I. The Problem of Osteoporosis

An osteoporosis web site opens with this question, Did you know that a womans risk of osteo-related fracture is greater than her risk of cervical, uterine, and breast cancer combined? Then why do people laugh when I tell them that Im scheduled for a baseline DEXA Scan next week at the age of 38? Why do you need one, youre so young? But you exercise and eat well, why worry? And my personal favorite, You are so body aware, wouldnt you know if you had a problem? Even with all the media discussion about osteoporosis and the fact that one in two women over the age of 50 will experience an osteoporosis related spinal fracture people still dont take the problem to heart.

In fact, I can check off twelve possible risk factors for osteoporosis: 1) I am caucasian. 2) I am female. 3) I suffered from severe endometriosis. 4) I was treated for the latter with GnRH inhibitors and Depo-Provera, both proven to cause bone loss. 5) I did not have a menstrual cycle for over 18 months during said treatment. 6) I over-exercised as a teenager. 7) I ate too little as a teenager. 8) I entered menopause at age 27 after a hysterectomy with removal of both ovaries. 9) I never gave birth. 10) I have a small frame. 11) I smoked for approximately 10 years. 12) I am adopted and do not know my family medical history. Not only am I at high risk for osteoporosis, I do a lot of Pilates (at least 2-5 sessions per week) in addition to teaching and teacher training. And there are a lot of Pilates exercises that I will need to stop doing or radically modify if my bones are weak.

The issue of osteoporosis comes up a lot at balanCenter Pilates. Our clients are mostly caucasian women over 50, many of whom are breast cancer survivors. On the whole, these beautiful active women all look pretty healthy. They have decent posture, play tennis and golf, walk a lot, and really try to eat well. They have access to the best doctors, the latest medical treatments, and the most cutting edge gyms, personal trainers, and Pilates studios. Even so, most of them have low bone density--osteopenia and osteoporosis (more on the difference in a minute) and the majority move on a daily basis in ways that put them at greater risk of fracture--EVEN THOSE WHO HAVE GONE TO CERTIFIED PILATES TEACHERS AND PERSONAL TRAINERS. My purpose here is to educate you, my dear readers, about osteoporosis so that you will know what to do and not do for yourselves and those you care about.

II. Definition of Osteoporosis

Basically, osteoporosis means porous bones. In the Greek it translates as passages through bones. (This makes perfect sense if you look at the images of osteoporotic bone as opposed to normal bone.) Osteoporosis is a silent disease in that there is no physical sensation associated with it. Some people experience back, neck, or joint pain with fractures, but most do not. Even so, Americans experience 1.5 million osteoporotic fractures per year.

Throughout our lives our bones constantly change. This process is actually called bone remodeling, where old bone is resorbed into the body with the help of cells called osteoclasts at the same time that new bone is being laid down by osteoblasts. The human skeleton reaches its maximum bone mass (amount of bone tissue) and density (how tightly it is packed) around ages 20-30, after which bone removal begins to occur faster than bone production.

Bone density is measured by comparison to that of this healthy young adult; this is called a T-Score. Normal Bone Density is defined by the World Health Organization as density within -1 standard deviation (SD) of the 20-30 year old norm (10-15% bone loss). Osteopenia, or low bone density, is defined as within -1 to -2.5 SD (15-25% bone loss). Osteoporosis is defined as lower than -2.5 SD (over 25% bone loss). You may also have heard of a Z-Score, which is a comparison to the average bone density of individuals in your age group. Primary osteoporosis is caused by either a natural estrogen deficiency or age; secondary osteoporosis is caused by certain medical conditions (see box). Osteopenia should be treated like osteoporosis in terms of preventing future loss. Once you have been diagnosed with osteoporosis, you have a documented severe and established loss of bone.

Note here that while bone density testing is typically done at several sites such as the hip, wrist, or spine, these findings should be generalized to your entire skeletal system. Many clients have told me that I shouldnt worry about their spines because their osteoporosis was only in their hip--WRONG! If you are losing bone you should be worried, period.

III. Prevention and Treatment of Osteoporosis

All sources are in agreement that getting enough calcium, magnesium, and Vitamin D combined with proper exercise is necessary to prevent osteoporosis. Even once you have a diagnosis, these factors will help decrease your likelihood of fracture and prevent further bone loss. On the medication front, biphosphonates such as Fosomax and Actonel have been shown to increase bone density and reverse bone loss.

Our bones hold 99% of our bodys total calcium. If we do not ingest enough calcium to assist the bone remodeling process our system takes it out of the bones themselves. Therefore, adults over 50 should take 1200-1500 mg of calcium per day along with 600-750 mg of magnesium and 400-600 mg of Vitamin D to assist absorption. As our bodies do not hold on to the calcium we dont use, it is better to spread your calcium supplements over the course of the day. And always take your pills with 8 ounces of water.

In addition to nutrition and medication, the best thing we can do for our bones is exercise on them. Wolffs law states that bone becomes stronger in response to increased stress i.e., exercise. Weight bearing activities such as walking and dancing are done upright and require our bones to fully resist the forces of gravity. Maintenance of this density is accomplished by long term routine loading on our bones, which will revert to pre-training density when exercise is discontinued. To best maintain what you have and avoid more loss, follow these rules:

DO weight bearing exercise on your feet every day. The other day an osteoporotic client in the studio asked why she should not continue doing the plow in yoga, since being in that extreme flexion was certainly bearing weight on her spine. Weight bearing in our case means standing on your feet! Rolling on your back not only doesnt cut it, but can actually cause vertebral fractures. Just say NO!

DO work on your balance in standing as often as possible. The less you fall the less your risk of wrist or hip fracture. Standing yoga postures and PhysicalMinds Standing Pilates can be very helpful here.

DO resistance, cardiovascular, and flexibility training within safe guidelines.

DO focus on spine and torso extension. As our bodies give in to gravity we begin to round forward. It is crucial that we work constantly to stay upright with a gentle squeeze of the shoulder blades and a lovely lift of the breastbone.

DO be careful sneezing and coughing. Many fractures happen during forceful coughing and sneezing. Try to stand or sit with your back against something for support.

DO NOT flex your spine forward. Dont bend over to tie your shoes or pick something up off the floor. Dont round forward while getting in and out of bed. And never roll around on your spine! Yes, spinal flexion is healthy for healthy bones. It is completely contraindicated for low bone density. As you can see in the fracture image, the micro fractures occur in the front of the spine and are irreversible. Do you want to look like a round ball all the time for the rest of your life? I know I dont!

DO NOT roll around on your spine. I know, Im saying it again, but this is so important! And I am scared to tell you how many clients with osteoporosis I have seen who have been given extreme flexion exercises by certified Pilates teachers in studios.

DO NOT forcefully twist your spine. Be nice to your spine. Forceful torsion will hurt.

DO NOT do sit ups or crunches! Remember the flexion discussion above? A good Pilates teacher can show you many abdominal strengthening alternatives.

DO NOT take your leg far out to the side of your body (abduction). This where many a hip fracture has occurred.

Now, is there a chance that you could do all of the movements I say are bad for osteoporosis and be fine? Sure. But why take the chance? The death rate after hip fracture is 20% for women and 30% for men. Spinal fractures can cause the dowagers hump which is uncomfortable, unattractive, and unhealthy. And osteoporotic fractures cost this country $14 billion per year in medical costs, expected to increase to $62 billion by 2020.

I know that even with all this information some of you still dont buy it. You are still sitting there thinking I just have a little bit of osteoporosis, or I only have it in my hip, or I dont have osteoporosis very badly. Or you know that I am right and yet you still love the feeling of rolling and flexing through your spine. Well, I love those exercises too. I am horrified at the thought of never doing the open leg rocker or curling up my head for the Hundreds. But you had better believe that if my bone density is low I will stop those exercises and focus only on those that will help me stand tall, reduce my risk of fracture, and help build my bones! Until next time, be strong and safe.