Although yoga exercise may be effective and recommended for musculoskeletal pain of various types, persons with bone loss — whether osteopenia or osteoporosis — should be specially warned and educated on safe techniques. Of particular concern might be spinal flexion exercises, which a newly reported cases series suggests may lead to compression fractures in older women.
Writing in an early online edition of the journal Pain Practice, Mehrsheed Sinaki, MD, of the Mayo Clinic, Rochester, Minnesota, notes that awareness of the benefits of physical exercise and the popularity of yoga have increased among the older population [Sinaki 2012, ref below]. At the same time, however, some of these activities may exceed the biomechanical competence of these persons’ spines, leading to painful fractures.
In his article, Sinaki describes 3 otherwise healthy women — ages 61, 70, and 87 years — with low bone mineral density (osteopenia) and yoga-induced painful spinal fractures. None had prior vertebral fractures and they all had started yoga exercises to improve their musculoskeletal health. New back or neck pain attributed to vertebral compression fractures occurred as a direct result of their participation in yoga postures that involved strenuous spinal flexion.
Depending on the type of flexion each patient focused on, they variously developed factures of lumbar, thoracic, or cervical vertebrae. Their bone mineral density T-scores ranged from minus 1.2 to -1.8, depending on anatomical location. In post-menopausal women or men over aged 50 a normal T-score is -1.0 or higher; whereas, osteopenia is defined as between -1.0 and -2.5, and osteoporosis is defined as -2.5 or lower (meaning a bone mineral density value that is two and a half standard deviations below the mean of a 30-year-old person). Therefore, the 3 women in this case series had significant bone loss but not the more advanced damage of osteoporosis that would more readily predispose them to bone fractures.
Although exercise can be an effective approach for improving bone mineral density and reducing fracture risk, the neck and back pain in the 3 women described by Sinaki developed while they were engaged in yoga position exercises. Considering kinesiology and biomechanics of the spine, Sinaki describes several yoga flexion positions that might be of special concern due to their compressive forces on vertebral bodies (photos at left).
The position shown in the top figure could strain the cervical, upper thoracic, and thoracolumbar spine. During the yoga spinal flexion posture shown in the middle figure, the weight of the lower extremities and pelvis is imposed on the flexed thoracic spine and neck. The position in the bottom figure could result in thoracic vertebral anterior wedging or compressions and increased kyphosis over time. In all three postures, strenuous loading of the osteopenic or osteoporotic spine occurs while the spine is in an undesirable biomechanical flexion position, and a potential for vertebral compression factures is understandable, Sinaki suggests.
Of course, most older patients would probably not be able to achieve the full flexion displayed by the young models in the photos; yet, even attempting to approximate those or similar postures might be enough to cause problems. However, Sinaki does suggest that proper back-strengthening exercises may beneficially contribute to axial strength and improvement of posture, which can ultimately reduce the risk of vertebral fractures.
Sinaki concludes that the assessment of fracture risk in older persons performing yoga and other exercise activities is an important clinical consideration. The development of pain and complications with some yoga positions in patients with osteopenia leads to a concern that fracture risk would be even greater in persons with osteoporosis. Exercise can be effective and important for treatment of osteopenia and osteoporosis, but yoga should be cautiously prescribed for patients with vertebral bone loss, keeping in mind that some positions can contribute to extreme and potentially harmful strain on spines with bone loss.
COMMENTARY: It must be acknowledged that anecdotal case reports, such as described by Sinaki in this article, are a quite weak form of evidence. Certainly, however, randomized controlled trials to examine yoga-induced vertebral factures could be impractical and unethical. So, these cases are an example of when evidence appears to have practical value, or “prima facie validity,” serving more as a caution than a clinically validated contraindication regarding the selection of yoga exercises in women with preexisting bone loss.
In a prior UPDATE [here] we described a recent meta-analysis of 16 studies examining yoga as an adjunct for chronic pain management. There was a significant degree of diversity (heterogeneity) among the studies and other limitations, but the conclusion was that yoga is a useful supplementary approach with at least moderate effect sizes for relieving pain and disability associated with several chronic pain disorders. Moreover, some data suggested that even short-term yoga interventions might be of benefit in certain cases. However, almost all of the participants in the studies were ≤50 years of age, and bone health was not reported as a factor of concern.
In other UPDATES we reported on studies of yoga for back pain as compared with usual medical care or self-care [here and here], and yoga compared with simple stretching exercises [here]. Overall, the studies showed that yoga in appropriately selected patients may provide both short- and long-term benefits in terms of pain relief and improved functionality. However, those studies also demonstrated that yoga is not completely without risks of adverse effects, such as increases in pain, and some patients might achieve only modest gains in functionality without associated reductions in pain. To our knowledge, reductions in fracture risk resulting from yoga, as a strengthening form of exercise, have not been formally assessed.
REFERENCE: Sinaki M. Yoga Spinal Flexion Positions and Vertebral Compression Fracture in Osteopenia or Osteoporosis of Spine: Case Series. Pain Practice. 2012(Mar 26); online ahead of print [abstract here].
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