When I set up The Osteopathy & Pilates Studio 15 years ago I had a very definite vision for my business. I wanted to provide a place where female issues were at the forefront. It seemed to me that topics relating to women’s health, especially those relating to older women, were seldom spoken of and so it was my plan to provide a nurturing environment where women had access to the most up-to-date advice on matters relating to them.
Osteoporosis is a condition that has a 5:1 female to male ratio and last month the National Osteoporosis Society (NOS) brought out a new statement on how physical activity should be used in the treatment of osteoporosis. Until this statement the message had been very confused, with many doctors advising their patients to stop moving for fear of doing more damage. This new statement sets out clearly that exercise is necessary for maintaining strong bones and there is no evidence that moving well will cause a worsening of the condition.
For Pilates teachers all over the country this statement has been like a roll down articulating smoothly through each vertebra (that’s an in-joke that means we like it). It always seemed nonsensical to have medical professionals refer their osteoporotic patients to us, when the official advice was to limit their movement.
The aims of this piece are to explain a few facts about osteoporosis, discuss the advice suggested in the NOS statement, and relate this to how we work at The Osteopathy and Pilates Studio.
Osteoporosis is a condition that causes bones to weaken, eventually leading to fractures and a change in the body’s shape. It is mainly associated with post-menopausal women, but men and younger women can also be affected.
Osteoporosis will affect all bones, but it is most commonly diagnosed after a fracture to the wrist, spine or hip. A fall causing a broken hip or wrist might alert a health professional to test for the condition. The loss in height that we associate with aging is generally caused by osteoporotic changes to the spine, especially if it is coupled with a kyphosis.
It is thought that one in three post-menopausal women in the UK has osteoporosis and many of them don’t know it.
Our skeleton is a living, changing structure, made up of protein, water and minerals. It acts, not only to give our body a shape and allow movement, but also as a bank for calcium and phosphorus - two minerals that are critical for life; both play a part in many vital functions of the body, but are particularly important for nerves and muscles. Calcium must be kept at a constant level in the blood and small amounts of it are continually being exchanged between the skeleton and extracellular fluid. This balance is managed by a complex system of hormones. Throughout our life bone is continually being formed and reabsorbed; but it is only when we lose more bone than we make that our bones become weaker.
The skeleton is still developing into our early twenties and so it is important to have a good diet and take exercise in our growing years. Our bones are at their strongest once we have fully matured and this strength is dependent on our genes, and on our health through those early years. Generally, if we eat and exercise sensibly (and don’t smoke), then the calcium reserves stay pretty similar throughout our fertile years. It is when women reach menopause and their oestrogen levels reduce that the problem of osteoporosis can occur.
Both male and female sex hormones have an effect on bone growth. Oestrogen stops the breakdown of bone and may also stimulate bone formation. As menopause occurs, oestrogen reduces and therefore bone strength decreasesat a rapid rate. Interestingly, most older men have higher levels of circulating oestrogen than post-menopausal women. This is because testosterone is converted into oestrogen in fat cells and therefore their bone health is maintained whilst testosterone levels are sufficient.
We have understood the importance of loading bone since Julius Wolff wrote about The Law of Bone transformation (now known as Wolff’s Law) back in 1892. He wrote that the bone grows and remodels in response to the forces placed upon it. Today we understand that a mixture of genetics, nutrition and mechanical force determines the strength and shape of bones. Muscles contracting against the bone, or the force of gravity as we impact with the ground - these actions stimulate more bone to grow, resulting in changes to our skeleton throughout our life as we use our body in different ways. Examples of this can be found in tennis players, where their dominant arm has a thicker outside layer of bone than the non-dominant arm.
Bones will weaken if they are not subjected to adequate amounts of stress for adequate amounts of time. Astronauts lose up to 10% of their bone mass in just three months of micro-gravity. The greatest bone loss occurs in weight-bearing bones such as the calcaneus (the heel bone), the tibia, and the femur, with far less change to the upper limbs. Patients who are bedbound also suffer bone loss. Paraplegics lose bone in their lower limbs, whilst quadriplegics lose bone strength in both their upper and lower limbs. Victims of a stroke lose bone strength in the limb affected by the stroke; the most likely reason for this is the reduction in pull from the muscles affected by the condition.
The NOS used three words to relay their message to health professionals at their most recent conference in December - STRONG, STEADY and STRAIGHT. The word STRONG was selected to encourage weight-bearing exercise with impact and muscle resistance. STEADY was chosen to represent balance and muscle strength to avoid falls, and STRAIGHT was used to indicate the importance of back muscle strength for good posture and the reduction of pain in those with vertebral fractures.
Physical activity was the number one take-away message from the conference, and this activity should be varied. The evidence now suggests that impact exercise - such as running, jumping and dancing - contributes to STRONG bones; but the important message is to start slowly and increase steadily; this needs to be a long-term commitment. Brisk walking (where you are slightly out of breath) is suggested for those who are less active or have vertebral fractures. The recommended time for this is 30 minutes each day.
It is estimated that one third of people over the age of 65 fall every year. 95% of non-vertebral fractures and 20% of vertebral fractures occur after a fall. With this in mind, the NOS advises balance training to help keep us STEADY. This is valuable for all people with osteoporosis, but particularly for those over 65 who don’t exercise regularly. Balance and muscle strength exercises - such as those done in Pilates, yoga, tai chi and dance - are recommended at least twice a week.
The bone at the front of the spine is naturally weaker than that at the back of the spine. Much of modern life takes us into a flexed position (looking at our phone, slumping at the computer, sitting on the sofa, driving the car) which puts more load on this already weakened area. For this reason, the NOS put an emphasis on STRAIGHT in their recommendations. Strengthening the back muscles will reduce the load on the anterior structures of the spine, improving posture, and possibly relieving pressure on painful structures caused by vertebral fractures. It is recommended that exercises targeting the back are performed at least twice a week.
The advice for those already doing Pilates is to keep doing what you are doing - just ensure your teacher is aware of your condition and keep length in your spine when flexing, so you don’t collapse through it.
All over 50s classes at The Osteopathy and Pilates Studio are designed with the presumption that some participants have osteoporosis. They are themed around weight-bearing exercises to load the bones, back-strengthening with length, balance, and stretch. Many other classes at the studio are also suitable for participants with the condition. Our timetable indicates these classes with (O) or (Oa) next to the ability level. (O) classes are designed for clients with the condition and (Oa) classes have exercises that can be easily be adapted. It is important that the teacher knows of your condition so that she can guide you correctly.
All classes are aimed at improving our daily function. The creation of length through the body is continually emphasised – this counters our daily slumping and reduces the stress on the front of the vertebrae while we exercise. The hip is moved through multiple positions, which not only strengthens the hip muscles, but also loads all parts of the head of the femur. As falling onto an outstretched wrist is the cause of fractures in many younger osteoporotic people, classes generally involve all fours work, as well as hand and wrist strengthening exercises.
We will always do our best to ensure our clients exercise safely at the studio, but our most valuable gift to you is our knowledge of movement and how the body functions. This lasts far longer than the hour or two you spend with us in class. It is something you can take home and use for the rest of your life. With this in mind, I ask you to remember that bones need movement, and don’t benefit from long periods of inactivity. Sitting in a flexed position for sustained periods is possibly the most damaging thing we can do to our spines if our bones are weak. One or two hours of Pilates exercise will be completely undone by three hours of sofa slumping in an evening. So, get up regularly, go to the loo, and practice your pelvic floor exercises. Make a cup of tea (herbal, of course) and jump ten times while the kettle boils. Find physical activities you like and create weekly routines to do them for at least four hours per week. Make them varied to include some STRONG, STEADY and STRAIGHT exercise, starting slowly and then increasing the intensity and load when you are ready.
The advice from the NOS is to do exercise under the supervision of a professional with knowledge of the condition. This will ensure you work safely at an appropriate level whilst keeping the exercises varied and motivating. So keep coming to The Osteopathy & Pilates Studio – and don’t forget to bring your friends with you!