Bone Up With Pilates

by Leslie Braverman on June 22, 2015

Pilates Education: Six Tips for Working with Osteoporosis 

The National Osteoporosis Foundation (NOF) declares that 54 million U.S. adults age 50 and older are affected by osteoporosis and low bone mass. To Pilates teachers these numbers are significant: It means that one of every two female clients—and one of every four male clients—who walk into a Pilates studio may have low bone density and or be at risk of a fracture.

Illustration of Osteoarthritis

Osteoporosis means “porous bone” and low bone density can lead to fractures especially of the spine, hip (neck of the femur) and wrist. It is called a “silent disease” because it often goes undiagnosed until a bone breaks.

Height Loss over time

Fractured bones in the spine can cause sharp pain—or there may be no pain. After several breaks, people may start to have a curved spine (kyphosis) and lose height.

Research shows consistent weight-bearing exercise—along with a healthy diet and lifestyle—is one of the best ways to prevent osteopenia (the early stages of osteoporosis) and osteoporosis and to build and maintain strong bones.

Pilates is often considered a safe exercise choice for people with osteopenia and osteoporosis. However, many exercises are contraindicated. Knowing what is safe for clients with low bone density may mean the difference between helping them build more bone density or increasing their risk of a fracture.

Here are six crucial tips for Pilates instructors:


1  Screen for osteoporosis

New clients can forget to mention that they have osteoporosis when describing their history. If you don’t ask this question on your intake form, make a point to ask. If they know they have low bone density, request a release form from their physician before you begin programming.

2  Omit exercises that could lead to fractures

Remove or modify any Pilates exercise that flexes the spine, combines flexion and rotation or loads the spine in flexion when programming for a student with low bone density.

Pilates saw exercise on mat

The Saw is a classic Pilates exercise. It is a great stretch for the spine and legs, but is not recommended for a client with osteoporosis. A healthy spine would be able to accept the increased compressive forces on the front surfaces of the spine during this exercise. A porous osteoporotic spine could fracture.

 Do No Harm

Valuable as exercise is for building bone density, wrongly directed exercise can be perilous for those with osteoporosis. 

A 1984 study (Sinaki & Mikkelson) tested four separate groups of people with osteoporosis. Group one did only extension exercises, group two only flexion exercises, group three extension and flexion, and group four did no exercise. Eighty-nine percent (89%) of group two participants subsequently had more wedge or compression fractures after the test—the highest incidence. By comparison, only 67% of group four participants (that’s the group that did no exercise) ended the test with fractures.

Conclusion: Forward bending, side bending and twisting movements will cause fractures for those with low bone density.

3  Teach excellent movement principles

STOTT PILATES® Five Basic Principles are always the first step to safe and effective exercise. Pay special attention to the way a student with osteoporosis is breathing. Encourage good three-dimensional, lateral costal breathing. Teaching neutral pelvic placement will help a student understand how to begin to do functional activities—such as picking something up from the floor—without rounding their back.

Hip hinge

Educating a student to bend from the hip instead of the spine will decrease their risk of spinal fractures and strengthen their gluteals and hamstrings to do the heavy lifting.

4  Set appropriate goals

Pilates is a low-impact weight-bearing exercise that incorporates muscle strengthening against resistance—the elements cited for building better bones. Setting intelligent goals and expectations will help you design a program that is safe, functional and effective for your client.

Pilates also optimizes the symmetry of posture, develops strength and muscle mass, and improves balance and body awareness. Enhance a client’s overall condition to reduce the risk of falls and fractures.

5  Educate your client

Teach your client how to modify their own exercises safely. Use a prop to sit straight, avoid exercises that are contraindicated for their condition, and teach them how to get off and on the equipment correctly. These are all strategic tools to help students care for their bodies in the studio and will translate to how they move at home.

Effective Pilates programming on split pedal stability chair for client with osteoporosis

Foot Press on Long Box on the Split Pedal Stability Chair is an example of a safe and functional exercise for students with osteoporosis.

6  Educate yourself

Feel confident and focused when you work with clients with osteoporosis. Annual continuing education workshops and STOTT PILATES Injuries and Special Populations taught by Melanie Byford-Young teach you how to use the biomechanical foundation of STOTT PILATES to create informed, safe and effective programs for this special population.

For more information about PNWP rehabilitative education workshops or studio client sessions, please contact us at 503-292-4409 or

Yours in health,

Leslie Braverman

Pacific NW Pilates is studio, school and fitness family under one roof. Click to learn more about our education courses and workshops, private studio sessions and group classes. Or call for details: (503) 292-4409.

{ 6 comments… read them below or add one }

Meirav August 11, 2017 at 11:02 pm

Thank you so much for sharing your knowledge:)

Meirav, mindful Pilates
Raanana, Israel


Leslie Braverman August 13, 2017 at 12:26 pm

You’re so welcome. Thank YOU for your interest.


Wendy schuchart November 10, 2017 at 7:24 am

What exercise can I give as an alternate to the saw while others are participating in the saw?


Leslie Braverman November 10, 2017 at 4:54 pm

Hello Wendy,

Absolutely. Teach your client a reverse saw. In other words, instead of flexing and rotating the spine, the client will lean on a slight diagonal—like Lean on the Reformer. Minimize the rotation and focus the exercise on controlling the spine in neutral or a slight imprint at that angle. You can have them place their hand on a ball to help support their weight. The opposing hip should follow the movement of the body and the ribs and crest of the hip should maintain the same distance during the lean, so it doesn’t become a side bend (lateral flexion). Hope that helps.

Thanks for your interest in Pacific Northwest Pilates.


Premkumar Harimohan March 18, 2018 at 10:34 am

Thks for the site. Could you post exercise advice/info for senior folks with muscular dystrophy who can’t stand up at all and have osteopenia and have practiced yoga spine bending and twisting postures as taught by a yoga teaching rehab medicine MD in NYC who may not have considered this aspect of safety to prevent spinal fractures.


Leslie Braverman March 18, 2018 at 1:40 pm


Thanks for your question.

In a healthy body, any exercise that fatigues the muscle within 10 repetitions at a high enough intensity will help build muscles and bone. So, for an individual who can’t weight bear and do traditional balance exercise to stimulate bone growth, resistive training can still be effective. There are many exercises that can be done to avoid spinal rotation and flexion and strengthen the legs, arms, develop core control, thoracic extension and overall body awareness. I would advise keeping joints (spine and otherwise) in neutral positions as much as possible to avoid the risk of fracture. With individuals who are particularly compromised and fragile, a guided and very hands-on approach may be best.
Nevertheless, exercise guidelines for individuals with muscular dystrophy are very specific and it’s important to seek the advice from a fitness professional (PT or otherwise) who is familiar with the specific characteristics of the person’s type of MD and who understand the process and patterns of weakness.
My advice would be to find a professional who has experience with patients with muscular dystrophy and who is versed in exercise programming that is specific to reducing building bone density and reducing the risk of fractures.
Here are some other references that may be helpful.


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