Fishman, Loren M. MD, BPhil(Oxon)
OSTEOPOROSIS and osteopenia are better understood than they were even a decade ago, yet ancient methods appear applicable to their prevention and cure. We conducted a pilot study using yoga to reduce and ultimately prevent osteopenia and osteoporosis. Many of the world's estimated 200 000 000 sufferers of osteoporosis and osteopenia are unlikely ever to be able to afford either medication for these conditions or treatment of the fractures that are their consequence.1 Those receiving bisphosphonates, by far the most common pharmacological treatment, are at increased risk for gastrointestinal disorders, osteonecrosis, and severe muscle cramps,2,3 and while medicines such as loop diuretics strongly promote osteoporosis through calcium loss, calcium itself promotes cardiovascular and cerebrovascular events and sudden death in people older than 75 years.4
Over 55% of everyone older than 50 years will have low bone density,1 and a woman's risk of hip fracture is equal to the combined risk of breast, uterine, and ovarian cancer.5 Women are as likely to die after a hip fracture as from breast cancer.1,3 Men older than are more likely to contract hip fracture than prostate cancer.1,6 Yet a recent “definitive” review of chronic disease in a leading journal does not even mention osteoporosis.7
Everett Smith outlined the support for “unusual pulls” bones as a means of building bone strength. In a study of turkey wings published in this journal almost 20 years ago, he outlined this application of Wollf's law: “The architectonic of bone follows the lines of force to which that bone is exposed.”8,9 Biochemical markers of osteoid synthesis such as 3H-uridine have very persuasively risen in intracellular concentration after as little as 10 seconds of osteocyte compression.10 Japanese and American studies sending ovariectomized mice into space confirm that gravity, while a ubiquitous and powerful force, is second-best compared to the action of muscles themselves.11 Their point is that muscles are stronger than gravity. One need do no more than lift a finger to prove it.
Tennis players' dominant arms clearly share genetic and nutritional conditions with their contralateral partners, but asymmetrically increased bone mineral density (BMD) is evident there and in many other examples of response to physical stressors.12,13 The often observed fact that yoga practitioners seem to live long and fracture-free lives suggests that the unusual and unusually prolonged pulls they voluntarily self-administer may be a stimulus to bone health.
MATERIALS AND METHODS
Study participants were invited through public announcement and from among our current patients. Inclusion criteria were osteopenia or osteoporosis by dual energy x-ray absorptiometry (DEXA) scan, that is, T-scale values below −1.0 for spine or hip, and commitment to 2 years of daily or near-daily yoga. Exclusion criteria included history of bone disease, such as osteofibrosis cystica or osteomalacia, or metabolic or endocrine disorders specifically affecting bone, as detected by tests listed below, and current pregnancy.
Each patient had BMD tested by DEXA scan within 6 months of joining the study, and once osteoporosis or osteopenia was confirmed, urine was tested for collagen cross-linkage (NTX), and blood was drawn for tests including the following: thyroid stimulating, parathyroid hormone, erythrocyte sedimentation rate, electrolytes and blood chemistry (SMA-18), complete blood cell count (CBC) with vitamin D 25-OH, and vitamin D1,25- dihydroxy.
Only patients with normal laboratory values were then taught a regimen of 10 yoga postures, with frequent adaptations in keeping with the participants' abilities and limitations. The poses taught were the triangle pose (Trikonasana), the upward and downward dog poses (Adho Mukha Svanasana and Urdhva Mukha Svanasana), the bridge and rainbow (Setu Bandhasana and Urdhva Dhanurasana), 1-legged and 2-legged forward bends with specific personal instruction on keeping the back straight and avoiding kyphosis while doing so (Janu Sirsasana and Paschimottasana), the boat (Navasana), Supta Padangusthasana, and 3 twisting poses with straight-back instructions (Marichyasana, Matsyendrasana, and Jathara Parivarthanasana) (Figs 1–13).
Participants were taught simpler alternatives when necessary for safety, for example, modified forward flexion to avoid vertebral fractures,14 advised to stay in each position for 20 to 30 seconds, and asked to rest for 5 to 10 minutes following the 8- to 10-minute routine. For pictures and more details, see the Web site sciatica.org.
We telephoned the patients periodically to give them encouragement and discuss problems. When we saw that compliance was below 30%, we instituted a newsletter and online notice board.
Patients succeeding in doing yoga consistently for 2 years and controls were then given another DEXA scan. In patients receiving medication such as bisphosphonates, the nomogram for improvement for their particular dosage and duration was taken as baseline, and improvement/deterioration only beyond the nomogram's mean was taken as change. In patients receiving medications that had no nomogram and those with multiple previous DEXA scans, projections based on previous data were used to establish the predicted change in BMD, and deviation from that prediction was taken as change due to the study intervention.
A total of 117 patients entered the study between October 10, 2005, and May 2, 2008. There were 9 men in the group, which consisted of 87 people with osteoporosis and 30 with evidence only of osteopenia. Compliance thus far is poor, with only 31 of 117 patients responding positively to telephone inquiries (26.5%).
To date, 11 patients have completed the 2-year protocol and 7 patients have served as 2-year controls. The mean BMD of the 11 intervention patients has improved well beyond that of the controls (Table 1 and Fig 14).
The patients doing 10 minutes of yoga daily showed an increase in spine BMD equivalent to 0.563 units on the T-scale; their hip BMD increased to 0.867 units. Control values were −0.12 and −0.07 for spine and hip, respectively, over the 2-year study period. Although the number of patients who have completed the study at this point are insufficient for rigorous statistical analysis, there are strong trends worthy of note: People doing yoga have improved their spinal T-scores by an average of 0.69 T-score units and their hip T-scores by 0.87 T-score units in 2 years.
Because of the small number of patients in the control group, we analyzed these results by comparing them with the null hypothesis, that yoga did not improve bone density. This is a strong condition, because, in fact, in patients older than 30 years, BMD actually declines without any treatment. This is what has been revealed thus far in our group overall. Using 1-tailed t tests, the DEXA scan results from only 11 patients proved significant, P < .01 for both the spine and the hip (Table 2).
We will certainly continue our study. Still, these early findings are encouraging.
The value of a low-cost and healthful means of combating osteoporosis is considerable. While bisphosphonate use is associated with gastrointestinal toxicity, jaw and other sites of osteonecrosis, severe and sometimes irreversible leg cramps and bone pain, and other side-effects, yoga injuries are uncommon15 and nearly always minor. Yoga has been shown to reduce back pain, arthritis, and anxiety and to improve gait, neural plasticity associated with motor learning, all capacities that mitigate against the falls that produce osteoporotic fractures.15–21
This study will continue until a statistically significant internal sample is reached. Assuming for the moment that the results obtained so far are borne out, we may draw optimistic conclusions: There is no tachyphylaxis known with yoga, no law of diminishing returns that is well known with bisphosphonates and some other medicines. The effects of yoga are therefore likely to be additive: 6 years are likely to yield 3 times the benefit seen after 2 years. At that rate, a person with osteopenia (T-score of −1.0 to −2.5) or minimal osteoporosis (T-score of −2.5) will have spine and hip BMD that is neither osteoporotic nor osteopenic within 6 years of a quiet, costless, and virtually riskless practice of 10 min/d.
Because of confounding factors such as calcification of the aorta and osteoarthritis of its many joints, the spine's T-score is a less reliable indicator of total bone mass than is the hip's T-score. In this pilot study, the hip BMD increased 54% more than the spine BMD, lending further credence to the efficacy of yoga in building bone.
THE TROUBLE WITH THIS STUDY
This study focuses on the currently standard measure of bone strength, BMD as determined by the DEXA scan. But bones are not solid; they have a varying delicate internal structure of struts and crosspieces that also contributes to their overall resistance to fracture, known as bone quality. The quality is a function of both the BMD and the structure of trabecular bone, inner elements that span bones' interior to support the cortical bone that forms the hardened outer region of most bones. Bone quality contributes an estimated 40% to 60% of bones' abilities to withstand traumatic stress. Bone biopsy and noninvasive techniques such as micro-magnetic resonance imaging and supercomputer imaging are currently in the mid-stage of development; before long, they will add to our understanding of bone strength and what activities or medications are most effective in creating and sustaining it.
This pilot study tends to give support to the hypothesis that practicing yoga for as little as 8 to 10 minutes daily will raise T-scale ranking in older patients.
We are currently beginning a second trial that we believe will be safer than the first, though the first trial has had no fractures or other mishaps to date. We are supplying a 10-minute video along with entrance to the study. It is possible that we will be able to noninvasively examine bone quality in this study as well. Those interested should communicate with us through our Web site sciatica.org.
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© 2009 Lippincott Williams & Wilkins, Inc.