who have lost more than 1.5 inches in height
are likely to have prevalent vertebral fractures, which in turn
will put them at much greater risk f or subsequent fractures.
Second, as noted earlier, those with marked hyperkyphosis who
are unable to perform flexion poses with a straight spine should
be considered at high risk for vertebral fractures. Supine, non-
weight-bearing movements of the spine are the best course of
action for these individuals.
There is no one-size-fits-all approach when working with
individuals with osteopenia or osteoporosis. Individuals with
low risk for spinal fractures, such as those with osteopenia or
without a history of vertebral fractures, might be ill served by
eliminating yoga postures necessary to maintain the health and
strength of the vertebral bodies. At the same time, extreme care
should be taken when working with individuals who are at high
risk for fractures.
Although preliminary studies have shown yoga to improve
balance for older adults (Schmid, van Puymbroeck, & Koceja,
2010) and for po s tme n opausal women with osteoporo s is
( Tuzun, Aktas, Ak ari rmak, Sipah i, & Tuzun, 2010), well -
designed empirical studies are needed to further our under-
standing of which yoga poses present the least risk and are of
greatest benefit to individuals with osteopenia and osteoporo-
sis. In lieu of these data, moderate weight-bearing activities that
strengthen t he muscles supporting the sp inal column, that
improve posture, promote balance, and enhance quality of life
are likely to be of greatest benefit.
Yoga, Vertebral Fractures and Osteoporosis: Research and Recommendations 21
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