Yoga spinal flexion positions and vertebral compression fracture in osteopenia or osteoporosis of spine: case series. Sinaki M. Pain Pract. 2013 Jan;13(1):68-75. [FREE FULL TEXT with good pics]
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.
Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.
Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.
3 thoughts on “Vertebral Fractures after Yoga in Women with Osteopenia”
General changes in lifestyle like smoking cessation, regular exercise, and optimization of nutrition should be implemented in all osteopenic patients. Patient compliance with these measures is, however, poor, and very few prospective data on the anti-fracture efficacy of such measures exist. Smoking has emerged as a significant risk factor for fracture in many epidemiological studies, albeit the influence of dose and duration is less well defined. The same holds for exercise, but exercise can slow down bone loss after menopause and is essential for muscular strength and coordination in the elderly. The impact of poor nutrition on skeletal health is apparent in its most extreme form in anorexia nervosa, where significant improvement of skeletal mass is important without a reversal of caloric intake in these young women. For more info on the importance of calcium diet … https://www.healthclues.net/blog/en/poor-mans-rich-calcium-diet/
Thanks so much for the information; as a yoga and senior fitness instructor I want to make sure that the exercises I am suggesting for my class participants are helping rather than harming them. Am I correct in concluding that any stretches/exercises where the participant flexes the spine (either intentionally or because of incorrect alignment) should be avoided? There is a certain exercise (variation of bird dog) done on all fours (hands and knees) where opposite elbow is drawn to the knee, the chin is taken toward the chest, and the spine is flexed (to work the core). This would not be recommended for older people, correct?
Also, in your pictures above, Setu Bandha Sarvangasana is OK as it extends the spine (as long as the cervical spine stays long). Do you agree?
Hi Carol, sorry for the late reply, I wanted to do some additional research before responding. Yeah I would endeavor to avoid spine flexion exercises, pretty much all the time. It’s not that spine flexion is inherently bad, it’s that too much flexion (in duration, repetition and magnitude) is bad, and in modern societies people tend to get too much flexion with daily activities well before they start working out. Such that exercises, cardio, weights or yoga that flexes the spine is often giving the spine what it already had too much of.
At the time I did the above blog I was a bit of a hater with regards to all things yoga. However, a friend recommended I read the Yoga Sutras of Patanjali and as a philosophy/way of life I thought it was a really cool system. It had a lot in common with some of the modern day mindfulness research, and I expect it inspired a lot of said research. Since then I have taken a few yoga classes myself to see what the appeal was and because, while I don’t like the spine stretches so much, I do like the people who take yoga. So it got me thinking about ways to have your cake and eat it too, or at least how not to injure your spine while doing yoga.
So I’ve had a number of thoughts, one that yoga is great for balance and isometric strength, and mindfulness wise it takes your full attention for the 60-90 minute session that you are doing it. I think if one has racing, ruminating, repetitive/anxiety type thoughts, yoga really gets you out of that better than standard aerobic or strength training. So I’m not a hater anymore. HOWEVER, so many of the poses bring the neck and lumbar spine into extremes of flexion (which can be really bad) and extremes of extension and rotation that aren’t as bad but can still be problematic. The bulk of the recent spine research tends to suggest that people are already getting too much spine flexion during the day, which results in cervical and lumbar herniated discs. Once you have a herniated disc, spine rotation at that segment becomes excessive, which combined with disc height loss like accelerates arthritic changes of the spine thus making extension and rotation poorly tolerated. All that is before osteoporosis and osteopenia are factored in, for which the above paper I discussed indicates can result in compression fractures. So I’m not a yoga expert by any means but I do know spine research and back pain pretty well and I think a yoga class could be modified to avoid end range spine postures and still preserve flexibility around the other joints, preserve the balance and mindfullness aspects, and maybe do a little more to increase strength and bone mineral density. So I just bought and looked through all the asanas in the books 2100 Asanas and The Yoga Bible (that was my research) and it looks like there are a lot of good asanas to choose from. Unfortunately there are a whole lot of asanas to avoid, those being the one’s that hyperflex or hyperextend the neck or back.
Regarding the bird dog like pose, you’re supported by both arms and legs so spine flexion minimizing the combination of compression with flexion, so it might not be that bad, but if it were me I’d still avoid it and look for alternatives. Bringing the neck down to the chin in the bird dog position might be worse for the neck because it’s unsupported relative to the low back. So I would prefer to substitute in more plank type movements to work the core like Kumbhakasana.
Much the same for the Setu Bandha Sarvangasana. The low back position looks great as you surmised and you are working your hip and lumbar spine extensor muscles, both of which I think are beneficial. However, while the upper and mid cervical regions don’t look bad, the lower cervical spine (which is most prone to disc damage) is in fairly sharp flexion. Not as bad as the inverted asana or shoulder stands, but in western societies almost everyone looks down too much, such that I don’t think anyone needs any additional cervical flexion stretches during exercise. Perhaps to hit the same muscles a Lucust Pose/Salabhasana would be better, though in doing so I still wouldn’t stretch into extremes of extension, rather just hold an balanced isometric contraction which would hopefully be hard on the muscles and easier on the vertebra while still requiring mindful attention.
I really appreciate you questions so feel free to ask more and maybe with some back and forth we could come up with something really cool.