What not to do in yoga class if you have osteoporosis
By Christine Saari, MA, E-RYT, C-BDYT
Head on over to your local yoga studio on a weekday morning, and you'll be likely to unroll your mat next to someone over 50.
That's because interest in trying yoga has surged among older adults in recent years. More and more people are overcoming common myths stopping them from trying yoga and beginning to recognize the physical, mental, and emotional benefits of the practice.
Yoga is a low-impact form of exercise that can be adapted to suit your unique needs and abilities, making it an accessible and enjoyable way to stay active and healthy as you age.
Yoga for health aging
At some point in life, it becomes clear that we're not getting any younger.
Take skiing, for example.
We may have the same ability to ski as we did the prior season, but the toll it takes can feel greater. At some point, the likelihood of injury increases when we do risky activities, or, for that matter, even while doing laundry.
Yoga practice is one form of self-care that can help maintain our body's resilience as we age.
By improving physical strength, reducing stress and anxiety, improving cognitive function, and enhancing emotional well-being, yoga can help maintain independence and quality of life as we get older.
Yoga also offers a pathway to nurture ourselves as we age through management of chronic pain and injury prevention.
A study published in the International Journal of Yoga found that regular yoga practice can improve physical function and quality of life in older adults with osteoarthritis (1). Another study published in the Journal of Geriatric Physical Therapy found that yoga can help reduce falls and fear of falling in older adults (2).
The practice of yoga can also help counter the ageism pervasive in our culture.
As a Yogi, I pride myself on embracing my aging self. I practice welcoming change and yielding to its flow.
I'm not going to lie: there are times this is not so easy to accept!
But with each passing year, I get to know myself better and accept and love myself more. These are the gifts my yoga practice has given me.
So, if you are yoga-curious and over 50, now is the time to give yoga a try!
You won't be the only one: According to a survey conducted by Yoga Alliance and Yoga Journal, 38% of Americans aged 50 and older are interested in trying yoga, and 17% of yoga practitioners are over 55 and have already taken the plunge (3).
But what if you have been diagnosed with osteopenia or osteoporosis? Is yoga safe?
And can yoga be used to reverse bone loss?
Read on to discover how to reduce the risk of injury while practicing yoga with osteoporosis, and how to use yoga therapy protocols to reverse bone loss.
Aging and bone loss
Aging can have a significant impact on bone loss for both women and men. As we age, our bones naturally become weaker and more fragile due to a variety of factors, including hormonal changes, reduced physical activity, and changes in calcium and vitamin D metabolism.
Women tend to experience more rapid bone loss after menopause due to a decline in estrogen levels, which can accelerate the breakdown of bone tissue. Men also experience a gradual loss of bone density as they age, but at a slower rate than women.
Osteoporosis, a condition characterized by low bone density and increased risk of fractures, is a common result of age-related bone loss.
It's nothing to be ashamed of.
And, you can do something about it.
While traditional treatments such as medication and hormone therapy can be effective, they also come with potential risks and side effects. To reduce the risk of further bone loss, it is important to engage in regular weight-bearing exercise such as yoga, consume a diet rich in calcium and vitamin D, and talk to a healthcare provider about other strategies for bone health. When deciding on a treatment plan, always consult with your doctor to determine what course of action is right for you.
More and more often, doctors are recommending yoga for osteoporosis.
But the choice of postures–and the way you do them–matters.
A lot.
When prescribed therapeutically, yoga has the potential to be a lower-risk intervention for maintaining or improving bone density for those with osteoporosis.
Ready to try yoga for osteoporosis?
Before you head to your nearest yoga studio, educate yourself about the risks of certain types of yoga postures, and the benefits of certain approaches to modifying and practicing postures for managing your bone health.
Learn what types of poses not to do in yoga class, what types of poses you can do, and how to do them most effectively.
A word of caution about gentle yoga
Just because yoga is "gentle" doesn't mean it's safe for people with osteoporosis.
Because individuals with osteoporosis have weakened bones, they may be at increased risk of fractures and other injuries during certain yoga poses or movements.
Too often, patients with osteoporosis are directed by their doctors to try yoga, and they find themselves in a group yoga class led by instructors without specific training in pathology, and with limited training in contraindications for certain health conditions.
Yoga therapists are a type of yoga teacher trained specifically in using yoga to treat osteoporosis and other health conditions. Yoga therapists are certified by programs accredited with the International Association of Yoga Therapists, which is a different accrediting body than the one most yoga teachers are registered with (the Yoga Alliance).
A yoga therapist can educate you on how to self-modify your personal practice while attending a group yoga class to lower your risk of injury.
If your yoga teacher is not a yoga therapist, you will need to take responsibility for educating yourself on how to keep yourself safe in their class.
If you are unsure how to do this, ask your doctor, and consider consulting with a yoga therapist to learn which movements and postures are likely to place you most at risk given your individual health status. You can usually learn all you need to know about modifying common yoga poses in a few sessions.
Armed with this knowledge, you can then focus on attending gentle, low-impact yoga classes that emphasize static strong holds of postures, stability and balance.
Finally, remember that it is important to talk to a healthcare provider before beginning any new exercise program, including gentle yoga.
What to avoid in yoga class if you have osteoporosis
If you have osteopenia or osteoporosis, there are a few guidelines to help keep yourself safe practicing yoga.
Certain poses commonly considered by yoga instructors to be "gentle" may not be safe for people with osteoporosis.
Other types of poses are less risky, but would not serve a therapeutic purpose when working with osteoporosis, meaning they just aren't as helpful. In this case, you'd be better off substituting a different pose to maximize the benefits of your practice.
Here are some specific risks to consider:
Spinal flexion: Forward-bending poses that involve spinal flexion, such as seated forward fold, can put excessive pressure on the vertebrae and increase the risk of vertebral fractures.
Twisting: Twisting poses, such as seated spinal twist, can also put pressure on the vertebrae and increase the risk of fractures.
High-impact movements: Jumping or other high-impact movements can put stress on your bones and place you at risk for injury.
Risky balance poses: Some poses require balance and may increase the risk of falls, which can be especially dangerous for individuals with osteoporosis. Make sure your studio has chairs available, and if not, set yourself up near a wall for extra support during balance poses.
Spinal flexion
Let's consider spinal flexion.
Spinal flexion is a movement of the spine that involves bending forward or flexing the spine. It occurs when the anterior portion of the vertebral column (front of the spine) shortens, and the posterior portion (back of the spine) lengthens.
During spinal flexion, the head moves forward towards the chest, and the shoulders move towards the hips. This movement involves the contraction of the abdominal muscles, which help to pull the ribcage downward and compress the abdominal cavity.
Spinal flexion is a common movement in everyday activities such as bending over to tie your shoes, or picking up an object from the ground.
In yoga, some examples of poses with spinal flexion that are commonly considered to be "gentle" or "safe" include cat pose and standing forward fold.
Cat pose is unhelpful for people with osteoporosis because it emphasizes a hump shape in the thoracic spine while bearing weight on the shoulders and arms.
Avoid standing forward folds with a rounded back.
As you hang out in a forward bend, the force of gravity on your upper body mass could place excessive pressure on the spinal vertebrae and risk fracture. This is especially true if you were to fold with downward momentum from a standing position.
Instead, if possible, bend from the hips and keep your spine long and extended, rather than rounded, when folding. If your hamstrings are tight, you may need to bend your knees and temper how low you go.
Finally, simple seated twists can be dangerous for people with osteoporosis if leveraged by a hand pulling on a knee, or by a well-intentioned "assist" from a yoga teacher.
For people with osteoporosis, twisting may be contraindicated entirely. But in some cases, twisting could be safer if done hands-free to avoid using the strength of the arms to pull the body too forcefully into the pose.
In both scenarios, seated twists should not involve binding the arms or pulling oneself deeper into the twist. Rather, use forced exhalation to engage the trunk muscles and support a more moderate twist.
Yoga therapy for osteoporosis
Yoga therapy uses metrics to track health outcomes for conditions. For osteoporosis, increased bone mass might be the targeted metric.
But does it work?
Can yoga therapy protocols really improve bone density in people with osteopenia and osteoporosis?
The research is promising.
Perhaps one of the most exciting advances in the field of yoga therapy is in the area of research on yoga for osteoporosis, which has led to the coverage of yoga therapy for osteoporosis by some insurance companies in California, Maryland, New Mexico, and Ohio.
And for this, we have Dr. Loren Fishman to thank.
Dr. Loren Fishman is a medical doctor, researcher, and yoga teacher who has developed an approach to using yoga therapy to treat osteoporosis. His approach is based on a series of 12 yoga poses, known as the "Fishman Poses," which are designed to target the areas of the body most affected by osteoporosis.
The Fishman Poses include a range of weight-bearing and strengthening poses, such as tree pose, warrior pose, and triangle pose.
Dr. Fishman's approach to using yoga therapy to treat osteoporosis also emphasizes the importance of proper alignment and modifications to ensure that the poses are safe and effective for individuals with osteoporosis. He recommends starting with gentle variations of the poses and gradually building up to more challenging versions as strength and flexibility improve. Additionally, he recommends incorporating breathing exercises, meditation, and relaxation techniques to help reduce stress and support overall health and well-being.
How yoga works to change your bones
Dr. Fishmans' work is based upon the principles of Wolff's Law, informing how yoga therapy is used clinically for clients with osteoporosis.
Wolff's Law is based on the observation that bones will change in response to the mechanical forces acting upon them.
According to the law, bones will adapt to become stronger in areas where they are subjected to greater loads or stresses, while areas that experience less stress will become weaker. This principle is now widely accepted and forms the basis for much of our understanding of bone physiology and the effects of exercise on bone health.
Yoga postures create stress on bones, which stimulates osteocytes. Osteocyte activity then leads to a biochemical process that increases bone density.
Osteocytes are specialized cells that are found within the bone tissue. They are derived from osteoblasts, which are bone-forming cells. Osteocytes are responsible for maintaining the structure and function of the bone tissue.
When osteocytes are stimulated through mechanical loading, they can activate a signaling pathway that leads to increased bone formation and decreased bone resorption. Mechanical stress placed on the bone tissue during exercise causes the osteocytes to activate signaling pathways that lead to increased bone formation. Over time, this can lead to stronger, denser bones. This is why weight-bearing exercise, which stimulates osteocytes, is often recommended as a key component of osteoporosis treatment and prevention.
Go for long static holds of at least 30 seconds
In the case of weight-bearing exercise for osteoporosis treatment, the amount of time needed to load the bones can vary based on the type of posture and the individual's fitness level.
There is where working one-on-one with a yoga therapist can be useful in developing a personalized sequence of poses, with a prescribed amount of time to hold each pose, according to your needs.
A yoga therapist will write you a personalized sequence and teach you how to do it at home on your own. They will advise you on the recommended frequency and duration of your practice.
The good news is that most personalized yoga therapy sequences for osteoporosis take less than 15 minutes to complete.
Yoga therapist Brandt Passalacqua of Breathing Deeply Yoga Therapy has established protocols based on Dr. Fishman's body of work. He recommends holding isometric contractions during static postures for a minimum of 30 seconds to stimulate osteocyte activity.
Unlike exercise programs intended to increase muscle mass, exercises intended to stimulate bone stress can be performed in short bursts multiple times per day without the need to rest for long durations between sessions.
Passalacqua's approach highlights an important distinction between a yoga therapy approach for osteoporosis and commonly practiced exercise aimed at improving muscle strength.
For instance, instead of lifting weights in three sets of 10 reps for muscle strength, a person seeking to increase bone density should aim for strong long holds of at least 30 seconds to stimulate osteocytes.
Not sure how strong or hold long to hold your poses, or for that matter, how often to practice?
Try consulting with a yoga therapist to develop a customized sequence you can practice at home.
A yoga therapist will review your bone scans in order to tailor your regimen to your particular abilities and level of bone density. They can help determine the appropriate duration and intensity of weight-bearing exercise needed to effectively load the bones and improve bone density.
Can yoga therapy reverse bone loss?
The research is promising.
Dr. Fishman's approach has been the subject of several research studies, which have found that the Fishman Poses can improve bone density and reduce the risk of fractures in individuals with osteoporosis.
In a pilot study published in Topics in Geriatric Rehabilitation, Fishman and colleagues found that practicing a series of 12 yoga poses for 10 minutes a day for two years resulted in significant improvements in bone mineral density in 11 individuals with osteoporosis (4), and a randomized controlled trial published in the journal Osteoporosis International echoed these results in 74 individuals with osteoporosis (5).
A follow-up study published in the Journal of Osteoporosis found that individuals who continued to practice the Fishman Poses after completing the two-year trial maintained their bone mineral density gains over a six-year period (6).
Overall, these studies suggest that the Fishman Poses can be a safe and effective form of exercise for individuals with osteoporosis, and may help improve bone density and reduce the risk of fractures.
However, it is important to note that additional research is needed to confirm these findings and to determine the optimal dose and duration of yoga therapy for osteoporosis (7).
Additionally, it is important to work with a qualified yoga instructor or yoga therapist who can provide modifications and support as needed to ensure that the practice is safe and effective. Make sure you are cleared by your doctor to participate in yoga therapy for osteoporosis before beginning any exercise regimen.
Conclusion
Yoga offers many benefits for healthy aging and maintaining bone health. Before attending a gentle yoga class, make sure you get clearance from your doctor and that you are fully educated on the contraindications for yoga for your condition. Know which poses to avoid for your condition.
Yoga therapists educate people with osteoporosis on how to self-modify a general yoga practice to minimize the risk of fracture or falls. Yoga therapists are also trained on how to work with people with osteoporosis to keep them safe while reversing bone loss.
Though research is still in its infancy, there are promising studies supporting the use of yoga therapy protocols for reversing bone loss in people with osteopenia and osteoporosis.
Citations:
Ebnezar, J., Nagarathna, R., Yogitha, B., & Nagendra, H. R. (2011). Effects of an integrated approach of hatha yoga therapy on functional disability, pain, and flexibility in osteoarthritis of the knee joint: A randomized controlled study. International Journal of Yoga, 4(2), 55-63. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099099/
Schmid, A. A., Van Puymbroeck, M., Altenburger, P. A., Schalk, N. L., Dierks, T. A., Miller, K. K., & Damush, T. M. (2016). Postural control and balance in an aging population with a history of falls: A community-based study. Journal of Geriatric Physical Therapy.
Yoga Alliance and Yoga Journal. (2016). Yoga in America Study: https://www.yogaalliance.org/Portals/0/2016%20Yoga%20in%20America%20Study%20RESULTS.pdf.
Fishman, L. M., et al. (2009). Yoga for osteoporosis: A pilot study. Topics in Geriatric Rehabilitation, 25(3), 244-250.
Lu, Y. H., et al. (2016). Twelve‐minute daily yoga regimen reverses osteoporotic bone loss. Osteoporosis International, 27(12), 3605-3614.
Fishman, L. M., et al. (2012). Twelve‐minute daily yoga regimen preserves bone density in aging skeletons: A randomized controlled trial. Journal of Osteoporosis, 2012, 1-9.
Fishman, L. M. (2010). Yoga for osteoporosis: A review of the research. International Journal of Yoga Therapy, 20(1), 81-87.
