So, Pilates and Bone Health : what’s the deal?
Well it is a big one: As we age we need to work at bone health: Guard against losing strength and bone mass. How can Pilates help with that?
Osteoporosis, or Brittle Bones is a health problem waiting in the wings for us all in the UK, especially as we age and especially if you are female
The thing about Osteoporosis is that it can be silent, becoming a problem if you break a bone, as a result of the Osteoporosis. The most likely factor that precipitates this is falling but you can get stress fractures as a result of chronic misalignments of the bone, or of excess stress placed on the bone on a day to day basis.
Recent data from England and Wales counts 180 000 fragility fractures annually. A fragility fracture is one where the cause is the fragility of the bones due to decreased bone density, not fragility of the person. Mostly (but not always) they are in the wrist, thigh bone or spine and generally as a result of a fall, although not always. Spinal vertebrae can fracture spontaneously.
The fractures are costly to the NHS. To the person who has experienced it, fracture is painful and awkward. They can lead to fear of movement, chronic pain and impacts on daily living. One fracture is a risk factor for further fractures and for the most frail, a significant proportion of people don’t survive the fracture at all
So there are 2 separate issues here and that can be confusing: one is the Osteoporosis, one is the broken bones. Read on though. Pilates can help your bone health.
What is/are Brittle Bones
The NHS website defines Osteoporosis very simply
Osteoporosis is a health condition that weakens bones, making them fragile and more likely to break. It develops slowly over several years and is often only diagnosed when a fall or sudden impact causes a bone to break (fracture).
The disease is diagnosed by assessing the density of the bone using a DEXA Scan. The scan is almost always done following a bone fracture and is a specialist form of X ray scanning.
Osteopenia is the stage before osteoporosis. It differs significantly from Osteoporosis, even though they kind of sound similar
Here is what the NHS says:
This is when a bone density scan shows you have lower bone density than the average for your age, but not low enough to be classed as osteoporosis. Osteopenia does not always lead to osteoporosis. It depends on many factors.
If you have osteopenia, there are steps you can take to keep your bones healthy and reduce your risk of developing Osteoporosis, which is kind of good news albeit wrapped up in the difficulty of receiving the diagnosis
What are the Risk Factors for developing Osteoporosis
Some risk factors are “just there” and we can’t really do anything about them. Here are the major ones
- Your age. As we age our bones weaken
- Your gender. Women are more at risk
- Going through the menopause
- Certain medical conditions. Chronic kidney and liver disease, Rheumatoid Arthritis, and food absorption conditions such as Crohn’s , Colitis, Coeliac disease,
- Certain endocrine/hormonal conditions including Diabetes
- Having a parent with Osteoporosis
- A history of taking oral steroid medication
However some risk factors can be modified and this is where Pilates comes in!
- Smoking
- Alcohol consumption
- Having a body mass index of less than 18.5 kg/square metre. In short, being borderline or actually underweight. You can argue whether or not this is modifiable of course. It is theoretically , but perhaps not in practice
- Activity Levels and exercise
- Diet, and most importantly, beyond overall healthy diet: levels of Vitamin D and Calcium.
So, exercise is a modifiable risk factor to reduce the onset or severity of the disease that is Osteoporosis, or, for that matter, Osteopenia. It is not a cure. To reduce the severity of the disease or combat the severity of the disease needs a multifactorial approach and the most important one of all is drug treatment. Basically the drugs work to stimulate new bone growth, or prevent the breakdown of existing bone. Some treatments are a combination of both of those approaches
The UK based Royal Osteoporosis society has produced an assessment tool for you to check your own risk for Brittle bones and you an try it out here
From here on I’m going to mix and match a bit, because there are different categories of people who have an interest in their bone health and using Pilates. It is really hard to talk separately in one article, about all these different groups who have slightly different needs. Please do forgive me for jumping about.
Different types of people are interested in Bone Health & Pilates
Our categories are, firstly people who have their Osteopenia or Osteoporosis diagnosis who want to use Pilates to achieve bone health positive changes to their body. This could be men or women. The change could be bone mass and it could be strength of the bones and muscles. Next we have groups of people who have no diagnosis : women who are entering, going through or who have left the menopause. There are younger women who have other risk factors like a family history of early menopause or who have a history or on going issues with eating disorder.
What will Pilates actually do to help Bone Health?
Well lets look at the wider context: low levels of physical activity and low levels of exercise are a risk factor for developing brittle bones. So firstly we might be doing Pilates to help prevent that. It is important to bear in mind that a Pilates class is beneficial in the context of enduring and ongoing levels of good physical activity.
The Government advises 150 minutes of moderate activity per week or 75 of vigorous activity per week. I was gratified to find that Pilates is included in the list of strength training modalities. It does not count as cardio or the kind of exercise that makes you a bit out of breath, or increases the body’s impact on the ground . That would be things like jogging, running, Zumba, aerobics, sporting activities. The full guidelines are widely available online and are outlined on the NHS website here
Secondly if you have a diagnosis of Brittle bones then you want to firstly get your bone density up and prevent fractures. These are 2 separate things and exercise in the main, targets the latter not the former. It helps reduce fractures but doesn’t, for the most part, actively address bone density directly
The benefit of Pilates is mostly to reduce the chance of fractures
This is quite an important point. We aren’t doing the Pilates to increase the bone density, although it may. We are doing it to impact the strength of the muscles and the bones. It is an all round benefit to make the body stronger, more resilient, less prone to falls, better able to do everything we want it to do.
As well as strength and resilience of the bones, Pilates will help to improve balance and flexibility, which in turn reduces the risk of falls, which in turn reduces the risk of fracture. Not only that, but regular exercise improves stamina, which again reduces fall risk, and also gives us more confidence to engage in more and more varied activity.
Fundamentally we do want to reduce fall risk. Osteoporosis is a silent disease. Until you fracture a bone you may not know you have it. If we reduce the fall risk you impact the chances, massively, of Osteoporosis causing real harm to your lifestyle
In short, Pilates will deliver strength and stamina of the whole body and improvements in balance . Also, joint mobility and flexibility which, along with balance also reduces the risk of falls.
Can’t you do that with other types of exercise?
Yes you can! You can go to the gym and lift weight. Not only that, but deadlifting, over head press, back squats and pull ups are something of a gold standard to help strengthen bones. This is because of the increased load that you lift over and above body weight, light hand weights or exercise bands. The strongest evidence base for exercise to actually increase bone density is on the low side (6-8) repetitions at high load strength training, combined in a weekly regime, with Cardio/aerobic exercise.
Pilates can’t quite replicate the sheer load involved with , for example deadlifting. however….
A well planned Pilates programme can deliver extras.
Pilates delivers direct benefits for bone health and also Pilates provides indirect benefit for relevant to people with Osteoporosis or who are worried about it
For me as A Pilates instructor this is dear to my heart, that Pilates can provide added extras
- Body alignment strategies to use in order to safely move about and avoiding over straining bones. When the spine is overly rounded is the spine position most likely to lead to stress fractures and we can train to avoid that as much as possible
- Safer lifting strategies, again, to avoid over using the spine
- You still do need to round the spine forwards. After all, how are you going to do your shoe laces up? There is a right way and a wrong way to go about it. Pilates will teach you that
- Joint mobility as part of a session so that all the joints move more freely, avoiding compression and over use of certain joints. The latter can increase the chances of compression fractures
- Flexibility training to simply enable the body to move with more ease.
- Optimising the breathing. Some of you will be saying “really Alison, are you going to try and shoe horn breathing into this too?” Well yes I am! The aim is to improve our breathing mechanics so that the ribs and upper back are more mobile and freer so that we can avoid the tendency of the upper back to curve forwards and stiffen up.
Can Pilates alone help me?
Sadly No. Pilates is not a one stop shop for Bone Health. You need to get moving and do some kind of aerobic exercise.
The good news if you are a post menopausal women is that it doesn’t need to be high impact, Examples of high impact would be running, HIIT training, Brisk walking counts. If you are younger then the high or higher impact type stuff is still recommended.
I have talked about walking in a recent blog post here https://www.pilates-leeds.com/walking-back-to-happiness/
Cycling, or all its benefits is not great for bone loading and I have talked about that too. I actively try to run and walk as an alternative to cycling some of the time and part of this is to get some regular bone loading for my thigh bones that is lacking in my walking and cycling regime. https://www.pilates-leeds.com/why-i-have-decided-to-walk-more-cycle-less-and-run-less/.
Is the Exercise Advice for Bone Health the same or different for Pre and Post Menopausal Women
Nothing is written in tablets of stone here, but the main evidence based take away is, that pre menopausal women benefit far more from weight bearing high intensity exercise. Jogging, running or high impact cardio. This category of people is better able to still significantly affect their bone density.
Post menopausal women are better served by a gentler approach although the evidence is not massively strong. It is sufficient though for post menopausal women to not worry if they feel unable to do high impact exercise
What if you are perimenopausal?
Peri menopause is poorly studied. Logically, if you are perimenopausal, high impact exercise would be fine in small amounts if you did it prior to this new phase in your life. Definitely avoid over doing it. For example don’t rush headlong in to a Half Marathon training regime if it is totally new unless you go very cautiously indeed. I’d advise caution if you are suddenly starting exercise after a history of doing little or none. Having said that, I would never say don’t do it, just take care. Money and time aside, there is probably some kind of aerobic exercise to suit each one of us.
What about recommendations for men?
This is a bit like the peri menopause:. The evidence base is insufficient to give specific advice for men and so most experts are using the recommendations for women. Basically, the big trials and research has often been conducted on women, and often looking at separate populations who are pre and post menopausal.
What kind of Pilates Exercises are Best for your Bone Health?
In the exercise world, the Osteoporosis world or even via NHS advice, it is not always clear if exercise advice is to increase bone density, maintain bone health, or maintain strength in general. I found it hard to work this out and I’m in the business
This link is from the Canadian equivalent to the Royal Osteoporosis Society. https://osteoporosis.ca/exercise-recommendations/
The exercise guidance is super gentle and really aimed at frail elders. It is a good example of how confusing the guidance is.
What if you are not that really frail person, thinking back to my list of the various categories of people who seek to sustain or improve their bone heath. Some people need far more intensity
In my new Pilates for Bone Health class, I plan to make the class as hard as possible but with the important caveat that alternatives are available for all or most exercises.
My mantra is: All Bodies and Everybody Welcome
Body weight bearing exercise, if possible: Squats and lunges . If not, a modified version, for example. sit to stand from a chair. Better still add a bit of extra load using exercise bands
Standing on one leg. This helps strength and balance and is a basis for other leg strength work To be honest, balance, balance and more balance work. I’d be inclined to give this as homework too!
Weight bearing exercise for the arms and shoulders: from an All Fours position and Side Lying/lifted position, or using exercise bands in standing.
Leg/bottom strength from lying on your back or side. In these positions we can also look at full body exercises: ones that integrate the whole body and lead to more supple movement, but without the intensity of your more typical full body exercise like a Plank or Deadlift
All exercises with sufficient intensity and repetition to induce a feeling of fatigue in the muscles
In all positions, spine mobility work but mostly avoiding forward bending (flexion) of the spine.
Specifically for the upper back: mobility & strength. This is pretty tricky but essential. Rather than work with back bends, “half back bends” or relative extension are safer and more suitable. In addition , for the help of the thoracic spine I’d work on breathing, to ensure the mobile thoracic spine and ribs and adequately and correctly expand and change volume. Most of us are tight in this area, leading to stress and misalignment which can increase the risk of rib and vertebral fractures
Foot mobility and strength work. I’m a big believer in foot work and in this context, mobile, strong supple feet, without doubt, reduce the risk of falls
Class Conundrum
Amongst the many eh!
Whether or not to include some basic drills that involve impact. This is generally way out of the scope of a Pilates session, unless you have access to Reformer sessions involving the Jump Board. This is lying down jumping, suitable for many people who wouldn’t normally jump but that is another story
So, impact: to do or not to do? I’m really conflicted to be honest. It is highly beneficial but not for everyone and not what you necessarily expect. I am referring to jogging on the spot for 30 seconds type stuff. It is very good bone loading activity. However, I’m unsure to the point that I plan to discuss the pros and cons with the group first. We may then very gently experiment with the impact related exercise for the legs, hips and pelvis.
Making an impact (with no impact just yet)
Here is a video clip I made last year talking about Squats and how to make them both easier and harder.
My new Pilates for Bone Health starts in April 2023. Visit the website for more details https://www.pilates-leeds.com/
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