Modifying Pilates for Clients With Osteoporosis
Find out who is at risk for fracture and which exercises they should avoid
Osteoporosis is globally epidemic in Europe and in USA : more and more people, younger and younger are concerned.
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
Among women over 50, 1 in every 2 who walk into your exercise classes has low bone density and is at risk for fracture.
In France : 3 millions of women are touched by osteoporosis and 130 000 fractures caused it.
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 a report called: Bone Health and Osteoporosis—A Report of the Surgeon General (U.S. Department of Health and Human Services [HHS] 2004) has been published.
It treated 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 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 world: Studies have found that doctors and physician too commonly fail to diagnose and treat osteoporosis, even in elderly patients who have suffered a fracture .
Persons with osteoporosis usually discover bone loss insidiously or later at their on cost: often they find out that their pants, clothes are too long; People around 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 Pilates instructor, I am finding that clients and even Pilates teachers are discovering they have osteoporosis at younger and younger ages.
Now I’m frequently seeing osteoporotic clients in 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 & European are not engaged in enough physical activity, do not take in enough nutrients to support good bone health
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 link between urbanized cultures and these diseases, which Campbell has even called “diseases of affluence” (Campbell 2005).
In modern societies : 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”. M
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 assistant labor-saving lifestyle is destroying our bones.
Who is at risk ?
Instead of what we think osteoporosis is largely spread out among populations. We estimate that 30% of women at 50 years old, and 50% of women above 5Os have osteoporosis.
Women are more subject to osteoporosis than men:
Factors that help increase osteoporosis
- Hormones (lack of oestrogen during menopause or before)
- Some medications like pain killers, corticoïdes and hormones.
- High intake of alcohol and caffeine
- Big smokers
- Lack physical activity
- Lack of calcium and D Vitamin Intake
The Solutions: Two types of bones:
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 together, 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 renewed, and over time, bone mass and density decrease.
While modern medicine offers significant benefits for those at risk for osteoporosis, studies with no doubt suggest that individuals can do a great deal to promote their own bone health.
For example: Engaging in regular weight-bearing exercise, following a bone-healthy diet and avoiding pattern such as smoking and drinking excessive amounts of alcohol can all contribute to strong & healthy bones.
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 decrease the progression of bone loss.
One program that is often suggested for building strength is Pilates.
For most people, this is a great idea. Careful!
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.
Let’s say a client in her early 50s says she has had a BMD (bone density) 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. 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.
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.
Forward flexion causes excessive compression force on the anterior (or front) surface of the vertebral bodies, where most of the trabecular bone is located.
Compression forces on the vertebrae are also excessive during side-bending of the thoracic and upper-lumbar spine. Forward flexion, side-bending and particularly forward flexion combined with rotation are therefore contraindicated for clients with osteoporosis—and hence for clients with osteopenia.
Spinal extension is a different story. 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.
Testing with 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.
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.
- 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 Stand: Instructor must closely keep an eye at the client. Test a 10-second stance on one leg, or single-leg heel-raises 10x (tiptoes)
Teach Proper Breathing. Teach costal breathing, in which the ribs expand laterally (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.
When All of the Above Are Mastered, you can start the Bone-Building Program.
- Focus on the abdominals but without using “crunches,” which place the spine at risk for fracture
- Improve thoracic spine extension, reduce or prevent thoracic kyphosis. Foam roller can be a good tool for osteoporosis clients.
- Weight loads: planks, walking, jumping, are good low bone density exercises.
1st of all: get your self diagnosed :
Not only women over 50 have osteoporosis, and we tend to have more and more people with osteopenia at our modern age, best is to know your condition, then we can work on it.