The objective of this report is to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. We previously described subjects with known osteoporosis in whom vertebral compression fractures (VCFs) developed after spinal flexion exercise (SFE) and recommended that SFEs not be prescribed in patients with spinal osteoporosis.
This report describes 3 healthy persons with low bone mass and yoga-induced pain or fracture.
All 3 patients had osteopenia, were in good health and pain-free, and had started yoga exercises to improve their musculoskeletal health. New pain and fracture areas occurred after participation in yoga flexion exercises.
The development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. Although exercise has been shown to be effective for improving bone mineral density and decreasing fracture risk, our subjects had development of VCFs and neck and back pain with yoga exercises. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss. The increased torque pressure applied to vertebral bodies during SFEs may be a risk. Exercise is effective and important for treatment of osteopenia and osteoporosis and should be prescribed for patients with vertebral bone loss. Some yoga positions can contribute to extreme strain on spines with bone loss. Assessment of fracture risk in older persons performing SFEs and other high-impact exercises is an important clinical consideration.
I had just received a solicitation for a yoga based exercise course for physical therapists for treating osteoporosis. I was curious about this as I think science based physical therapy for restoring bone mineral density and reducing fall risk should include a fair amount of progressive resistance exercise, and I don’t think yoga quite cuts it. I was curious if there was any science behind the method and found a few papers I intend to review. What immediately caught my eye was this paper citing 3 people with osteopenia (defined bone mineral density of 1.0 to 2.5 standard deviations less than an average 30 year old) who developed vertebral compression fractures and severe back or neck pain after beginning yoga classes. The first was an 87 year old woman who developed a compression fracture at L2, the second a 61 year old woman with a new compression fracture at T4, the third a 70 year old woman compression fractures at T8-9. Osteopenia is bone loss that is less severe than osteoporosis, which is when bone mineral density drops to >2.5 standard deviations below normal. So I think one might reasonably conclude that if these stretches are causing compression fractures with osteopenia, they are even higher risk for those with osteoporosis.
The author noted he had seen but not reported other compression fractures in women with yoga flexion stretches before and said they were considered incidental until other yoga related vertebral fractures were reported at which point he decided to do this paper. With a lot of vertebral compression fractures going unreported I expect the incidence is greater than this paper suggests. The author did a good job of defining which yoga stretches are the problematic ones, which are those in which the person flexes their back or neck as they bend forward to touch the floor/their feet, or flexes their neck as they bring their chin forward towards their chest. These flexion stretches mimic the direction that causes lumbar discs to herniate. However in this case osteopenia/osteoporosis the vertebral bones are weaker than the discs, or the discs are already degenerated, so the next thing to break is the the vertebral bones themselves
Also worth noting is that extension strengthening, contrary to flexion stretching, has been shown to be protective against vertebral compression fractures and squats with accelerating progressive resistance has been shown to increase both hip and lumbar bone mineral density. The right exercises are good, the wrong exercises are bad and physical therapists need to differentiate what exercises are going into their programs to maximize rewards and minimize risks. Yoga instructors as well might want to bone up (haha) on the risks of spine flexion. I’ll read through the rest of the papers to see if research demonstrates any particular yoga specific benefits, but depending on the exercises it appears there are significant risks. In the meantime, I think I’ll have my patients do squats.
As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.
Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.