Osteoporosis (from the Greek “porous bone”) is a condition in which bones become less dense, increasing the risk of fractures. It is often called a “silent” disease because bone loss is not easily noticeable. Many individuals only become aware they have osteoporosis after a bone breaks or they experience vertebral fractures, leading to a rounded upper back.
Osteoporosis involves the demineralisation of calcium in the bones, resulting in decreased bone density at the cellular level. The femur (especially the neck) and the spinal vertebrae (especially the thoracic region) are most prone to bone loss and fractures. To diagnose osteoporosis, doctors typically order a bone density scan known as a DXA or DEXA.
Recognized by the World Health Organization as a disease in 1994, osteoporosis is a silent, progressive condition affecting both men and women, however women are particularly vulnerable to low bone density and are four times more likely to develop osteoporosis than men. Despite its widespread impact, osteoporosis is often underdiagnosed, even after fractures occur.
When bone mass is low but not low enough to qualify as osteoporosis, the condition is termed osteopenia, or “bone poverty.” Osteopenia does not always lead to osteoporosis, but it is a precursor that increases the risk of fractures, especially in the spine, hip, and wrist. Interestingly, more fractures occur in individuals with osteopenia than osteoporosis due to the higher number of people affected by osteopenia.
Globally, osteoporosis and osteopenia affect up to 200 million people worldwide, with an increasing burden as populations age; 1 in 3 women and 1 in 5 men over 50 will suffer an osteoporotic fracture. In the UK, around 3 million people have osteoporosis, leading to approximately 500,000 fragility fractures and around 70,000 hip fractures every year; a critical concern given that hip fractures have significant mortality and disability rates.
Key points about osteoporosis include:
- It affects the femur, vertebrae, wrists, and other bones
- Symptoms may include height loss and kyphosis (curved spine), but often there are no clear symptoms other than fractures
- Individuals may experience multiple fractures without knowing
- It commonly causes microscopic fractures in the hip, which makes breaks easier to occur
- 30% of people and half of all women who suffer hip fractures die within a year of the event, making it the most disabling type of fracture
- Whilst it is primarily caused by ageing, it can affect individuals of any age due to hormonal imbalances, dietary deficiencies, immobilisation, medication side effects, or tumours.
Risks & Complications
Osteoporosis and fracture risks increase due to various factors, with lack of physical activity and calcium deficiency being two major contributors. A wide range of conditions can elevate the risk of osteoporosis, including genetic disorders, rheumatic and autoimmune diseases, endocrine disorders (like thyroid dysfunction), digestive diseases, blood disorders, alcoholism, heart failure, multiple sclerosis, emphysema, chronic kidney disease, epilepsy, scoliosis, eating disorders, and depression.
For women, a significant drop in oestrogen levels during menopause leads to accelerated bone loss. In men, a decrease in testosterone, often starting around the age of 70, can contribute to bone density loss. Additional risk factors include a family history of osteoporosis, smoking, a small and thin body frame, a sedentary lifestyle, prolonged use of steroids, inadequate intake of calcium, vitamin D, or protein, or excessive consumption of sodium.
Common complications of osteoporosis include comorbidities such as cardiovascular disease and the side effects of associated medications, which can lead to fatigue and limit the ability to exercise. Medications for high blood pressure, for instance, may cause orthostatic hypotension (low blood pressure when standing quickly), resulting in dizziness or lightheadedness. For people with diabetes, complications such as peripheral neuropathy (nerve damage) can impair sensation in the feet and fingers, affecting balance. In older adults, these factors contribute significantly to the risk of falls.
In the UK, one in three people over 65 experience a fall each year, leading to broken bones or head injuries. Around 30% of falls result in an injury, and fractures are a common consequence. Similarly, in the US, one in four older adults fall annually, with 36 million falls leading to 32,000 deaths.
The Global Longitudinal Study of Osteoporosis in Women (GLOW), an international study aimed at improving care for osteoporosis patients, revealed that women with osteoarthritis experienced 30% more falls and a 20% greater risk of fracture than those without the condition.
Research shows that most osteoporotic vertebral fractures are not caused by falls or traumatic accidents, but by everyday movements like bending over, reaching, or even sneezing. Additionally, individuals who have already had a vertebral fracture are five times more likely to suffer another within the following year.
Fracture warning signs include persistent or worsening pain in the spine or hips. Symptoms are variable, but vertebral fractures (even microfractures) often cause pain or kyphosis (curved spine). Any ongoing pain should be addressed by a healthcare professional immediately. Treatments can include supplemental oestrogen and fracture management.
Medical Recommendations
Common medical advice for managing osteoporosis and osteopenia includes medication, calcium and vitamin D supplements, avoiding alcohol and tobacco, and staying hydrated by drinking plenty of water to help prevent falls related to dehydration. Additionally, patients are encouraged to engage in at least 90 minutes per week of weight-bearing and muscle-strengthening exercises.
For those with osteopenia, most activities can generally be performed safely with approval from a healthcare professional. However, for those with osteoporosis, it is essential to avoid certain exercises due to the increased fragility of bones and joints. High-impact activities, such as jumping rope or high-intensity step aerobics, are not recommended, as they may cause fractures. Likewise, intense cardiovascular exercises like running should be avoided. Caution is also advised for sports that involve rapid changes of direction, such as football, basketball, tennis, or rugby, as these can increase the risk of falls and bone fractures, particularly in the hips, thighs (femurs), and lower back. Golf also poses a risk, as the repetitive forward bending to retrieve the ball and the twisting motion of the swing can lead to small fractures in the spine over time.
When exercising whilst standing, it is important to have adequate support, such as leaning against a wall or holding onto a sturdy chair to reduce the risk of falls. Forward bending, especially with a rounded back, should be avoided, as it can compress the vertebrae and cause fractures. Additionally, deep spinal bends or hip bends may also place excessive stress on the joints and bones, raising the risk of fractures.
The best exercises for those with osteoporosis are frequent, gentle to moderate, weight-bearing activities that work against gravity, as these help stimulate bone formation. Exercises that strengthen the muscles supporting the spinal column, improve posture, enhance balance, and promote a better quality of life are particularly beneficial. Some studies also suggest that gentle spinal rotation may contribute positively to spinal health. Suitable exercises include walking, stair climbing, low-impact aerobics, resistance training (using weights or bands), and low-impact dancing. These activities place positive stress on bones, helping maintain or increase bone density.
There is no single approach that suits everyone with osteopenia or osteoporosis, however gentle weight-bearing exercises, such as yoga, can help prevent or slow their progression.
Osteoporosis & Yoga
Yoga can provide beneficial mechanical stress on bones through weight-bearing postures, helping to improve bone density not just in the legs but also in the arms. Many yoga poses involve bearing weight on all four limbs, and the combination of muscle contraction and stretching offers additional positive stress on the bones.
One particularly beneficial form of yoga for older adults is Hatha Yoga, which has been shown in research to improve upper body strength, core strength, flexibility, endurance, and even help manage pain and joint stiffness. A study by the Gait Study Center demonstrated that after nine weeks of Iyengar Yoga, participants had improved walking speed, lower limb flexibility, better balance, and increased confidence in their ability to move and avoid falls.
Those with osteopenia can usually engage in a wider variety of yoga poses, including those that involve more spinal movement, compared to those with osteoporosis. However, the extent of bone density loss should always determine the types of exercises and ranges of motion that are safe, and there are specific recommendations to follow. For individuals with osteoporosis-related thoracic kyphosis (rounding of the upper back) or fractures, yoga should be approached with extra caution.
Increased thoracic kyphosis puts individuals at higher risk for fractures in the thoracic vertebrae, which are particularly vulnerable due to low bone density. Forward folding or twisting when the spine is in a C-shape is especially risky, particularly for those with a history of fractures.
For individuals with advanced osteoporosis, certain forms of yoga posture (asana) may not be advisable. In such cases, non-weight-bearing activities such as swimming, water aerobics, and exercise biking may be safer options for exercise that the bones can tolerate. It is always wise to obtain your doctor’s approval to practice yoga and heed their advice on any movements to avoid.
General yoga recommendations for osteoporosis:
- Neutral-spine postures that focus on spinal alignment and core strength
- Spinal elongation through poses that lengthen the spine
- Poses that allow the hands to bear weight, strengthening the upper body
- Gentle backbends such as bridge, sphinx, baby cobra, and baby camel to reduce kyphosis
Movements to avoid for osteoporosis:
- Extreme ranges of movement, especially movements that involve spinal flexion (rounding the back) such as crunches or sit-ups
- Deep backbends, which can compress the posterior spine and the joints
- Extreme twists and side bends, as these can also be compressive
- Be cautious with inversions – postures like shoulder stands, headstands, plough poses, and crow pose are contraindicated
- Fast-paced flow yoga as it may increase the risk of falls and create excessive stress on the body
Those with varying degrees of reduced bone density can still practice yoga with great benefit. With carefully selected and sometimes modified postures, clients can maintain or even regain strength in both their muscles and bones.
Yoga also improves the ability of older adults to transfer themselves from the floor – a key component of independence as people age. Many older adults fear falling, but yoga can increase their confidence and feelings of overall well-being by improving balance, leg strength, and ankle range of motion. In a study at UCLA led by Dr. Gail Greendale, elderly women with hyperkyphosis (commonly known as dowager’s hump) participated in a yoga programme focused on posture and alignment. Hyperkyphosis is often caused by osteoporosis or age-related inactivity. By the end of the study, the participants stood taller and straighter, and showed increased leg strength and improved balance, both crucial for reducing the risk of falls in older adults.
By using yoga postures and breathwork therapeutically, we can help moderate the effects of ageing. Yoga teachers working with older adults should understand how to modify postures to accommodate any contraindications and be able to clearly explain both the postures and necessary modifications to ensure their students’ safety and success in practice.
Yoga Therapy in
Osteoporosis Management
In the UK, older adults aged 65 and over represent the fastest-growing demographic, and many are increasingly drawn to yoga therapy as an alternative and complementary approach to their health and well-being. Yoga therapists can provide a safe and supportive environment for this vulnerable group. While some older adults remain in good health, the majority face various health challenges – around 80% have at least one chronic health condition, and 50% have at least two.
Yoga therapists can work safely and effectively with the growing number of older adults engaging in yoga therapy. The most common health concerns among this population are sedentary lifestyles, cardiovascular disease, and osteoporosis.
The annual cost of fragility fractures in the UK is estimated at £4.4 billion, factoring in healthcare costs, rehabilitation, and long-term care. Globally, osteoporosis-related fractures result in substantial economic burdens, with worldwide healthcare costs in the billions. Yoga therapists offer a cost-effective and empowering solution to people with osteopenia and osteoporosis, helping to slow the progression of these conditions and assist in fall prevention and balance while improving overall health and wellness.
Yoga therapy also goes beyond just the physical practice of asana (postures). As Gary Kraftsow explains:
“A yogic model of practice evolves with age. In midlife, the focus is on stability through pranayama (breathwork), and later in life, the emphasis shifts to meditation and prayer, with asana and pranayama supporting these practices. By broadening our perspective of osteoporosis as not only a physical but also a cultural condition, we can offer students a deeper practice that addresses the root of their challenges”.
While genetics and ethnicity play a role in osteoporosis, there are also larger systemic factors at play, including workplace environments, diet, healthcare access, and social attitudes. These factors all contribute to the collective challenge of bone health.
From a yogic perspective, proper alignment and movement are critical to promoting bone health at all stages of life, but they are just one part of the holistic approach yoga therapy offers. Other aspects, such as breathing, sitting, and lifestyle also influence bone health.
Dr. Loren Fishman, MD, developed a 12-minute yoga regimen specifically designed to improve bone density. Published in the journal Topics in Geriatric Rehabilitation, his study highlighted 12 yoga poses aimed at reversing bone loss in osteoporosis. Dr. Fishman suggests that not only weight-bearing exercise is crucial, but that stretching also creates muscle forces that place positive stress on the bones:
“By pitting one group of muscles against another, yoga exposes bones to greater forces, and therefore might enhance bone mineral density more than other means. To date, with over 90,000 hours of yoga practised by individuals with osteoporosis or osteopenia, there have been no reported fractures or serious injuries among the 741 participants.”
The 12 poses in the study have been shown to be a safe and effective way to reverse bone loss in the spine and femur, with some indication of benefits to the hip as well. Additionally, there is qualitative evidence suggesting improvements in bone quality from regular yoga practice.
Osteoporosis is a serious health issue, and yoga therapy has the potential to play a vital role in supporting those affected by the condition. By bringing a thoughtful and compassionate approach to working with individuals with osteoporosis, yoga therapists can support their clients’ physical, mental, and emotional well-being.
Clients are encouraged to explore and address not only the physical symptoms of osteoporosis but also the emotional and social effects, such as fear, pain, breathlessness, social isolation, and body image issues. Yoga therapy provides a comprehensive approach to supporting individuals at risk of skeletal fractures and compromised bone health.
Yoga therapists are also in a position to be able to collaborate with other healthcare professionals to ensure the safety and best outcomes for their clients. Through this multidisciplinary approach, yoga therapy can serve as an integral part of osteoporosis care.
As the ancient Greek physician Hippocrates once said, echoed by Patanjali’s principle of ahimsa (non-harming), “Above all else, do no harm.” As a yoga therapist I am called to honour this principle.
Yoga therapy can become a key resource for those managing osteoporosis, providing tools to promote safe movement, better balance, posture, and increased body awareness as well as providing support, which is an essential aspect of healing.
In gratitude to my teachers Sandi Russom, Emily Smith & Mark Uridel for their invaluable expertise in this area; their teachings are peppered throughout this piece.
Sources & Resources
Fishman, Loren 12 minute yoga practice – video: sciatica.org/new-study
FitzGerald G, Compston JE, Chapurlat RD, Pfeilschifter J, Cooper C, Hosmer DW, Jr., Adachi JD, Anderson FA, Jr., Diez-Perez A, Greenspan SL, Netelenbos JC, Nieves JW, Rossini M, Watts NB, Hooven FH, LaCroix AZ, March L, Roux C, Saag KG, Siris ES, Silverman S, Gehlbach SH. Empirically based composite fracture prediction model from the Global Longitudinal Study of Osteoporosis in Postmenopausal Women (GLOW). J Clin Endocrinol Metab. 2014; 99:817-826.
INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 15 (2005) 97 Osteoporosis: An Opportunity to Serve Matthew J. Taylor, M.P.T., R.Y.T.
INTERNATIONAL JOURNAL OF YOGA THERAPY – No. 19 (2009) 69 Research Effect of Therapeutic Yoga on Balance and the Ability to Transfer from the Floor in an Older Adult Population Nancy Glenmore Tatum, MS, E-RYT 5001 , Charles Christopher Igel, MS2 , Rodney C. Bradley, MS, PT, RYT1
INTERNATIONAL JOURNAL OF YOGA THERAPY — No. 23 (1) | 2013 17 Yoga, Vertebral Fractures, and Osteoporosis: Research and Recommendations Eva Norlyk Smith, PhD, RYT-500,1 Anita Boser, LMP, CHP, RYT
Janisse, Marie. Correcting movement imbalances with Yoga therapy. International Journal of Yoga Therapy, 2001, no. 11, pp. 15–22.
Safe Yoga for Osteoporosis Training: http://www.sarameekspt.com
Smith, E. (2021) ‘The Principles of Adaptive Therapeutic Yoga’ (Lecture). YT106.13: Essential Applied Yoga Therapy. 17 August.
Uridel, M. (2022) ‘Osteoarthritis, Common Aging Concerns and Applied Yoga Therapy’ (Lecture), YT206.20: Essential Applied Yoga Therapy. 24 April.
Uridel, M. (2023) ‘Osteoporosis and Yoga Therapy’ (Lecture), YT306.09: Essential Applied Yoga Therapy. 2 November.
https://yogatherapy.health/how-can-yoga-therapy-help/well-being/