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Most Pilates instructors learn the same thing, and that’s avoid flexion for anyone with low bone density. That usually means no Roll Down, Roll Up or Rolling Like a Ball.
The rule is often presented as fact. Its main source is a 1984 study of 59 women. Only nine were in the flexion group, participants weren’t randomised, and 67 per cent of the group who did no exercise also experienced a fracture.
And it’s right, none of that makes deep, loaded flexion a good idea. But what it does show is that we need to understand the evidence first. Current UK guidance is more prescriptive than the blanket ban you may have been taught. The question isn’t only what to remove from a Pilates class, but what to add for those clients who need further guidance.
The rule began with a 1984 Mayo Clinic paper by Sinaki and Mikkelsen. The researchers followed 59 postmenopausal women with spinal osteoporosis and back pain. Clinicians had prescribed extension exercise to 25 women, flexion to nine, a mixture to 19 and no exercise to six. Spinal radiographs were compared over one to six years.
New wedging or compression fractures were seen in 16 per cent of the extension group, 89 per cent of the flexion group, 53 per cent of the combined group and 67 per cent of the no-exercise group (Sinaki and Mikkelsen, 1984).
The figures certainly makes you stop and think, which helps explain why the study has shaped teaching for four decades. Remember though, this was a retrospective comparison, not a randomised trial. The groups weren’t matched, clinicians chose the exercise allocation, and the group associated with harm contained only nine people. The study has never been replicated in a randomised trial and, for ethical reasons, is unlikely to be.
More recent observational evidence supports caution. A 2018 systematic review of adverse events in people with osteoporosis or osteopenia linked spinal-flexion activities, including some yoga postures and sit-ups, with greater vertebral fracture risk. It also stressed that these events were rare and that people with low bone density can take part safely in structured exercise.
So the direction of the advice still makes sense, but the certainty behind it is lower than what we’ve been taught.
The current UK position comes from a consensus statement published in the British Journal of Sports Medicine and developed with the Royal Osteoporosis Society. It’s organised around three ideas:
Strong means activity that supports bone strength. Steady means activity that reduces falls. Straight means protecting the spine, improving posture and managing symptoms after a vertebral fracture.
On flexion, the statement doesn’t say ‘never’. It recommends modifying or avoiding movements that involve sustained, repeated or end-range flexion. Smooth, comfortable rotation should be safe. People who already do Pilates can continue if they’re fit enough to manage it comfortably, with alternatives considered for exercises such as the Roll Down and Curl Up.
We can now rest assured that there’s little evidence physical activity causes significant harm, and its benefits generally outweigh the risks.
Being aware of the risks along with cautious teaching will lead to beneficial results. Teach a sound hip hinge, keep the upper back straight during bending and lifting, and include enough load to make a difference. It’s not about striping movement out of class, it’s about small modifications where necessary.
A meta-analysis found three Pilates and bone-density trials with at least six months of follow-up. Compared with controls, pooled differences were 0.019 g/cm2 at the lumbar spine, 0.012 at the total hip and 0.000 at the femoral neck. None was statistically significant, every confidence interval crossed zero, and only one trial was judged methodologically satisfactory (de Oliveira et al., 2022).
A broader review combined Pilates and yoga data from 11 studies involving 591 women. It reached much the same conclusion, with an effect size of 0.07 against controls. The authors described this as maintenance rather than failure. Maintenance has value when bone would otherwise decline, but it isn’t the same as building bone.
Telling a client that Pilates will improve her bone density is not what the evidence supports.
MEDEX-OP compared a genuine Pilates-based bone programme with high-intensity resistance and impact training, rather than with no exercise.
The trial randomised 115 postmenopausal women with a T-score of minus 1.0 or below. For eight months, they trained twice weekly in either a high-intensity resistance and impact programme or a low-intensity Pilates-based bone programme. Lumbar-spine bone density increased by 1.9 per cent in the high-intensity group and 0.1 per cent in the Pilates group. Both groups improved function, although the high-intensity group gained more in leg strength, back strength and the five-times sit-to-stand. Across all 115 women, there were seven adverse events which included four in the heavy-training group and three in the Pilates group (Kistler-Fischbacher et al., 2021).
A companion analysis of hip geometry was even clearer. Trabecular bone density at the total hip increased by 1.5 per cent with heavy training and fell by 1.6 per cent in the Pilates-based group. The authors concluded that the low-intensity programme was largely ineffective at the proximal femur.
Both approaches were safe. Only one produced a meaningful change in bone.
Here we look at the LIFTMOR trial which shows what carefully supervised progression can achieve.
The study included 101 postmenopausal women with a T-score below minus 1.0 and an average age of 65. They trained twice a week for eight months in 30-minute sessions which included five sets of five repetitions above 85 per cent of one-repetition maximum on the deadlift, overhead press and back squat, plus a jumping chin-up with a drop landing. The comparison group followed a low-intensity home programme.
Lumbar-spine bone density rose by 2.9 per cent, compared with a 1.2 per cent fall in the control group. Femoral-neck density rose by 0.3 per cent, compared with a 1.9 per cent fall. Femoral-neck cortical thickness improved. Participants gained 0.2 cm in height while the control group lost 0.2 cm, and compliance reached 92 per cent (Watson et al., 2018).
These were older women with diagnosed low bone mass, lifting heavy weights twice a week for 30 minutes.
Safety is the obvious concern here, and the trial addressed it.
A follow-up analysis used lateral thoracolumbar imaging and formal vertebral-fracture grading before and after the programme. Fracture classification didn’t change in the heavy-training group. The only new wedge deformity appeared in the low-intensity control group. Thoracic kyphosis improved by 6.7 degrees in the heavy group, compared with 1.6 degrees in the control group.
Over the full eight months, the training group recorded one adverse event, a minor lower-back spasm that led to two missed sessions out of 70.
This doesn’t tell us everything. The trial lasted eight months, involved 101 women, used close supervision by exercise scientists and measured bone density rather than fractures. It doesn’t prove that heavy lifting prevents fractures. It does, however, offer strong evidence that properly coached heavy lifting didn’t cause them in this population.
Pilates has an important role, we just need to be careful about what we claim.
The strongest Pilates trial in women with diagnosed postmenopausal osteoporosis lasted a full year. Seventy women completed either twice-weekly Pilates or a home thoracic-extension programme. Pilates produced significantly better results for pain, the six-minute walk, sit-to-stand performance, disease-specific quality of life and general health status (Küçükçakır et al., 2013).
The trial didn’t measure bone density or fractures.
Pilates met the ‘steady’ and ‘straight’, but not the ‘strong’. It also offers balance, postural control, spinal-extensor endurance, confidence in movement, hip and trunk control, and an activity people may enjoy enough to keep attending. Reducing falls, as we know, is one of the best ways to reduce fracture risk than a tiny change in bone density.
In short, yes, teach Pilates to clients with osteoporosis. Just make sure it isn’t the only training they do.
What we have discussed so far assumes low bone density without a previous spinal fracture. A vertebral fracture is a whole different story.
People with a vertebral fracture or several low-trauma fractures have greater bone fragility and a higher risk of another fracture. For these clients, we must limit impact work to intensities up to brisk walking, aiming for about 150 minutes a week. Both impact and progressive resistance training should follow individual advice from a physiotherapist. Daily back-extensor strengthening is recommended.
For everyone else, the recommend is that progressive resistance training with a load which can be lifted eight to 12 times, building to three sets on two or three days each week. The guidance also recommends moderate impact on most days, with at least 50 impacts per session.
A typical Pilates class contains none of those 50 impacts.
The Royal Osteoporosis Society provides named Pilates modifications. Use that published list rather than relying on personal judgement; it gives you a clear, defensible starting point.
| Classic Mat Exercise | Why It Is a Problem | The Modification |
|---|---|---|
| Roll Down | Unsupported, repeated end-range spinal flexion under the weight of the upper body | Stand with the back against a wall, feet slightly forward, supporting the spine through the movement. Or substitute The Cat |
| Roll Up, Hundred, Single and Double Leg Stretch, Scissors, Criss Cross | Loaded, repeated flexion of the thoracic and lumbar spine with head and shoulders lifted | Support the spine on a wedge, or substitute the Knee Fold with optional leg extension and arm circles |
| Rolling Like a Ball | Sustained full flexion plus repeated impact through a flexed spine | Not recommended with osteoporosis or increased fracture risk. Use The Cat for the spinal mobility intent |
| Rollover | Extreme loaded flexion with body weight passing over the neck and upper back | Not recommended with osteoporosis or increased fracture risk. Substitute the Spine Curl |
| Spine Stretch Forward and The Saw | End-range flexion, and in The Saw flexion combined with rotation | Bend the knees and hinge forward from the hips with a straight back |
| Curl Up | Repeated loaded flexion of the thoracic and lumbar spine | Substitute the Knee Fold, or extension work such as Diamond Press, Dart and Star |
| Hip Roll | Rotation through an unsupported lumbar spine | Keep the feet on the floor so the spine stays supported through the movement |
Making these substitutions creates a safer class, but it doesn’t add the loading needed to support bone.
The missing elements are progressive resistance training and, where there is no vertebral fracture, impact. That doesn’t mean sending a 68-year-old onto a commercial gym floor alone. Start with a well-taught hip hinge, loaded carry, progressive squat and overhead press, then build from heel drops and low hops before attempting anything more demanding.
Begin well below the eventual training load and progress to a plan, rather than changing it according to how the client feels that day. Work towards eight to 12 repetitions for three sets, twice a week. Once technique is sound, add load rather than more repetitions. It’s ordinary strength coaching applied carefully to a specific population.
Set honest expectations too. LIFTMOR took eight months to change bone density by a few percentage points. Clients should understand that the process is slow at the outset so they are not disappointed down the line.
Some clients may already have osteo related conditions with a list of things of what not to do, rather than what to do.
The evidence suggests to use Pilates for balance, posture, spinal-extensor strength, movement confidence and the consistency that comes from enjoying a class. Use progressive resistance and impact training to target bone. Modify the small number of end-range flexion exercises that need it, rather than total avoidance, and be honest with anyone who believes mat work alone is protecting their skeleton.
The flexion rule isn’t wrong; it’s simply older and less absolute than it is often made to sound. The consensus is to avoid sustained, repeated and end-range flexion, not everyday bending or smooth rotation.
For many over-60s, a weekly class may be their only structured movement. That makes it an excellent place to introduce the load they may not be getting elsewhere.
Brooke-Wavell, K., Skelton, D.A., Barker, K.L., Clark, E.M., De Biase, S., Arnold, S., Paskins, Z. and Robinson, K.R. (2022). Strong, Steady and Straight: UK Consensus Statement on Physical Activity and Exercise for Osteoporosis. British Journal of Sports Medicine, 56(15), pp.837-846. Click here to review the full research article.
de Oliveira, R.G., Anami, G.E.U., Coelho, E.A. and de Oliveira, L.C. (2022). Effects of Pilates Exercise on Bone Mineral Density in Postmenopausal Women: A Systematic Review and Meta-Analysis. Journal of Geriatric Physical Therapy, 45(2), pp.107-114. Click here to review the full research article.
Kistler-Fischbacher, M., Yong, J.S., Weeks, B.K. and Beck, B.R. (2021). A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women with Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. Journal of Bone and Mineral Research, 36(9), pp.1680-1693. Click here to review the full research article.
Küçükçakır, N., Altan, L. and Korkmaz, N. (2013). Effects of Pilates Exercises on Pain, Functional Status and Quality of Life in Women with Postmenopausal Osteoporosis. Journal of Bodywork and Movement Therapies, 17(2), pp.204-211. Click here to review the full research article.
Sinaki, M. and Mikkelsen, B.A. (1984). Postmenopausal Spinal Osteoporosis: Flexion Versus Extension Exercises. Archives of Physical Medicine and Rehabilitation, 65(10), pp.593-596. Click here to review the full research article.
Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., Horan, S.A. and Beck, B.R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women with Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research, 33(2), pp.211-220. Click here to review the full research article.
Many people in a typical mat class are over 50, and some will have a bone-density diagnosis they’ve not mentioned. Knowing which exercises to adapt helps you deliver a class that is both enjoyable and genuinely useful.
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