This is not a concise blog with handy pictures.
This is me giving as much information as I can because I am still seeing Yoga teachers the world over recommending this protocol to people with low bone density. I wish Yoga could reliably increase bone density, but to claim it does is to fly in the face of everything we know about bone turnover stimulus.
What follows in an excerpt from my Yoga for Bone Health training manual. Thus far I have kept it only available to those who pay for the course, because a lot of work went into examining the study, double-checking my thoughts with a researcher etc. But I am still gobsmacked at how many teachers still recommend it, especially when a diagnosis of osteopenia or osteoporosis is serious, and the people affected need information and protocols that are safe and reliable.
Here we go:
“There is an obvious plus for yoga and BMD (bone mineral density), which is that it has been proven to reduce stress and stress is a considerable risk factor for the development of osteoporosis. But though it must in some way contribute to BMD, there is not enough rigorous and repeated evidence to definitively support the use of yoga exercise to prevent or reverse osteoporosis. Results are conflicting, and even logic suggests that it would not be sufficient to treat osteoporosis.
You will most likely have heard about a study by Yi-Hsueh Lu, Loren Fishman et al ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4851231/ ) that suggests that a particular 12 yoga postures were found to increase bone density in the spine and femur (not the hip). Many yoga teachers use this as “proof” that yoga increases bone density in people with osteoporosis. However even the study authors acknowledge limitations and that much more study needs to be done.
In addition,
Holes in the study:
- In my opinion, the biggest issue is that subjects were required to continue their pre-study dietary, exercise and medical regimes which may have had a significantly positive bearing on their scores over the course of the study. This means that there may have been SIGNIFICANT compounding factors to BMD improvement like HRT, supplementation, nutrition and other forms of exercise. The job of research of this kind is that it MUST ISOLATE THE INTERVENTION (i.e. “this, and only this could have produced the results seen.”).
- Some very common fracture sites were not targeted so even if the evidence was watertight for the areas studied we cannot say that Yoga improves BMD body-wide based on this study.
- The study was only on 12 postures, so if it was watertight we could only say that these 12 postures, not Yoga as a whole, improve BMD.
- Full DEXA scan reports were only available for 43 of the 227 subjects who were considered sufficiently compliant to be part of the measurements taken and entered into the data.
- The study admits to using “qualitative bone quality measurements” (essentially interpretation) yet talks about quantitative (numbers) results. The very proof of whether bone density is low or high as listed in this study is a quantitative measurement. Bone quality is also a precise measurement which was not performed. Qualitative study is a respected type of research, potentially of great value to patients with osteoporosis regarding their care for example. Paragraphs in the study refer back and forth from BMD to bone quality, making for confusing reading. So even if the qualitative part is in regards to quality rather than density, this is a red herring, as it quite separate from what the study purports to prove.
- Results for the hip region were hugely varied, so much that the study could not conclude that the regimen supported increased BMD in the hip. This means that the range of effect will likely have varied from loss of BMD in some subjects, to very significant gain in others.
- The study acknowledges the need for it to be repeated with “improved bone quality measures”.
- The study has not yet been repeated or improved with the specific improvements that it lists itself as being required to enable us to say that Yoga can be a route for reliable bone-building, and with some of the self-stated limitations ironed out that would make it a study more worthy of the headlines it has created.
- The study was funded by Fishman and is used to support the selling of his protocol and his teacher trainings.
Concerns with the regimen:
- The study claims to have selected poses for their safety, yet despite more than gentle-to-moderate twisting being contraindicated where osteoporosis is present, 3 twisting poses were included, 2 which use manual force. Fishman has defended this saying that twisting is the only way to achieve muscular stress on the vertebral bodies (though this is not the case). Twisting is indeed important to maintain in the spine, even with osteoporosis, but 2 of these involved binding or levering with the hands. If we want to strengthen the spine safely using twisting, we need the muscles of the back to do the twisting, not the arms.
- The DVD labels the different options as being for Osteopenia, Osteoporosis and Classical, yet in the study they are called elementary, intermediate and classical with participants told to progress as far as they “safely” could. These participants went on to do these poses for two years on their own, being trusted to know what felt safe while having a disease that is known to be “silent”, i.e. you can’t “feel” when a movement is not safe for your osteoporosis.
- There are some good options given for people with osteopenia and osteoporosis, but in the “elementary”/low bone density options for:
- Virabhadrasana II and Parsvakonasana are sitting on a chair which would offer no weight bearing stress to the femur or hip, making it almost valueless for those with osteoporosis.
- Salabhasana option reduces the muscular effort on the target muscles of the back by (unnecessarily in my opinion) placing the hands on the ground.
- Setu Bhandasana option (fully supported) though safer for the neck, has no muscular engagement at all so could not possibly improve muscular strength (needed to stimulate bone).
- Supta Padangustasana option looks more risky in terms of students being tempted to round the spine because they are upright (sitting in a yoga chair) rather than having the floor to rest their spine on and give feedback as to their spinal position. In my opinion Supta Padangustasana is safer on the floor, cueing osteopenic and osteoporotic students to avoid lifting the head and shoulders and to avoid pressing the lower back into the floor will cut out any unconscious spinal flexion.
- Twisting options for osteoporosis are sound, but the participants were told to try to work towards the “classical” version during their time doing the study. It is not clear whether those with osteoporosis were told never to aim for these twists with binding which would be very risky.
- One pose (supta padangustasana) used a strap for those with low BMD, which would reduce the need of muscular engagement to perform the pose because of the ability to do it passively rather than actively, relying on the strap to hold the leg.
- We know that bone needs surprises, and ceases to respond to the same stresses when applied over and over, so even if this regimen of 12 poses over and over did work for a while, it would become less effective over time.
Better news is that a meta-analysis into the effects of Pilates and yoga on bone density found that these interventions resulted not in increased bone mass, but in a maintenance of bone in postmenopausal women. At a time when we would expect to see bone loss, this is encouraging. A fly in that ointment though is that better results were evident from Pilates than from yoga (Fernández-Rodríguez et al, 2021 https://pubmed.ncbi.nlm.nih.gov/33961670/ )” From Yoga for Bone Health teacher training manual by Niamh Daly of Yinstinct Yoga
Please credit me if you are reproducing this information.
Sincerely,
Niamh Daly