Osteoporosis is epidemic in the United States.

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 classes has low bone density and is at risk for fracture (NOF 2005). And 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 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 1987). 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 programs, 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.

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. The risk of additional fracture within 1 year in clients who have already experienced at least one vertebral fracture is 500% (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 1½-2 inches. Teach them to avoid lifting the chest wall or flaring the ribs.

7. When All of the Above Are Mastered, Then Begin a Bone-Building Program.
Progress clients safely─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).

Safe Pilates Mat Exercises
Hundred – with head down
Single Leg Circles
Single Leg Stretch – head down
Double Leg Stretch – head down
Single Leg Stretch With Straight Legs – head down
Double Leg Stretch With Straight Legs/Lower Lift – head down
Criss-Cross – head down
Swan-Dive (1 only)
Single Leg Kick
Double Leg Kick
Shoulder Bridge – not too high
Side Kick
Hip Circle/Hip Twist With Stretched Arms – neutral spine
Leg-Pull – Front
Side Kick Kneeling – neutral spine
Side Support – neutral spine

Contraindicated Pilates Mat Exercises
Hundred – unmodified
Roll-Over – both ways
Rolling Back/Rolling Like a Ball
Spine Stretch
Rocker With Open Legs/Open Leg Rocker
Neck Pull
Spine Twist
Control Balance

Note: this is an excerpt of a larger article and is meant for general educational reference only.

You can read the entire article on the Inner IDEA archives.

Bonner, F.J., et al. 2003. Health professional’s guide to rehabilitation of the patient with osteoporosis. Osteoporosis International, 14 (Suppl. 2), S1-22.
Cummings, S.R., & Melton, L.J., 3rd. 2002. Epidemiology and outcomes of osteoporotic fractures. Lancet,359 (9319), 1761-67.
Keller, T.S., et al. 2003. Prediction of spinal deformity. Spine, 28 (5), 455-62.
Lindsay, R., et al. 2001. Risk of new vertebral fracture in the year following a fracture. Journal of the American Medical Association, 285 (3), 320-3.
Meeks, S. 2004. The role of the physical therapist in the recognition, assessment and exercise intervention in persons with, or at risk for, osteoporosis. Topics in Geriatric Rehabilitation (October).
Michel B.A., Bloch, D.A., & Fries, J.F. 1989. Weight-bearing exercise, overexercise, and lumbar bone density over age 50 years. Archives of Internal Medicine, 149 (10), 2325-29.
National Osteoporosis Foundation (NOF). 2005. Fast facts. www.nof.org/osteoporosis/diseasefacts.htm; retrieved February 3, 2005.
Pilates, J.H., & Miller, W.J. 1945. Return to Life Through Contrology.Miami: Pilates Method Alliance.
Riggs, B.L., & Melton, L.J., 3rd. 1995. The worldwide problem of osteoporosis: Insights afforded by epidemiology. Bone, 17 (5 Suppl), 505S-11S.
Salkeld, G, et al. 2000. Quality of life related to fear of falling and hip fracture in older women: A time trade-off study. British Medical Journal, 320 (7231), 341-6.
U.S. Department of Health and Human Services (HHS). Office of the Surgeon General. 2004. Bone Health and Osteoporosis-A Report of the Surgeon General. Rockville, MD.