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Objective To analyze injuries that were directly associated with yoga practice and identify specific poses that should be avoided in patients with osteopenia or osteoporosis. Patients and Methods We retrospectively reviewed the medical records of patients with injuries that were primarily caused by yoga. Patients were seen from January 1, 2006, through December 31, 2018. Injuries were categorized into 3 groups: (1) soft tissue injury, (2) axial nonbony injury, and (3) bony injury. Patients underwent evaluation and were counseled to modify exercise activity. Results We identified 89 patients for inclusion in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease (46 patients [51.7%]) and facet arthropathy (n=34 [38.2%]) were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%). Spondylolisthesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. We correlated the kinesiologic effect of such exercises on specific musculoskeletal structures. Conclusion Yoga potentially has many benefits, but care must be taken when performing positions with extreme spinal flexion and extension. Patients with osteopenia or osteoporosis may have higher risk of compression fractures or deformities and would benefit from avoiding extreme spinal flexion. Physicians should consider this risk when discussing yoga as exercise.

To determine the outcome of intervention with a spinal weighted kypho-orthosis (WKO) and a spinal proprioceptive extension exercise dynamic (SPEED) program on the risk of falls in ambulatory community-dwelling persons older than 60 years with osteoporosis-kyphosis at risk for falls.The study had 3 stages. At stage 1 (baseline), the 12 women in the kyphotic group were compared with 13 healthy controls to assess the risk of falls and balance disorder in the kyphotic group. At stage 2, the 12 kyphotic women began the SPEED program with a WKO (2 supervised sessions in an outpatient clinic and a 4-week, daily home-based training program). At stage 3, baseline and follow-up data of the kyphotic group were compared to determine the effect of intervention.At baseline, there were significant differences between the osteoporotic-kyphotic group and the control group in balance (P=.002), gait (P.05), and strength (P.05). After a 4-week intervention, comparison of the kyphotic group's baseline and follow-up results showed a significant change in balance (P=.003) and several gait parameters (P.05). Mean back extensor strength improved significantly from baseline (144.0-46.5 N) to follow-up (198.6+/-55.2 N; P.001). Lower extremity muscle strength was not changed significantly, except for improved left ankle plantar flexors (P=.02). Back pain decreased significantly (P=.001).Balance, gait, and risk of falls improved significantly with the 4-week SPEED program.

To determine the effect of application of back supports on back strength in subjects with osteoporosis.In a prospective, randomized, controlled study, we compared compliance and evaluated changes in back strength in 45 women with osteoporosis who were older than 40 years of age and were randomly assigned to one of three groups: (1) postural exercise only, (2) postural exercise and a conventional thoracolumbar support, or (3) postural exercise and a Posture Training Support (PTS) (a weighted kypho-orthosis).Of the 45 study participants, 15 were assigned to a PTS group, 15 to conventional thoracolumbar support, and 15 to no orthosis. All subjects were instructed in basic body mechanics and postural exercises. Back extensor strength, grip strength, and patient's physical activity were measured at baseline and at subsequent 8-week intervals for a 16-week period. Each patient's compliance during the study period was also recorded.compliance was poor among the thoracolumbar group; only 5 of the 15 subjects completed the study (P0.001), in comparison with 11 of the 15 patients in the control group and all 15 in the PTS group. Analysis revealed statistically significant mean increases in back strength in the PTS group (23%) and the control group (13%) and a nonsignificant increase in the thoracolumbar group (15%), although poor compliance in the thoracolumbar group yielded insufficient power to detect a significant difference in this group. No statistically significant difference was found between the improvements in the PTS and control groups, possibly because of the small sample size in this pilot study. One patient who wore the PTS for only 4 hours a day rather than 8 hours had the largest percentage increase in back extensor strength of this group (78%). At 16 weeks, decreases in back strength of more than 5% below the initial measurements were noted in 1 of 11 subjects (9%) who completed the control arm of the study, 2 of 14 (14%) who completed the PTS arm, and 2 of 5 (40%) who completed the thoracolumbar arm.Compliance with use of the PTS was better than that with the thoracolumbar support. Back extensor strength may increase in patients who comply with the PTS and postural exercise program. We caution, however, that this pilot study requires replication in a larger series to determine the clinical and statistical generalizability of these findings to a wider population.

Back supports are often used to minimize or prevent complications of osteoporosis. Nevertheless, the few related studies to date reveal that the currently available thoracolumbar and lumbosacral supports have substantial limitations, including (1) poor compliance because of discomfort or restricted motion, (2) expense, (3) unacceptable cosmetic and aesthetic appearance, and (4) medical contraindications to the use of rigid supports. We report the initial results of a clinical trial of the Posture Training Support (a thoracolumbar support) in 29 women and 1 man with osteoporosis or osteopenia of the spine (ages 37 to 87 years), who were referred because of back pain or kyphosis. We hypothesize that this inexpensive, unobtrusive device promotes improvement in posture and reduces back pain either by acting as a proprioceptive reinforcer or by producing a force posteriorly below the inferior angles of the scapulae and thus decreasing the anterior compressive forces that are commonly exerted on the spine. Among the 23 patients who reported substantial back pain before use of the support, relief of the pain was "significant" in 17 and minimal in 6. Nineteen patients noted improvement in their posture. No patient reported worsening of back pain or posture, nor did any patient discontinue use of the device for cosmetic reasons, discomfort, or other complaints. Four patients previously could not tolerate other back supports, and 14 had previously used other supports without substantial improvement. These preliminary results suggests that the Posture Training Support may be of considerable symptomatic and prophylactic value to patients with osteoporosis who cannot tolerate conventional back supports.

The correlation of muscle strength at various sites of the axial and appendicular skeleton with physical activity and aerobic capacity was assessed in women 29 to 40 years old. Muscle strength of the spine and upper extremities was determined with strain gauges in 96 healthy white women, and power grip was used as an indicator of upper extremity strength. The physical activity score, which reflected the level of daily weight-bearing activity and was based on a standardized scale, ranged from 3 to 15. Maximal oxygen uptake (aerobic capacity) was measured in 69 of the 96 subjects. The mean values for maximal oxygen uptake were 1.9 liters/min and 27.9 ml/kg per minute when normalized for weight. In general, muscle strength was significantly correlated between axial and appendicular sites; thus, the axial musculature usually represents overall muscle strength. Maximal oxygen uptake in milliliters per kilogram per minute was not correlated with back extensor strength or upper extremity strength. Physical activity score was significantly correlated with back extensor strength but not with maximal oxygen uptake (aerobic capacity) either in liters per minute or in milliliters per kilogram per minute. Thus, maximal oxygen uptake is an invalid marker for level of daily weight-bearing physical activity.

Considerable concern has been expressed about the type and level of exercise that are safe for women with osteopenia and osteoporosis; however, published information on the effect of golfing on the osteoporotic spine is meager. We describe three postmenopausal patients with acute compression fractures of the vertebrae that occurred during midswing while golfing. These healthy, active women were long-term golfers; their ages at the time of the trauma were 63, 58, and 66 years. In one patient (case 1), osteoporosis was diagnosed before the golf-related injury. The two other patients (cases 2 and 3) sought medical attention after the trauma and were found to have osteoporosis. The bone mineral density of the lumbar vertebrae (L2-4) in the three patients at the time of or shortly after the trauma was as follows: case 1, 0.77 g/cm2 (3rd percentile of normal, corrected for age); case 2, 0.63 g/cm2 (less than 1st percentile of normal, corrected for age); and case 3, 0.69 g/cm2 (2nd percentile of normal, corrected for age). These findings raise the issue of the safety of golfing for women with previously diagnosed osteoporosis and for those with predisposing risk factors for the disease. Research studies of the kinematics and kinetics of the spine during the golf swing should be conducted. In the interim, a rigid back support for golfers with osteoporosis may be helpful until more conclusive evidence is available from controlled trials.

Improvement of back extensor strength (BES) can be used as a therapeutic method for patients with chronic back pain and osteoporosis. The method of evaluation must be reliable and accurate without compromising the condition of the patient. We report the development of a back isometric dynamometer (BID-2000) designed specifically by two of us to address these concerns in elderly patients with osteopenia or osteoporosis. As the demographics of the general population change, increasing numbers of patients will need the type of monitoring that the BID-2000 provides. Aging has been shown to cause a reduction in the number of functional muscle motor units. To examine this effect on BES, we tested 50 normal, healthy women who were 30 to 79 years old. Proper testing of BES in patients with fragile vertebrae should include isometric measurement in the prone position, maneuverability of the device to allow comfortable positioning of the patient, and simplicity of technique to minimize repetitious performance of maximal contraction. The BID-2000 incorporates each of these features and also provides meaningful results inexpensively. The device offers a safe, reliable (coefficient of variation = 2.33%), and valid (P = 0.001) method of evaluation. The results of our study demonstrated moderate, steady reduction of BES with increasing age and with each successive decade.

OBJECTIVE To determine whether patients with osteoporotic compression fractures would have decreased fracture recurrence or a longer time before refracture after percutaneous vertebroplasty (PVP) if they also participated in the Rehabilitation of Osteoporosis Program-Exercise (ROPE) instruction, which includes back-strengthening exercises. PATIENTS AND METHODS We reviewed and collected data from the medical records of 507 patients with osteoporosis who were treated at Mayo Clinic's site in Rochester, MN, from July 1, 1998, through August 31, 2005. Patients older than 55 years with at least 1 radiographically confirmed nontraumatic vertebral compression fracture (VCF) were identified, and those with evidence of secondary osteoporosis, traumatically induced VCF, long-term oral corticosteroid use, or bone malignancy were excluded. The remaining 57 patients were categorized into 3 groups: those receiving treatment with ROPE only (n=20), PVP only (n=20), or both PVP and ROPE (n=17). The end point was the refracture date or date of the last recorded follow-up if no refracture occurred. Statistical analysis of time-to-recurrence data was performed using the Kaplan-Meier method and the log-rank test (P RESULTS The median time before refracture for patients treated with PVP was 4.5 months (95% confidence interval [CI]), 1.4-9.3 months; for patients treated with ROPE only, 60.4 months (95% CI, 27.6 months-upper limit undefined); and for patients treated with PVP-ROPE, 20.4 months (95% CI, 2.8 months-upper limit undefined) (P CONCLUSION This retrospective study showed that a targeted exercise program after PVP significantly decreased fracture recurrence. Refracture rates also were lower in the ROPE-only group vs the PVP-only group. A targeted exercise program after percutaneous vertebroplasty (PVP) significantly decreased fracture recurrence; refracture rates also were lower in the back-extensor-strengthening-only group vs those in the PVP-only group.

Objective To determine the effect of regular exercise with use of stepper or skier machines on muscle strength, cardiovascular fitness, bone mineral density, and markers of bone turnover in women aged 29 to 45 years. Subjects and Methods We evaluated 14 women: 5 who used a stepper machine for at least 3 hours each week for 2 years, 4 who used a skier machine for at least 3 hours each week for 2 years, and 5 who did not exercise (controls). All women were healthy, had no history of disease or medication use known to affect bone metabolism, and had normal levels of estradiol-17β. Differences between the exercise and control groups were analyzed with the Kruskal-Wallis test. Results No significant differences were noted between the exercise groups and the control group with respect to age, height, total body bone mineral density, calcium intake, and metabolic bone markers. Significant differences were noted between the groups in body weight (stepper vs control, P =.03; skier vs control, P =.02), body mass index (stepper vs control, P =.03; skier vs control, P =.02), Physical Activity Score (stepper vs control, P =.009; skier vs control, P =.01), percentage body fat (stepper vs control, P =.03; skier vs control, P =.02), and maximum oxygen consumption (stepper vs control, P =.009; skier vs control, P =.009). Bilateral hip extensor strength was significantly stronger in the stepper group than in the skier group ( P =.03). Grip strength was significantly stronger in the stepper group than in the skier group (right, P =.01; left, P =.049). Conclusion Although comparable health club exercises can contribute to fitness, their site-specific effect varies. Stepper machines are preferred over skier machines for improving hip extensor strength.

Objective To determine the correlation of trunk muscle strength with age in children and the effect of gender on changes in trunk muscle strength. Material and Methods Strength of the back extensors and back flexors was evaluated in 137 healthy boys and 109 healthy girls who were 5 to 18 years old. Anthropometrie determinations of height and weight were done in all study subjects. Maximal back muscle strength was measured with an isometric dynamometer (BID-2000). Standardized positioning techniques were used to allow comparison with the follow-up evaluations. Results Regression analysis revealed significant increases in trunk strength with increasing age; the strength of the boys began diverging from that of the girls at age 9 to 10 years. Back extensor strength also increased with increasing height and weight, and expected differences were noted between boys and girls. Strength levels ranged from 80 to 774 newtons (18 to 174 lb). Mean back extensor strength in 2-year age intervals ranged from 153 newtons (34.4 lb) in girls 5 to 7 years old to 504 newtons (113.3 lb) in boys 16 to 18 years of age. (Each newton is equal to 0.2248 lb.) Conclusion Results of this study demonstrated that age, height, and weight are all important predictors of trunk strength in children, and the effects of these factors are modulated by gender.

Objective To determine the influence of back extensor strength on vertebral fractures in 36 women with osteoporosis. Design We conducted a cross-sectional study of female patients with osteoporosis by assessing anthropometric variables, bone mineral density, muscle strength, level of physical activity, and radiographic findings in the spine. Material and Methods The 36 study subjects with osteoporosis, who ranged from 47 to 84 years of age, satisfied specific inclusion and exclusion criteria that minimized confounding factors related to pathophysiologic features, diet, and medications. A physical activity score was determined for each subject on the basis of daily physical activities relating to homemaking, occupation, and sports. Results The range of the physical activity scores—from 2 to 13—indicated that no subject was involved in unusually demanding physical activities. Bone mineral density values ranged from 0.49 to 0.92 g/cm 2 . Thoracic kyphosis ranged from 31.0 to 84.0°. Isometric strength of the back extensor muscles ranged from 7.3 to 34.0 kg. Statistical analysis demonstrated a significant negative correlation between the strength of the back extensor muscles and thoracic kyphosis. Significant negative correlations were also found between back extensor strength and the number of vertebral compression fractures and between bone mineral density and the number of vertebral fractures. Conclusion The negative association between back extensor strength and both kyphosis and number of vertebral fractures suggests that increasing back strength may prove to be an effective therapeutic intervention for the osteoporotic spine. In persons with stronger back muscles, the risk of vertebral fractures will likely decrease.

Objective To evaluate the effect of back-strengthening exercise on posture in 60 healthy estrogen-deficient women. Design The 60 study subjects were randomly assigned to either an exercise or a control group, and various factors were assessed at time of enrollment in the study and at 2-year follow-up. Material and Methods The 32 women in the exercise group were instructed in progressive back-strengthening exercises, whereas the 28 women in the control group had no exercise prescription and were asked to continue their usual physical and dietary activities. At baseline and 2-year follow-up examinations, back extensor strength was measured with a strain-gauge dynamometer, and lateral roentgenograms of the thoracic and lumbar areas of the spine were obtained to measure the angles of thoracic kyphosis, lumbar lordosis, and sacral inclination. The changes in radiographic measurements and back extensor strength were analyzed statistically. Results Back extensor strength increased significantly in both the exercise and the control groups, but no radiographic measurements were significantly different between these groups. The significant increase in back extensor strength in both groups of healthy women suggested that the original grouping did not accurately reflect the amount of exercise. Thus, the 60 subjects were reclassified for comparison on the basis of increase in back extensor strength—27 with more than or equal to the mean increase of 21.1 kg and 33 with less than 21.1 kg. Furthermore, each of these groups of subjects was subdivided on the basis of degree of thoracic kyphosis. Among the subjects with substantial thoracic kyphosis, those with a significant increase in back extensor strength had a significant decrease in thoracic kyphosis (−2.8 ± 4.2°; P = 0.041), whereas those with a small increase in strength had a nonsignificant increase in thoracic kyphosis (1.8 ± 5.3°). The increase in back extensor strength did not seem to affect mild degrees of kyphosis. Conclusion Increasing the back extensor strength in healthy estrogen-deficient women helps decrease thoracic kyphosis.

To the Editor: We read with interest the excellent review article on osteoporosis by Mauck and Clarke in the May 2006 issue of Mayo Clinic Proceedings, which summarized current strategies for the diagnosis, screening, prevention, and treatment of this disorder. However, we found one area that we believe deserves further elaboration—the role of exercise in the prevention and treatment of osteoporotic compression fractures. In their article, Mauck and Clarke reported that “weightbearing exercise appears to be effective in maintaining or increasing bone density at the lumbar spine and hip in postmenopausal women, but currently, no evidence suggests that it decreases fractures.” They referenced the report by Bonaiuti et al in the 2002 Cochrane Database of Systematic Reviews, which included studies up to 2000. However, since that time evidence has accumulated that substantiates the use of targeted back extensor–strengthening (BES) exercise to reduce the risk of vertebral compression fractures in the postmenopausal population. For example, in 2002, Sinaki et al published the results of a prospective 10-year follow-up study showing a statistically significant reduction in vertebral compression fractures in a group of women who had participated in BES exercises compared to a control group of women who did not participate in such an exercise program (Figure 1). Stronger back extensors reduced the risk of vertebral fractures by 3-fold with no specific pharmacotherapy. In 2003, Turner and Robling noted that regular exercise can “effectively reduce fracture risk” while increasing bone strength. Pfeifer et al reviewed the literature in 2004 and concluded that exercise was associated with reduced risk of hip fracture. In a recent pilot study of the effects of BES exercise and refracture rates after vertebroplasty, we found not only a decreased refracture rate but an increased fracture-free interval when BES exercise was included. Bone mineral density accounts for less than 50% of fracture risk; the remaining risk depends on other factors such as muscle strength and risk of falls. Thus, given the safety of an appropriately designed exercise program in this population, we believe that targeted BES exercise should be considered for fracture prevention and as a treatment option for all osteoporotic individuals.

We determined the bone mineral density of the lumbar spine and the strength of back extensors in 68 healthy postmenopausal Caucasian women. Bone mineral density of the second to fourth lumbar vertebrae was measured by dual-photon absorptiometry, and back extensor strength was determined with use of a strain-gauge dynamometer. The bone mineral density percentile ranged from 2 to 99%, and back extensor strength ranged from 37 to 145 lb. Statistical analysis demonstrated a significant positive correlation (P = 0.004) between bone mineral density and back extensor strength, even when bone mineral density was corrected for age. Bone mineral density was also significantly positively correlated with body weight (P = 0.003), height (P = 0.001), and arm span (P = 0.008). These data suggest that the strength of back muscles may contribute to the bone mineral density of vertebral bodies.

Segmental spinal muscular atrophy of adolescence is a clinical syndrome that can be distinguished from the more common forms of motor neuron disease. A patient with this syndrome who was no longer able to care for herself is described. After selective tendon transfers in her right upper extremity, she has been able to perform many of the activities of daily living. This improved function has been maintained for more than 2 years. We suggest that transfer of tendons and muscles may be indicated in selected patients with slowly progressive muscular atrophy.