To Twist or Not to Twist? Dr. Loren Fishman Weighs in on Safe Yoga Postures for Osteoporosis in the New York Times

Yoga U presenter Dr. Loren Fishman was recently featured in a series of blog posts in the Booming section of the New York Times. Dr. Fishman was asked to respond to questions from the 50+ crowd interested in starting yoga, but who were unsure how to start. 

One common concern? Safe yoga postures for people with osteoporosis. Which yoga postures are recommended for people with osteoporosis, and which should be avoided? Dr. Fishman writes:

Mehrsheed Sinaki from the Mayo Clinic showed long ago that forward bending does produce more osteoporotic spinal fractures. Once you have one fracture, your spine is inclined even more forward, and the risk of a second fracture is even higher. These fractures are not life threatening, but they are usually quite painful. And a second fracture raises the likelihood of a third.

So forward bends should be done only with a straight back, or, if you’re not confident you can do that, stick with Supta Padangusthasana: lying on your back and raising your straight legs as far as possible. Your back will stay straight, thanks to gravity and the good carpenter that made the floor, but you’ll get all the benefits of a forward bend, and some of the good that comes with inversion.

While there’s general consensus that forward bending with a rounded spine is contraindicated for people with osteoporosis, there is much greater controversy when it comes to the safety of yoga postures that involve twisting the spine. Here Dr. Fishman takes a stance against what appears to have become common wisdom in the osteoporosis community: Many fitness instructors, and some yoga teachers, caution against doing twists if you have osteoporosis. However, Dr. Fishman notes:

The only research papers addressing this in the literature that I have found actually say the opposite: that [twists] are safer than forward bends.

I recommend going along with the literature. But there is another reason not to avoid twisting: If you think about it, there are very few other ways to strengthen the vertebral bodies.

In a clinical trial I am conducting to examine the possible benefits of yoga for osteoporosis, more than 500 people have used my 12-minute DVD with what I consider safe and helpful yoga poses for osteoporosis. This amounts to over 60,000 hours of people, mainly with osteoporosis or osteopenia, doing three twists, without even one report of a fracture.

I repeat, there are no reports of fractures. Many of these people have before-and-after X-rays of the spine that have, at least so far, revealed no new fractures either. This is important because in spite of their often painful nature, some vertebral fractures are “silent.” So twists appear to be safe, provided you keep your back straight. Of course, until the trial is over no definitive conclusions can be stated, but the data so far are promising.

Carol Kruckoff, who teaches the Yoga for Seniors program at Duke University, and who Dr. Fishman referred to as one of the leading yoga teachers recommending against twisting postures, wrote a clarification to the New York Times to follow up on Dr. Fishman’s article.

“Rotation is an important movement for flexibility and function, and I do not advise those with compromised bone to avoid twists. Rather I follow the National Osteoporosis Foundation guidelines in cautioning against “twisting of the spine to the point of strain” and encourage students with osteoporosis to avoid extreme twists, to keep rotation in the mid-range and use a gentle quality of motion.”  ~ Carol Kruckoff

If we may add our two cents, the problem with the NOF recommendation is that twisting “to the point of strain” is so vague as to be open to pretty much any interpretation. Is twisting to the point of strain moving until one feels the muscles engage in a stretch? And if so, what constitutes the point of ‘strain’ in the stretch? And, since, as Dr. Fishman explains, the tug and pull of twisting movements is an important part stimulating bone strength in the intervertebral bodies, will that happen at all, if people stay within an overly cautious range of twisting movement?

When Dr. Fishman and Ellen Saltonstall teach their online course on Yoga U on Yoga for Osteoporosis, the safety of twisting movements for people with osteoporosis invariably is the first question that comes up. In the fitness and yoga community, it has become a common advice to ‘err on the side of caution’ and recommend people with osteoporosis to avoid twisting the spine altogether, even in activities of daily living. In our local classes, teaching people over 50, many students with osteoporosis or even osteopenia have told us that they have been told to avoid any kind of twisting movements.

Despite performing a literature review of all published studies on safe movements for osteoporosis (paper to be published in the June issue of the International Journal of Yoga Therapy), we have been unable to find a single study that indicates that twisting of the spine in yoga postures or normal activities of daily living is associated with increased fracture risk.

On the contrary, regular twisting of the spine is essential to keep the vertebrae strong, to retain the range of motion that we need to undertake activities of daily living, for retaining balance, and for the ability to catch ourselves when we trip to avoid a fall.

As Dr. Fishman once commented while teaching the Yoga for Osteoporosis course on Yoga U, if we tell women to avoid any kind of movement of the spine, we will create a generation of candy cane women, with such limited range of motion that they are liable to trip, fall and break at the minutest obstacle. We here at Yoga U applaud Dr. Fishman for his vision and clear-sightedness and for sharing his experience and expertise in this important debate.