Modifying Pilates for Clients With Osteoporosis

Osteoporosis is epidemic in the United States.

Why does this concern the fitness professional? One in every 2 women and 1 in every 4 men aged 50 or older will suffer an osteoporosis-related hip, spine or wrist fracture during their lives (National Osteoporosis Foundation [NOF] 2005). Among women over 50, 1 in every 2 who walk into your exercise classes has low bone density and is at risk for fracture (NOF 2005).

Research has shown that given the fragility of the osteoporotic vertebrae, most fractures are caused by the stresses of everyday life (Cummings & Melton 2002; Keller 2003). As the disease progresses, bones can become so vulnerable that fractures can occur spontaneously or through such mild trauma as opening a stuck window, lifting a light object from the floor with a rounded thoracic spine or even just coughing or sneezing.

The problem is so widespread that in October 2004, the U.S. Surgeon General released a 404-page document called Bone Health and Osteoporosis—A Report of the Surgeon General (U.S. Department of Health and Human Services [HHS] 2004). This report provides scientific information on how to improve bone health and reduce the risk of illness and injury. The document also raises the profile of a disease that too often has been overlooked.

What Is Osteoporosis?

Osteoporosis is the gradual and silent loss of bone and not a normal aging process. It is defined as a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture (NOF 2005). Osteopenia is mildly reduced bone mass—a loss of approximately 10%– 20%—indicating the onset of osteoporosis.

Clients who have their bone mineral density (BMD) tested receive a T-score, which tells them how their BMD compares with that of a young adult (25–30 years old). A standard deviation (SD) of -1 to -2.5 below the mean indicates osteopenia. An SD of more than -2.5 indicates osteoporosis. For every 1-point SD drop below the mean, fracture risk doubles.

The World Health Organization did not recognize osteoporosis as a disease until 1994. Since it is not only a newly recognized illness but also a “silent” one (bone loss stays hidden until we see its effects through changes such as height loss or kyphosis [dowager’s hump]), our lack of awareness is one of its biggest allies. This lack exists even in the medical field. Studies have found that physicians too commonly fail to diagnose and treat osteoporosis, even in elderly patients who have suffered a fracture (Andrade et al. 2003; Kiebzak et al. 2002; Feldstein et al. 2003). Persons with osteoporosis usually discover bone loss insidiously. Sometimes they find that their pants are too long; or relatives notice that they are shrinking in height, they’re developing a dowager’s hump or their arms look longer. Other persons complain of waistline pain (caused when the ribs sit on the iliac crests), mid-back pain or neck pain. Hip pain is not common with osteoporosis and is present only after a fracture.

A Question of Lifestyle

In my practice as a physical therapist and a Pilates instructor, I am finding that clients and even Pilates teachers are discovering they have osteoporosis at younger and younger ages. I used to treat osteoporosis only in nursing homes, but now I’m frequently seeing osteoporotic clients in outpatient facilities, Pilates studios, and health clubs where I teach Pilates mat classes. What are we doing wrong?

Evidence suggests that lifestyle is a major culprit. Studies have found that Americans do not engage in enough physical activity, are becoming obese and do not take in enough nutrients to support good bone health (Wright et al. 2003; Gordon-Larson et al. 1999). Researchers working on the China-Oxford-Cornell Project studied rural Chinese farm families for incidence of osteoporosis, heart disease and cancer and found that even with low calcium intake the incidence of these diseases was extremely low (Hu et al. 1994; Campbell 2005). In contrast, the researchers found a positive correlation between urbanized cultures and these illnesses, which Campbell has even dubbed “diseases of affluence” (Campbell 2005).

In the U.S. we base our habits of daily living on convenience and time management. We have computers for shopping; TVs to entertain us; and microwaves, washing machines, elevators, escalators, cars and high-tech devices to “save time” and to make our lives more efficient. But more efficiency means we are increasingly sedentary, and sedentary living is bad for our bones. We walk less, we bear less weight, and we do less physical labor. In short, our high-tech labor-saving lifestyle is destroying our bones!

Two Types of Bone

Bone is alive and continuously changing, remodeling itself, storing minerals, forming blood cells and providing a strong and hopefully stable structure that can protect organs and to which muscles and ligaments can attach. There are two main types of bone, cortical and trabecular.

Cortical bone is arranged in long, parallel, compact lines and found in the long bones of the femur, tibia, humerus, radius and ulna. Trabecular, or cancellous, bone is sponge-like and found in the vertebral bodies, in the neck of the femur (hip) and at the joint surfaces of all bones. Trabecular bone has an 80% faster metabolic turnover rate than cortical bone and is affected to a much greater degree by osteoporosis. Luckily, trabecular bone makes up only 20% of our total skeletal mass, whereas cortical bone makes up the other 80%.

Two cell types are at work in our bones: osteoblasts (bone “builders”) and osteoclasts (bone “cleaners”). In the healthy skeleton these two cell types are continuously working in sync, with osteoclasts breaking down old bone and osteoblasts replacing it with new bone. In someone with osteoporosis, however, the osteoclasts continue to break down old bone, while the osteoblasts get lazy. Bone breaks down more quickly than it is remodeled, and over time, bone mass and density decrease.

While modern medicine offers significant benefits for those at risk for osteoporosis, studies clearly suggest that individuals can do a great deal to promote their own bone health. Engaging in regular weight-bearing exercise, following a bone-healthy diet and avoiding behaviors such as smoking and drinking excessive amounts of alcohol can all contribute to strong, healthy bones (HHS 2004).

The Role of Pilates

The importance of weight-bearing exercise that loads and strengthens bone cannot be underestimated. In fact, research has shown that physical exercise alone can halt the progression of bone loss (Smith & Gilligan 1991). And according to the Surgeon General’s Report, “Health and Fitness professionals can play a major role in . . . identifying and advising high-risk individuals and those who have osteoporosis” (HHS 2004).

One program that is often suggested for building strength is Pilates. For most people, this is a great idea. But, despite the media hype, is Pilates safe for clients whose bones are compromised? To teach safe and effective osteoporosis Pilates exercises, all Pilates instructors should be educated about osteoporosis and know the precautions that apply to clients at risk for fracture. What instructors must know—if they are to help rather than harm these clients—is who is at risk and which moves are contraindicated. Without such knowledge, their clients may end up breaking a bone even as they’re exercising to build bone strength.

Which Clients Are High-Risk?

Let’s say a client in her early 50s says she has had a BMD test and was diagnosed with osteopenia, or slightly low BMD. Do the same contraindications apply to her as would apply to a client with osteoporosis?

The thoracic spine is the area of the spine at greatest risk of fracture. According to a famous study by Sinaki and Mikkelson (1984), T7, T8 and T6 (the spinal bones just between the shoulder blades) are, in that order, the spinal bones most prone to fracture. That’s because the vertebral bodies get smaller as you move up the vertebral column and also because the thoracic vertebral bodies’ orientation toward flexion loads the spine anteriorly. However, dual-energy x-ray absorptiometry (DEXA)—commonly used to test bone density—does not view the thoracic spine because it is surrounded by ribs and the sternum, which would skew the results of the BMD report. DEXA views the lumbar spine.

Statistically, we know that bone density decreases from the cervical to the lumbar spine. However, bone size and ability to distribute force load decrease from the lumbar to the cervical spine. So if someone has osteopenia of the lumbar spine, an exercise specialist should assume that the person may have osteoporosis of the thoracic spine (Grote et al. 1995). What’s more, until the results of the client’s next bone density test are known, the instructor doesn’t know if bone loss is progressing as he or she is working with the client. Therefore, all exercise specialists should use the same precautions for clients with osteopenia as for those with osteoporosis.

Contraindications for Clients With Low Bone Density

In 1984 Sinaki & Mikkelson tested four separate groups of subjects with osteoporosis. Group 1 performed only extension exercises (similar to Pilates Double Leg Kicks), Group 2 performed only flexion exercises (curl-ups in hook-lying position with feet on the floor; similar to the Pilates Hundred or Roll-Ups), Group 3 performed both extension and flexion exercises, and Group 4 did no exercises.

The results:

Group 1 EXTENSION: 16% had another wedge or compression fracture

Group 2 FLEXION: 89% had another wedge or compression fracture

Group 3 EXT + FLEX: 53% had another wedge or compression fracture

Group 4 NO EXERCISE: 67% had another wedge or compression fracture

The importance of these results cannot be overstated. Sinaki & Mikkelson found that 89% of the people who performed only flexion exercises suffered additional fractures during the study. This indicates that it is harmful and dangerous to allow clients to perform flexion exercises when they have known osteoporosis! Many subsequent research papers have affirmed this (Keller 2003; Meeks 2004; Bassey 2001). Forward flexion causes excessive compression force on the anterior (or front) surface of the vertebral bodies, where most of the trabecular bone is located. In those with low bone density of the spine, the weakened bone cannot withstand such force and fractures may—or will—occur. Compression forces on the vertebrae are also excessive during side-bending of the thoracic and upper-lumbar spine. Forward flexion, side-bending and— especially—forward flexion combined with rotation are therefore contraindicated for clients with osteoporosis—and hence for clients with osteopenia.

Spinal extension is a different story. The posterior surface of the vertebral bodies contains the pars interarticularis, the pedicals and the lamina, which have a higher composition of cortical bone and are at less risk for fracture. These areas do get compressed as the spine moves into extension, but the movement is much less risky than flexion because of the strength of cortical bone. One research study showed that people with stronger back extensor muscles had higher bone density in their spines (Sinaki et al.1986). Another found that strong back extensors correlated with fewer vertebral fractures and increased bone mineral density (Sinaki et al. 1996 & 2002). The problem is that clients intuitively avoid spinal extension because of the “bone on bone” feeling at the end range during back arching. They tend to like flexion because it feels soft owing to the cushioning of the disks.

For an essential list of contraindicated exercises, see “What’s Safe and What’s Not” on page 53.

Introducing Modified Pilates

When clients with low bone density or newly healed fractures are ready to start a strengthening program, modified Pilates is an option. But safety must be paramount. Clients who have already experienced at least one vertebral fracture have a 500% increased risk of additional fracture within 1 year (Lindsay et al. 2001)! For maximum safety and benefit, it is crucial to follow these steps in this order:

1. Make Sure Clients Have Obtained a Physician’s Clearance to Do Pilates. Anyone who has osteoporosis or is at high risk for it must have clearance before beginning a Pilates program.

2. Use Safe Evaluation Techniques. Do not test the spine’s mobility! The following tests are safe to use:

• Functional Reach Test: Assess how far the client can reach forward without excessive rounding of the thoracic spine. Normal is about 10–12 inches.
• Lifting: Have the client attempt to lift 5–10 pounds from the floor using proper knee and spine alignment.
• Supine to Sit, using “log rolling” method.
• Sit to Stand, without using hands and with knees apart.
• Hip Hinge: Check to see if the client can flex at the hip joint without rounding the low back.
• Abdominal Strength Test—Leg Lowering: The head is on the floor, or if the client is kyphotic, on a small pillow. The lumbar spine should be flat. Have the client perform single-leg lowering first, and then double-leg lowering if this is possible with a flat back.
• Balance Test—Tandem Stand: Instructor must closely guard the client. Test a 10-second stance on one leg, or single-leg heel-raises 10x.

3. Protect the Spine From Fracture. Before clients begin a program, make sure they clearly understand which moves are contraindicated and which are protective. Most important, teach them to avoid all flexion, side-bending and rotation (with osteoporosis and osteopenia of the spine) (Bonner 2003; Meeks 2004).

4. Teach Clients Their Neutral or Optimal Spine Position. For some clients, neutral spine will be impossible, in which case teach them their optimal spinal position (as near neutral as possible).

5. Teach the L-Shaped Hip Hinge. Use the hip hinge to instruct clients how to disassociate spine movement from hip movement.

6. Teach Proper Breathing. Teach costal breathing, in which the ribs expand posterolaterally (bucket-handle-style, encouraging breathing into the lower back) and the transversus abdominis muscles are contracted to prevent abdominal expansion or bulging. Placing a strap around the lower ribs at or near the level of the xyphoid process will give clients feedback. They should be able to expand 1¹⁄2–2 inches. Teach them to avoid lifting the chest wall or flaring the ribs.

6. When All of the Above Are Mastered, Then Begin the Bone-Building Program. Progress clients safely (see below for details)—and remember, exercise should still be fun!

Note: Do not allow clients to exercise to the point of caloric drain. Evidence has shown that women who exercised up to 5 hours per week had increased BMD, whereas women who exercised more than that showed a decrease in BMD. The conclusion was that exercise to the point of caloric drain or amenorrhea is associated with stress fractures and osteoporosis (Michel, Bloch & Fries 1989).

The Bone-Building Program

General principles:

• Throughout the program, emphasize body awareness, axial elongation (see “Case Study: Ilda” on page 48) and—always—alignment (Meeks 2004; Bonner 2003).
• Focus especially on the abdominals—but without using “crunches,” which place the spine at risk for fracture. The 90/90 Posterior Tilt and the 90/90 Lower-Abs Leg Lowering exercises (see page 52) are effective for abdominal strengthening.
• Require clients to maintain their neutral or optimal spine position during most exercises.
• Encourage clients to improve their thoracic spine extension (through backward bending, which is safe for the spinal vertebrae) to prevent or reduce thoracic kyphosis. A safe foam roller exercise that can be helpful for this purpose is the Thoracic Spine Extension (see page 51).