Osteoporosis: Considerations for Our Yoga Practice

 

by Diana Perez PT, Yoga Therapist, Yoga Teacher B.SC., M.Sc., CPYT

Although it is normal to lose bone as we age as a function of hormonal changes, many women and men over the age of 50 are experiencing accelerated levels of bone loss resulting in osteoporosis. And we are even seeing a surprising amount of osteopenia, the beginning of bone weakness, in younger people. There are probably various factors causing this: stress, sedentary lifestyles, lack of adequate exercise and movement to stimulate bone maintenance, poor nutrition (lack of vitamins and minerals), problems with the thyroid and parathyroid glands, chronic gut and systemic diseases associated with constant low-grade inflammation, lack of adequate amounts of sun exposure and vitamin D, and so on.

Let’s look at some staggering numbers. Osteoporosis is believed to be one of the most widespread chronic health problems found in Western societies, and it affects approximately 44 million Americans. It often results in very painful and life-altering vertebral and hip fractures. Of the million fractures per year attributed to osteoporosis, about 700,000 are vertebral and 300,000 are of the hip. Of the latter, 25% die from complications of their hip fractures and 25% end up in nursing homes and are never able to leave.

Currently the standard medical protocol for someone who has osteoporosis is usually medication, calcium and vitamin D supplementation, along with some exercise. Unfortunately, some of the current research indicates that in addition to the serious side effects of many of these medications, the quality of the increase in density of bone due to the use of these medications is not significant enough to prevent a fracture from falls or trauma. So what is the answer? I believe it is addressing some or all of the lifestyle factors I mentioned above that are resulting in the accelerated bone loss. Today we will address one of these in particular: exercise through yoga.

Yoga, and other forms of weight-bearing exercise, have been shown to have a significant effect on bone health, and have even been shown to be able to reverse osteopenia and osteoporosis. The compressive forces created by weight-bearing exercises, as well as the force generating positions and movements involved in yoga, stimulate the bones to become stronger (both in mass and density—two factors important in building stronger bones). Yoga also provides beneficial effects in improving balance and strength (two of the most important factors in preventing falls that result in serious fractures), range of motion, coordination, posture, and confidence in moving with more ease and resilience.

But if you are practicing yoga when you already have osteoporosis/osteopenia then you need to be aware that there are some postures and movements that could put you at risk for fracture.

Here are some suggestions:

1. First and foremost, get clearance from your doctor or other appropriate health care providers to practice yoga.
2. If you are not so familiar with yoga, finding a qualified teacher that has some training in teaching yoga to adults with osteoporosis or osteopenia would be ideal. This will ensure that you get personalized advice on alignment and proper engagement, as well as about what positions and movements you might need to be cautious about.
3. Make sure that you are practicing yoga at a level that allows you to be well in control of your movements and progress slowly. Do not be hesitant to use props, such as blocks, a chair, or a wall until you build enough strength and awareness to be in full control of the movement or pose, especially in the weight-bearing poses.
4. It appears that practicing yoga and/or exercising 5 days per week for a minimum of 30 minutes per day has the best effects on stimulating bone strength.
5. Make sure your practice includes poses that stimulate strength and bone compression. Two-legged standing poses, such as Warrior 1 and 2, Lunges, Chair pose, and standing balancing (one-legged) poses improve strength, particularly of the spine, core, hips and legs. Important: Modify poses and use props as necessary to meet your current ability and osteoporosis status. Weight-bearing poses on your arms, such as Downward-Facing Dog pose, Bird Dog pose, and Plank poses, stimulate strength of the core, arms, and upper body. Important: You may have to limit the amount of weight that goes unto your hands and wrists if these are areas of concern with bone or joints. Modify the poses to decrease the amount of weight bearing (for example, a Plank pose could be done standing with the hands on the wall and a Downward-Facing Dog pose could be done as a Puppy Dog pose.) Eventually, once you build enough muscular and bone strength in these areas it is usually possible to progress to support more or full body weight.
6. Because fractures can happen without the usual feedback cues from the body (such as pain, discomfort or increased muscular tension), you need to know which movements are a potential risk for osteoporosis. For the spine these include all movements done to excess and, in particular, forward bending, back-bending, and twisting. I will provide more detailed information on this below.
7. Headstands and handstands are generally not recommended because of the large amount of weight and stress that goes through the bones and joints, and because of the high risk of falling out of these poses. Less risky and stressful inversion poses are recommended, such as Downward-Facing Dog or Dolphin pose for active inversions or supported Bridge Pose or Legs Up the Wall pose for restorative inversions.

Risky Spinal Movements

As previously mentioned, the spinal movements that may put the body at more risk of fractures if there is osteoporosis or osteopenia are all movements done to excess and in particular forward-bending movements (especially when seated), back-bending movements, and twisting. Extreme side bending may also be included in this list.

This does not mean you cannot move into these movements at all, but rather that you may need to modify the depth of the movement. Finding the correct depth and alignment as well as the proper muscular engagement to make sure you are in control of the movement is critical to preventing injury. This is a very individual process, so it is important to move slowly and be ultra-aware of keeping proper alignment and moving from the correct body segments. This is also why working with a teacher individually, at least initially, may be very beneficial, especially if you are new to or less experienced with yoga. If this is financial or logistically not possible for you, then a small group class with an experienced teacher would be the best second option. Once you become familiar with your body, the poses, and how to modify your yoga practice for your osteoporosis/osteopenia it is usually then possible to continue practicing on your own or in larger group classes that are suited to your level and needs..

General considerations:

• Limit the depth of the movement—more is not always better! Do not try to go as deep as you can in the pose, but rather work to just the beginning of the stiff sensation or the first barrier.
• Do NOT push into the pose to get more range. Allow the breath, especially in twists, to guide your ability to move a little deeper.
• You may need to avoid going into the full range even if your body feels that you can, because of the excessive compression it might put on the bones. This is where you might need some help from a doctor, health care professional, or yoga teacher that is familiar with your particular medical condition.
• Generally, regardless of the type of pose, there should be a sense of elongating the spine (making the spine feel as tall as possible) using the support of your hands and/or props to help support you as necessary. The sensation should be one of the top of the head reaching for the sky, minimizing any excessive rounding, specially through the thoracic and lumbar areas.
• Correct alignment and adequate muscular control is important for not just the spine, but also all the other body parts. Should you desire to do a yoga practice that is more challenging, make sure you progress in a gradual manner.

Below are some yoga pose-specific suggestions that you should consider when practicing your yoga.

Forward Bends

Do:

• Elongate your spine and limit any excessive rounding (flexion) that may be taking place in the lumbar (low back) and thoracic (between low back and neck) areas of the spine.
• Hinge from your hips, rather than rounding from the lumbar or middle back. (This means that your pelvis should be tilting forward in the movement, and the sensation is one of the belly moving towards the front of the thighs rather than one of the chest collapsing forward towards the belly). This is especially true in seated forward bends.
• Bend your knees as much as needed (and for most people this is a lot!) when folding the body over the front of the legs, whether you are doing a standing or sitting pose. Eventually, as the tissues in the back of the body, legs, and hips becomes more flexible, it might be possible to forward bend with the knees straight, but for most people keeping the knees straight causes the spine to move into excessive rounding during forward bending.
• Keep your head in alignment with the rest of the spine, creating a sensation of length in both the back and front of the neck by gently tucking the chin in towards the throat.

Do Not:

• Round the lower-spine (lumbar) and mid-spine (thoracic) spine areas excessively, as this may put too much loading on the bodies of the vertebra of the spine. Ideally these areas should be kept in neutral or only mildly rounded (mild flexion), with most of the movement occurring through the hip joints (that is, hinging through the crease of the hips so that you feel the belly and chest moving towards the thighs and knees and there is still a sense of elongation in the spine).
• Allow your head to become disconnected from the rest of your spine by letting your head drop forward with the back of the neck collapsing into a step-like position.

Backbends

Do:

• Elongate the spine and make sure that the movement is occurring through the whole spine (and not just at one level). This is particularly true in standing back bends, where the back bend tends to occur in the lowest part of the lumbar spine creating excessive compression.
• Use supports as necessary.
• Backbends on the ground can be done both actively (such as Bridge pose) or passively (lying over blocks or rolls in Fish pose). The first promotes strength and the second promotes flexibility.
• Be cautious with or eliminate poses that can create deep backbends such as Upward-Facing Dog pose, Wheel pose (Upward Bow), Bow pose, and Camel pose with the hands on the heels.
• Keep your head in alignment with the rest of your spine, creating a sensation of length in both the back and front of the neck by gently tucking your chin in towards your throat.

Do Not:

• Create a back bend curve that is excessive in any area or overall.
• Over-force the muscles lifting you into the back bend more excessively than feels natural.
• Allow your head to become disconnected from the rest of your spine by letting your head drop backwards with the back of the neck shortening.

Twists

Do:

• Elongate the spine for twists. This is important in all yoga poses but particularly so for poses involving twists.
• Limit the depth of the movement, especially if your spine is stiff and fixed in a rounded position in the thoracic area (a kyphosis).
• Be especially aware of the need to limit the twisting when you are in a seated position (because the pelvis is fixed to the floor and can move very little to assist in the motion).
• Bring awareness to directing the twist to the mid-back (thoracic) area and not into the low back. (The majority of the rotation that occurs in the spine should be happening through the mid-back area and not the low back—lumbar— area.)

Do Not:

• In seated twists, don’t round your spine forward.
• In standing poses, do not lock the hips and knees into a fixed position as you twist. For example, when twisting in Chair pose (aka Powerful pose), as you twist to the right, frequently a yoga a teacher will cue you to keep your left knee back in alignment with your right knee. This can create excessive torsional stress on the sacrum and low back. Instead, allow your left knee to move forward rather than keeping it back in alignment with your right knee. And in standing twists, allow the hips to turn in same direction as the upper trunk twists, and do not lock them in a fixed position.

Side-Bends

Do:

• Elongate the spine.
• Make sure that you create is a lift through your torso so that your torso does not collapse to the side you are bending to. For example, in Crescent Moon pose to the right, you are lengthening the left side of your body, but there should still be a sensation of lift in the right side of body even though it is shortening.

Do Not:

• Over-reach the side motion, especially in standing poses, such as Crescent Moon.

Inverted Poses

Although some yoga teachers feel that Shoulderstand and Handstand are acceptable, my suggestion is that you avoid these (and especially avoid Plow!) because of the excessive compression through the cervical spine and upper body. There is also a higher risk of falling in these poses. If these poses are very important to your practice, then seek guidance in making sure that you are able to do them correctly and safely.

Conclusion

If you have osteoporosis or osteopenia, all this information may seem overwhelming! But it is important that your condition not create fear, cause you to stop moving, or make you feel that you are fragile. Everyone who steps unto a mat usually should to take into account their physical, mental, and spiritual states, and practice in a way that promotes health and resilience in the way that is suited to them. So I encourage you to explore what is possible, educate yourself so that you become an expert on how to best manage your condition, get guidance and professional help as needed, and embrace the practice of yoga with awareness, courage and joy!

Many blessings.

Namaste,

Diana

Diana Perez is a sports and rehabilitation Physical Therapist and a certified Professional Yoga Therapist (PYTI-2017) who has worked in the medical field, academia, and fitness industry for over 40 years. She completed a Masters Degree in Rehabilitation Science in 1997 (Faculty of Medicine; McGill University) and was a lecturer / professor at the School of Physical & Occupational Therapy; Faculty of Medicine (McGill University) from 1985-2004. She has advanced specializations in Sports Physiotherapy, Manual Therapy, Back & Neck Rehabilitation, Muscle Energy, and Myofascial Release, She also has formal training/certifications in the areas of wellness, functional nutrition, naturopathy, Ayurvedic medicine, acupuncture and yoga therapy, and has been integrating yoga into her clinical practices since 2004.

Diana Perez has been practicing yoga since 2002 and teaching yoga since 2004. Her yoga influences have been mainly from the schools of Hatha, Ashtanga, Moksha and Anusara and she completed 2 teacher training certifications (Hatha & Ashtanga; RYA-200 hours). Her specialties are in Yoga Therapy, Yoga Anatomy, Injury Prevention, Asana Alignment, and Yin Yoga. She is on the faculty of several Yoga Teacher Training Programs in Canada (Sun and Moon; Heaven & Earth; Happy Tree; Moksha WI Yin), and teaches yoga classes and many types of workshops to yoga teachers as well as to the general public. She is also on the faculty of the Atlas-Medic Medvox Program for who she develops and teaches  courses to health care professional on how to integrate yoga into health care. She currently continues to practice as a physiotherapist and yoga therapist at the Medi-Club Physio Centre in the West Island of Montreal.

 

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