Why can’t a person with Osteopenia flex the spine?

Regarding the difference between osteoporosis and osteopenia: Basically we must assume that if the person has osteopenia of the lumbar spine that they may very likely have osteoporosis of the thoracic spine. 1)The thoracic spine is more oriented to kyphosis and anterior loading of the vertebral bodies, 2)The vertebrae get smaller as we go up the vertebral column and 3) The most popular fracture site of the spine is at T6-T7 and T8. We also have no way of determining whether or not the disease is progressing as we are working with our clients. There is no way we can determine how much force it would take to cause a fracture in the spine. The statistics are clear; 1 in every 2 women over age 50 will have an osteoporotic fracture in their lifetime. Then after the 1st vertebral fracture the risk of having another one within 1 year is 500%!! We need to be very vigilant about preventing the 1st fracture. It’s not a good idea to “experiment” with clients when the research is very clear. A physical therapist is guilty of malpractice if they put a patient who has known osteoporosis in spine flexion.(Carole Lewis, PT) I am in support of “evidence-based” practice in PT and Fitness. I want to give my clients/patients SAFE exercises that WORK! Unfortunately with so many flexion exercises in our beloved Pilates method we are forced to be creative and compliant. Yes, we WILL narrow their options for movement somewhat but my clients from age 20-84 are completely happy with their exercise programs and feel very confident about their guidelines and exercises! They don’t want to have any/anymore fractures! I know very few people on the planet these days that need to increase their degree of thoracic flexion!

There is an article that explains all of the reasons for avoiding flexion, Modifying Pilates for Osteoporosis, published April 2005 in the IDEA Fitness Journal. It is downloadable on the Osteoporosis News page of this TheraPilates website.


Filed under Osteoporosis

22 responses to “Why can’t a person with Osteopenia flex the spine?

  1. Annette

    In an exercise like the double leg stretch then, is it OK to raise the head while you do it, or should you keep the head down flat with osteoporosis. I know it’s flexion, but it seems like so little.

  2. sherribetz

    In Double Leg Stretch, the position of the upper spine and neck is the same as in the Hundred. Actually just lifting the head is not the correct way to perform the exercise. You are meant to roll the thoracic spine into flexion so that the head just “floats” up. So in the correct performance of the Double Leg Stretch there is a significant amount of thoracic flexion in the upper and middle thoracic vertebrae. So, please keep the head down or on a pillow or wedge cushion.

  3. Annette

    My instructor has been having me do mat exercises – reaching across my body with one arm to touch the floor on the opposite side, and also lying on the mat with legs in the table position and swaying the knees from side to side. Having done some reading on your site it seems to me that that is twisting and not a good idea with osteoporosis.
    If that’s right I worry about how to tactfully refuse to do them.

  4. sherribetz

    If you have osteoporosis of the spine, even a partial curl up has been shown to cause micro fractures in the vertebral bodies. Read the Sinaki and Mikkelson article on the osteoporosis page of my website. If you curl up and twist, this puts the vertebrae at even greater risk of fracture due to the increased pressures on the vertebral bodies with the combined forces of rotation and flexion. Bring a copy of the article “Modifying Pilates for Osteoporosis” and have your instructor contact me with any questions they have. I am happy to help them understand in a positive and non-threatening way.

  5. Annette

    Thank you Sherri. I have read the article a few times. I will print it and give her a copy. I have become stronger despite the RA and osteoporosis, so I plan to carry on.

    I find it difficult to set goals in Pilates and know objectively whether I am progressing

  6. Hi Annette,
    Your instructor should have performed some type of fitness assessment at the start of your program and then periodically re-assess to see how you are progressing objectively. I use an assessment devoloped by Polestar Pilates Education for teaching my fitness instructors how to assess clients. Sherri Betz

  7. Nikki

    Hi Sherri!
    So, I have some clients that are “border line” or have osteopenia. I know this sounds a little repetitive, but this means NO flexion, in any direction, what so ever, right? So everything must (for safety) be done in extension or neutral. I just want to make sure I’m doing what’s best for my clients without limiting them too much. Hope all is well.

    • sherribetz

      Dear Nikki,
      Neutral or Extension are your safest positions. Flexion is the most at risk for causing fractures. Rotation and Sidebending are next. The thoracic spine is most likely to fracture at T6-7-8. So, upon discussion with Kathy Shipp, PhD, PT, Wendy Katzman, DPT, Carleen Lindsay, PT and other experts in this field at a symposium last year, we all thought that articulating bridges would be safe for osteopenic clients. This would allow a small amount of lumbar flexion. I do not allow clients to do exercises in thoracic flexion. Some cervical flexion is permitted. Avoid endrange movements of sidebending and rotation and do not combine flexion and rotation (like the saw). Combining extension with rotation is permitted. (like Swan with rotation). Exercises such as: Rolldowns, Rollups, Rollovers, Hundred are contraindicated.

      The only research we have on vertebral compression fractures shows that there is a pretty clear correlation between flexion, low bone density and fractures. (Sinaki, et al 1986, 1992, 2002, 2007)

  8. Melissa

    I have osteopenia of the hips and lumbar spine. My bilateral total hip T-scores is -1.2 standard deviations. I originally went to my PT for tendonitis on my rotator cuff on my right shoulder. Most recently, my PT has given me exercises for my spine thinking that this is the best place to start in order for the rest of my upper body to get stronger. She had me do spine flexion and after reading this article I will stop doing it. Can you give me recommendations on what exercises to do for my spine and hips? Thank you.

    • Dear Melissa,
      For the shoulder we usually start with core control exercises in neutral spine and breathing to relax the muscles on the tops of the shoulders. This helps to reduce the impingement. We then begin with small range of motion exercises to align the shoulders and get the humeral head seated in the socket properly. We also love using the Ron Fletcher Towelwork exercises. I would also add some thoracic extension exercises for better posture and head, neck and upper back alignment. I hope this helps! Where do you live? I might be able to reccommend a teacher for you in your area. Best of luck to you and happy new year!
      Sherri Betz

  9. sue

    Just got my bone density results today. I’ve been doing yoga for 2 years. My sipne is -1.9. I’m very scared. Should i continue with my yoga practices with all the twists, facing dog? Thanks

    • Dear Sue,
      Please don’t be scared. Just begin to make informed choices from here on. A -1.9 Tscore is not too bad. It does mean that you are about 20% lower than you should be at this time. Please be careful with your Yoga postures and avoid rounding the thoracic or lumar spine with Forward Bends and Forward Folds. Avoid Shoulder Stands, Plough and Deep Twists. Downward Facing Dog is just great if you keep your spine in good alignment (Lengthened Neutral Position)! Upward Facing Dog is an excellent pose for osteoporosis or low bone density. You might consider adding prone (face down) chest lifts to strengthen your back muscles and stimulate bone building in the spine. Use a pillow under your ribs and pelvis for this exercise. Best of Luck to you!

    • Hi Sue,
      Your yoga practice can certainly continue by including modifications to the risky poses. There is an NOF webcast that I did with Matthew Taylor on Pilates and Yoga for Skeletal Health that you might find helpful.

      Let me know how you do with it and if you have any additional questions!
      Best of luck with your yoga practice and bone health!

  10. Tony

    Where is the most flexion in the spine.


  11. Tatjana

    Hi Sherri,

    I am also a Pilates professional and I really like the way you write and work.
    My only concern about the whole subject is that the nutrition is never really addressed in any of the blogs, or it is more of a “common place” (correct me if I am wrong, please!).
    I have been Vegan for two years now and the 1st thing I learned on my Vegan journey was that cow milk drains calcium out of our bones and bodies and is THE nasty food nr.1.
    Yes, there is some amount of calcium in it for sure, but the number of bad substances in the cow milk makes it actually a poison for us, humans.
    All animal products are directly linked to many “modern” diseases, Osteoporisis is on that long list as well.
    The Myth of drinking a lot of cow milk for getting a good amount of calcium is the fastet way on getting Osteoporosis.

    I think our society (unfortunately many doctors and nutricionists included) needs to get educated on how bad animal products are for our bodies, and how beneficial a plant-based diet is.

    As Joseph Pilates used to say: ” I think everybody should practise Contrology”, I can only add: I think everybody should know the truth about the food they eat and start making better eating choices in order to prevent bad health conditions.

    • Dear Tatiana,
      Thank you for writing! One of the main reasons that I don’t mention food, nutrition or osteoporosis very often is that there is a plethora of information out there on nutrition and just as many opinions. I am a physical therapist and Pilates teacher and exercise is my expertise. I certainly do give recommendations on the amount of vitamins and minerals we should consume on a daily basis to feed our bones and our bodies but beyond that is out of my scope of practice. I agree with you that vegetables and especially leafy greens are one of the best and most absorbable sources of calcium. Consumption of milk and animal products are very controversial topics and sometimes take the focus away from the importance of exercise….I leave it to the client/consumer to decide whether or not to consume milk for him/herself. If you have some well designed research studies to support your statements about the link from consumption of animal products and disease, please share! What I often see is that people become very focused on their diet and they don’t exercise to stimulate their bones and muscles. (Which is why I talk less and less about food and more about exercise!) I see it as an input=output philosophy! Muscles require calcium to contract and magnesium to relax, so when we increase our exercise, we need additional calcium and other minerals to feed the muscles. If we don’t supply the body with additional calcium and minerals available in our bloodstream, the muscles must steal calcium from the bones to continue working!

  12. Thanks for sharing your thoughts about piltes yoga. Regards

  13. Sandy

    Sherri, You are bottom line awesome. Thank you for your expertise and dedication to our education. Sandy

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