Yoga and Osteoporosis: The Do’s and Don’ts
Editor's’ note: The below recommendations are intended to be general recommendations for yoga practitioners and teachers. They are not a replacement for the personal advice of a health professional.
Yoga may be an effective part of the treatment for osteoporosis: A recent small study found that practicing yoga for as little as eight to ten minutes daily can increase bone density.
Also, according to Bill Reif, physical therapist and author of The Back Pain Secret: The Real Cause of Women’s Back Pain and How to Treat It, “With a regular practice, yoga will improve strength, flexibility, balance, coordination, endurance, muscle mass, agility, and energy level—all important for older adults with osteoporosis.”
As more students with osteoporosis make their way into yoga class seeking these benefits, it’s important that both they and their teachers know what osteoporosis is and how best to accommodate and benefit those with the condition.
Definition and Prevalence
Osteoporosis (from the Greek “porous bone”) is a disease in which bones become less dense, predisposing them to fractures.
Osteoporosis is often referred to as a “silent” disease—because loss of bone density is not easily perceptible, a patient may not know she has the disease until she breaks a bone or finds her upper back rounding as the result of asymptomatic vertebral fractures.
In 2010, around ten percent of U.S. adults over 50 (or an estimated 10.2 million) had osteoporosis. Around 44 percent of adults over 50 (an estimated 43.4 million) had low bone mass.
When bone mass is low but not low enough to be classified as osteoporosis, the condition is called osteopenia, or “bone poverty.” It precedes, but does not always lead to, osteoporosis. While lower bone density means greater risk of fractures (most commonly in the spine, hip, and wrist), more fractures occur in those with osteopenia rather than those with osteoporosis—in large part because a greater number of people have osteopenia.
Many of those with low bone density are women: Women are four times more likely to develop osteoporosis than men.
Reif says, “For women, a drop in estrogen at the time of menopause leads to a more rapid and significant loss of bone mass. For men, a drop in testosterone, often beginning around age 70, can cause it. Also, certain medications (notably steroids), medical conditions (such as rheumatoid arthritis and eating disorders) can contribute to osteoporosis.”
Other risk factors include family history, smoking, small and thin stature, sedentary lifestyle, insufficient calcium, vitamin D, or protein, and excessive consumption of alcohol or sodium.
The common medical recommendations for osteoporosis and osteopenia—medication, calcium and vitamin D supplements, avoiding alcohol and tobacco, and drinking plenty of water to avoid falls caused by dehydration—also include at least 90 minutes a week of weight-bearing and muscle-strengthening exercise.
But, when it comes to osteoporosis, all exercise is not equal.
Exercising with Osteoporosis
While those with osteopenia can often participate safely in most activities with their doctor’s approval, Reif explains that those with osteoporosis are better off avoiding certain exercises: “Osteoporosis weakens the bones and joints, so jumping or dynamic weight-bearing activities are not recommended. These include activities like jumping rope or high-intensity step aerobics classes. It’s also a good idea to avoid intense cardiovascular exercise like running, or even walking on uneven surfaces.”
Reif advises caution for many sports as well. “Activities that may involve quick changes of direction, like basketball, baseball, football, or tennis could result in falls or bone shearing. These activities have a high fracture rate, especially in the hips, femurs, and lower back.
Even golf can be risky for the spine, because of the rounding of your back when you bend forward repeatedly to retrieve a ball and the quick twisting motion of the swing. These spinal movements can cause small fractures over time, weakening the spine further, or they can result in one large fracture, possibly immobilizing you.” Reif says that while these fractures may gradually heal, the structural weaknesses and postural misalignments they cause usually remain and can even worsen with age.
According to Reif, moderate weight-bearing activities have the greatest benefit for those with osteoporosis. He explains, “Exercises that work against gravity are more effective in stimulating bone formation.”
Among the weight-bearing movements that Reif suggests for his patients with osteoporosis are walking, slow jogging, climbing stairs, the racquet sport pickleball, and low-impact dancing. “These provide positive stress for bones, which helps to maintain or increase their density.” However, Reif also points to the limitation of many of these forms of exercise, which is that “They largely impact the legs.”
For those who wish to challenge the arms as well, Reif recommends yoga. “Many poses in yoga are weight-bearing on all four limbs, helping us build bone density in the arms as well as the legs.”
Can everyone with osteoporosis do yoga?
Those with osteopenia can often practice a broader range of poses requiring more extreme spinal movement than those with osteoporosis can. But since the degree to which one has lost bone density will determine the types of exercise and the ranges of movements that are safe, Reif encourages those with osteoporosis or osteopenia to seek medical assessment and get their doctor’s advice as to whether or not yoga asana is a good idea for them, and any specific movements they should avoid.
With those for whom osteoporosis has led to thoracic kyphosis (rounding of the upper back) or fractures, yoga should be approached with particular caution.
“Greater thoracic kyphosis means increased risk,” says Reif. “Folding forward or twisting while the spine is in a C-shape, for example, are dangerous for the thoracic vertebrae made vulnerable by low bone density.” As for those with a history of fractures, Reif points out that people who have already experienced at least one vertebral fracture have an increased risk of sustaining an additional fracture within the following year.
In cases of advanced osteoporosis, yoga (asana) may be inadvisable. “Non-weight-bearing activities—swimming, water aerobics, exercise biking—may be the only exercise that the bones can tolerate,” notes Reif.
Students who have been given their doctor’s permission to practice yoga should always let their teachers know about their condition and their doctor’s recommendations.
Yoga teachers should make sure that students with osteoporosis have obtained their doctor’s permission to practice yoga, confirm whether they were given specific advice as to which movements to avoid, and keep in mind the general recommendations below.
When practicing yoga with osteoporosis, or when teaching students with osteoporosis, Reif recommends emphasizing the following poses and actions.
1. Do…practice neutral-spine postures.
Students with osteoporosis should make neutral-spine poses like mountain the crux of their practice and should work on aligning the spine optimally in these poses.
“Tip the tailbone back enough that you create a curve in the lower back, and bring your head back over your shoulders. Imagine a plumb line dropping from your ear down through your shoulders, hips, and ankles. Maintain this optimal spinal position during most postures and flows,” Reif advises.
What about those with rounded upper backs who are unable to create a neutral spine? “Come as near neutral as possible.”
For example: Mountain, reclining hand to big toe pose (using a strap), low lunge, the warrior poses, tabletop, and plank are all neutral-spine poses.
2. Do…focus on lengthening.
Having arranged your spine in its neutral or near-neutral shape, work to elongate it since, according to Reif, “With osteoporosis, the weakened vertebrae sometimes collapse to the point of fracture.” Lengthening the spine creates space between the vertebrae, preventing or correcting that collapse.
For example: “Think often of a marionette string pulling up from your head no matter what position you’re in,” says Reif. Alternatively, imagine lifting up into an object—like a book or jug of water—balanced on the crown of your head.
3. Do…include poses that encourage the hands to bear weight.
Bring your hands to the mat! As noted, one of the advantages of yoga over other exercises is that bearing weight on the hands allows us to build bone density in the arms as well as the legs.
For example: Tabletop, plank, forearm plank, chaturanga, reverse tabletop, and downward facing dog.
(Please note: It is not safe to bear much weight on the hands if the upper back is rounded. In tabletop, work to indent the space between the shoulder blades, and only proceed to poses like chaturanga, plank, and downward facing dog once this is possible. Avoid arm balances like crow that call for a rounding of the back.)
4. Do…include gentle backbends.
Because osteoporosis is so often accompanied by thoracic kyphosis, it’s especially important to work on gentle backbends, which move the thoracic spine in and lift the chest, improving thoracic spine extension, according to Reif.
Even mild forward folds are not recommended for those with osteoporosis (see Don’t #2), but some mild backbending is fine. “The extension movement is much less risky than flexion because of the strength of cortical bone in vertebrae,” Reif explains. (Please note: Big backbends can be compressive, which is contraindicated and will be addressed in the Don’ts section.)
For example: Bridge, sphinx, baby cobra, camel pose (with hands on your lower back), lying down over a foam roller or rolled-up blanket (placed horizontally under the thoracic spine), and restorative backbends. This practice for kyphosis is safe for many of those with osteoporosis.
5. Do…include mild sidebends and twists.
Reif points out that “Varied spinal movement is important for preserving the health and strength of the vertebral bones,” although any pose that rounds the back should be avoided.
These varied movements include mild sidebends and twists, which Reif says “will allow you to maintain the greatest flexibility of your spine without causing the fractures associated with osteoporosis.”
But how far should you go? “The less the torso approaches end range [of motion] the less the strain,” says Reif, who encourages yoga students with osteoporosis to go only as far as they can without sacrificing spinal length.
When sidebending, go only as far as you can without collapsing the waist on the side to which you are bending. When twisting, go only as far as you can while maintaining a gentle inward curve in the lower back.
For example: Bend to the side by just a few degrees while standing or lunging, as well as in reverse warrior, gate pose, or while reclining in bananasana. Enjoy gentle reclining twists like “windshield-wipering” the legs from side to side. And when doing more vigorous twists, keep a neutral spine (i.e., do not round the back), twisting by only a few degrees.
6. Do…move from pose to pose slowly.
To decrease the risk of falling, it’s important that students with osteoporosis move from pose to pose slowly.
For example: Come up slowly from positions like half forward fold (bending the knees and bringing the elbows to the knees for a modified chair pose before rising to mountain pose) to decrease the risk of a head rush and a fall. Before stepping a foot back for a pose like warrior I or crescent, always make sure the front foot is well-grounded.
7. Do…challenge balance without sacrificing stability.
Because a fall could mean a fracture for students with osteoporosis, it’s vital to work on balance in yoga class. But, to avoid a fall, they should initially challenge their balance while making the most of the support available to them.
For instance, in standing balance poses, have them bring a hand to the wall to steady themselves, or keep the toes of the foot they’re about to lift on the mat until they feel stable. Reif notes, “You will still improve balance and coordination even if you are not in the ‘full’ pose.”
• In warrior III, keep your back toes (or the ball of your back foot) on the ground at first, while you work to bring most of your weight into the standing leg. (Lighten your back toes only if you do not feel challenged here.)
• When practicing standing hand to big toe pose, place the foot of your lifted leg on a wall, or bend your knee and place your foot on a chair. (Lighten your foot only if you do not yet feel challenged here.)
• Practice tree pose with your hand touching the wall, gradually lightening your hand on the wall when you are sure you are stable.
8. Do… add some weights.
Rather than increasing the challenge with more extreme poses, keep the pose straightforward and use light hand and/or ankle weights.
If a student with osteoporosis is comfortable in a pose like bird dog, it can be tempting for her to turn that pose into a big backbend (by bending her back knee and bringing her lifted hand up behind her to encircle her lifted ankle).
Instead, Reif would recommend lifting a weight with the front hand and strapping an ankle weight around the back ankle. “The weight should be an amount that you can lift 10 to 12 repetitions without strain, perhaps one to two pound dumbbells or ankle weights.”
For example: Hold hand weights with the arms overhead, alongside you in chair pose, or out to the sides in warrior II. And strap an ankle weight around the ankle of the lifted foot in single-leg balance poses like warrior III.
According to Reif, it’s essential for yoga students with osteoporosis to avoid extremes in range of movement. The poses and practices below are those he recommends avoiding.
1. Don’t….do crunches or sit-ups.
While core strength is important to support the lower back, “These poses require loaded lumbar flexion, placing a high demand on the lower back as you work to lift the weight of the upper body, leading to fractures in the thoracic or lumbar vertebrae,” explains Reif.
Instead: Work on core stability in all neutral-spine poses by drawing the belly in and up on the exhale. From a lying down position, work the core by lifting and lowering the legs rather than the upper body, keeping the spine in its neutral position.
2. In fact, avoid all poses that require spinal flexion (rounded-back poses).
Students with osteoporosis should avoid not only sit-ups and crunches, but all poses that require spinal flexion (rounded-back poses) because of the stress that puts on the lower back. This means steering clear of forward folds, even mild ones, and also avoiding hugging the knees in as you lie on your back—as you would for wind relieving pose or happy baby.
Certainly, rolling up to stand, a challenging movement to do well for even the strongest of yoga students, is one that students with osteoporosis should always avoid.
Instead: Skip uttanasana (standing forward fold) in favor of ardha uttanasana (half standing forward fold). In this “flat-back pose,” you might bring the hands to blocks, the seat of a chair, or to a wall, in order to maintain your optimal spinal shape.
Choose upright seated poses like staff over forward folds like stretch of the west (leaning back if necessary to curve the lower back in toward the belly and lift the chest).
To stretch the hamstrings, instead of going deeper into a forward fold, practice lying down hand to big toe with a strap around the foot of the lifted leg. In all of these poses, focus both on keeping the spine in its neutral position and on lengthening.
3. Don’t…practice big backbends.
While some gentle backbending, as mentioned above, is fine for students with osteoporosis, big backbends like upward facing dog, wheel, bow, and camel pose with hands on the heels, can be dangerously compressive. As Reif explains, “The thoracic spine is the area of the spine at greatest risk for those with advanced osteoporosis: This is where the majority of stress is placed in any rounding of the spine, but also in extreme spinal extension (backbending).”
Instead: Stick with the milder backbends recommended on the Do’s list above.
4. Don’t…practice extreme twists and sidebends.
“Trunk rotations cause torsional stress on the spine. The discs and vertebral bones are stressed most when in a rounded position combined with a big twist. Think of the motion involved with shoveling dirt or snow: That’s when many spines are injured,” says Reif.
That means that moving into a deep chair pose twist or a Marichi’s pose with your elbow to the outside of your thigh is off limits. Big sidebends (for instance, bringing your hand to your shin in gate pose or reverse warrior), often have an element of twisting to them and can be compressive too.
Instead: Stick with the milder twists and sidebends listed in the Do’s above.
5. Don’t…start an inversion practice.
Those diagnosed with low bone density who have practiced inversions regularly throughout their lives and are able to keep their neutral-spinal alignment in these poses may be able to safely practice inversions such as headstand, shoulderstand, and handstand, though they would be wise to consult with their doctors first.
If given permission to practice inversions, students with osteoporosis should practice them at the wall in order to minimize the risk of falling.
For those who haven’t already been practicing poses like these regularly, if you’ve been diagnosed with osteoporosis, this is not the time to start. “The weakened, low-density vertebrae will not tolerate the compression [of these inversions], especially if there is a loss of cervical curve,” Reif says.
Instead: For many of the circulatory and energetic benefits of inversions, practice milder inversions like downward facing dog, bridge, and legs up the wall.
6. Don’t…take fast-paced, competitive classes.
What’s the rush? Many—though not all—vinyasa flow or power yoga classes transition quickly from pose to pose, and stability is of the essence for students with osteoporosis. Steer clear of the classes and the teachers that encourage you to move so fast you risk your balance.
Instead: Take hatha, Iyengar, gentle, restorative, yin yoga, or any alignment-focused practice.
Want to put it all together?
Check out “A Yoga Sequence for Osteoporosis,” which offers a sequence that makes use of Reif’s recommendations above.
Those living with varying degrees of decreased bone density still have a rich practice available to them which has the potential to stimulate deep change. Through asanas that are carefully selected and, at times, modified for greatest benefit, we can retain—and even regain—not only strength of muscle but strength of bone.
Amber Burke lives in Abiquiu, New Mexico. She teaches alignment-based and restorative yoga privately (and occasionally at Ojo Caliente Mineral Springs), as well as various writing classes at UNM Taos. With her anatomically-focused articles, she aims to broaden the interface between yoga and physical therapy. She and Bill Reif, MPT, are hard at work on a book for yoga practitioners with injuries and pre-existing conditions. She is a graduate of Yale, the Johns Hopkins Writing Seminars MFA... Read more>>