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Episode 93: Should You Avoid Spinal Flexion with Osteoporosis?
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In this episode of the Movement Logic Podcast, hosts Laurel Beversdorf and Dr. Sarah Court critically examine common beliefs surrounding spinal flexion exercises and osteoporosis, particularly from a yoga and Pilates perspective. They delve into two pivotal studies on exercise and fracture risk, both led by Dr. Mehrsheed Sinaki, a renowned specialist in physical medicine and rehabilitation at the Mayo Clinic in Rochester, Minnesota.
The first study, Postmenopausal Spinal Osteoporosis: Flexion versus Extension Exercises, is frequently cited on Pilates websites and in yoga and Pilates teacher trainings as evidence that spinal flexion is risky for individuals with osteoporosis—even during bodyweight exercises. However, despite its widespread use to justify movement restrictions, the study has notable methodological flaws. The second study, Stronger Back Muscles Reduce the Incidence of Vertebral Fractures: A Prospective 10-Year Follow-up of Postmenopausal Women, suggests that progressively overloaded back strengthening exercises can reduce fracture risk—even if the strengthening occurred only for a few years in the distant past. Yet, this study also has its own limitations.
When viewed together, these studies present an intriguing contrast: one warns of the potential dangers of spinal flexion (even under low loads) based on weak evidence, while the other highlights the lasting protective benefits of strength training. Laurel and Sarah explore why bodyweight spinal flexion is often singled out as risky and question whether this caution is always justified.
They also discuss the ethical implications and the boundaries of a movement teacher's scope of practice—particularly when making broad recommendations to avoid certain movements based on limited or flawed research. The hosts emphasize the importance of individualized context in exercise prescriptions, the need to follow medical guidance from a student’s doctor, the evidence-backed benefits of strength training, and the necessity of empowering students with the autonomy to make informed movement choices.
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00:56 Podcast Production & Content Creation
01:33 Bone Density & Squat Depth
02:20 Benefits of Full ROM Strength Training
08:24 Is Spinal Flexion Dangerous for OP?
10:00 Issues with Yoga/Pilates for OP Classes
18:43 1984 Paper: Flexion vs. Extension for OP
40:22 Flaws in the 1984 Study
41:57 2002 Study: Stronger Back Muscles & Fractures
43:03 2002 Study Design & Methods
46:35 2002 Study Key Findings
52:09 2002 Study Limitations
56:30 Practical Takeaways
01:06:15 Ethics for Movement Teachers
01:17:43 Conclusion
References:
Episode 77: Make Dr. Loren Fishman Make Sense
Episode 92: Are You Getting Dexa Scammed?
1984 Sinaki paper
2002 Sinaki paper
Recommended
Transcript
Introduction to the Movement Logic Podcast
00:00:02
Speaker
Welcome to the Movement Logic Podcast with yoga teacher and strength coach Laurel Beaversdorf and physical therapist, Dr. Sarah Court. With over 30 years combined experience in the yoga, movement and physical therapy worlds, we believe in strong opinions loosely held, which means we're not hyping outdated movement concepts.
00:00:22
Speaker
Instead, we're here with up to date and cutting edge tools, evidence and ideas to help you as a mover and a teacher.
00:00:40
Speaker
Welcome back to season six of the Movement Logic Podcast. I'm Laurel B. Resdorf and I'm here with my co-host Dr. Sarah Court.
00:00:51
Speaker
We are still in Alabama. We are still in Alabama. We might have gone away previous episodes, but what happens actually is that we record these out of order. And what have we been doing? So far, we went to the YMCA. It's fun to be at the YMCA.
00:01:10
Speaker
So we went and worked out. We're here doing a bunch of work. A lot of what Laurel and i do is she comes to me or I come to her and then we just work our fucking asses off for five days. And then we create stuff.
00:01:21
Speaker
Some of what we're creating is this podcast episode you're listening to right now. Some of what we're creating is a new content. Surprise. Surprise content.
Squat Techniques and Challenges
00:01:31
Speaker
So that's gonna be fun. Yes, very fun.
00:01:33
Speaker
All right, well, let's talk a little bit about some things we're noticing in bone density course. Absolutely. What I've been noticing, tell me if you've been noticing, is that people's squat depths, the depth of their squats is increasing, that I no longer have to say, maybe you should use a box to sit to, to ensure you're hitting so the depth of your squat each rep or things of that nature. And I think that this is great because Squatting to depth is relative. There are reasons why people can squat their hips below their knees and reasons that they cannot and it's all well and good. But ultimately think it's a good idea that if you have the range to explore it.
00:02:14
Speaker
I think that training in that full range of motion, whatever that is for each individual, is a good idea. I mean, from a strengths perspective, it's a good idea because you're going to see greater overall strength and muscle development from full range of motion strength training. But also if we're doing this for the purpose of longevity, which many participants are because the name of the course is bone density course, right? But it's lift for longevity. It's lift for longevity. Exactly. Longevity is in the title. Yes.
00:02:42
Speaker
That full range of motion strength is just something you want to have for as long as possible. Absolutely. that you can get up and down off the ground and toilet. In and out of a chair. Stand up from the toilet. um There's a toilet in our ah house is particularly low seat.
00:02:56
Speaker
Oh, there it Stuff like that. So being able to stand up or being able to get up off of the floor, we probably want to explore ah little bit more detail. range of motion to be able to have the strength for that. and For the first couple of months, something that we noticed now, two cohorts running, is that squats can get pretty shallow.
00:03:14
Speaker
What happens I think sometimes is that because it's hard to feel how deep you're squatting, unless you can see yourself in the mirror, but even that's hard to see because you'd have to look profile and then turn your head while squatting, which I don't recommend.
00:03:25
Speaker
It's hard to know proprioception wise. So that's one reason. The other reason is that if you're increasing weight on the bar, let's say we're working like a 10 to 12 rep range and then we're shifting toward an eight to 10 rep range and maybe you added like five or 10 pounds to the bar, the heavier the bar gets, the smarter your body's gonna try to get about moving it through space. And one of the ways our body tries to preserve energy is by reducing a range of motion.
00:03:47
Speaker
So your body's going to say, oh okay, I see that that this is heavy. So instead of squatting hips below knees, we're just going to squat hips slightly above knees. And it's still going to be the pattern of movement you're trying to achieve. And it's all well and good. And then Sarah and I are on the other end of Zoom being like Nancy or Sally or Susan. I noticed that your squat has gotten a little shallower. I wonder if you might put the box there so you can feel where your hips are in space. You're touching down to that point each time and It's just taken a lot of, i found like per persuasion.
00:04:14
Speaker
But finally, I'm starting to notice difference. And I think one of the things that's helped is, first of all, the way we're warming up. I'll have students sit on a box that guarantees their hips are below their knees and then lift off and hover body weight just slightly above that box.
00:04:29
Speaker
So their hips are below their knees at that point or level with their knees at that point. They're hovering body weight. They're starting to get a kind of a feel for where hips below knees is in the warmup. And then i think giving a lot more context around why range of motion is important, like what the benefits of it are to the point where now we're in month four, they're starting to take weight off the bar, five, 10 pounds to really prioritize that depth.
00:04:51
Speaker
Because if we make our squat deeper, it's going to be more overall work. Chances are we can partial range of motion squat a bar that's heavier than we can full range of motion squat. So they're learning that there are often battles that we need to pick.
00:05:06
Speaker
right? So we can't pick the increasing load battle and the range of motion battle often at the same time. We have to choose one or the other. And it's sometimes really tempting to want to just add more plates to the bar as our squat gets shallower and shallower and shallower because, hey, look, I'm squatting more weight. But I'm really happy to see that I like that there has been a maybe reprioritization of goals, which is that, okay, I can let go of five to 10 pounds if that means that I'm able to control a really nice squat to depth.
00:05:34
Speaker
yeah And it just makes me so Like I'm looking at the rectangles, I'm like, oh my God, these squats, gorgeous. Yeah, yeah. How about you? I'm definitely also noticing that. And one of the the reasons that I think, in particular, people who have come from a yoga background have not explored a squat to depth is that their experience of squat from yoga is either chair pose, which would be like a partial range of motion, or malasana, which is all the way down. Ass to grasp. Ass to grasp.
00:06:04
Speaker
but unweighted. yep And also a lot of the time the molasana is not control your movement down into the molasana. It's just like clamber into this shape however you can. Think into it, hang out in it, rest in it. Yeah, exactly. Or support it, put some blocks under your butt or something like that. I know that for
Critiquing Movement Myths in Osteoporosis
00:06:19
Speaker
myself, when I first started, like even when I was weight training with things like kettlebells, not yet with barbells, I was doing what would be called partial squats. Because in my mind, that's, I was squatting.
00:06:29
Speaker
Squat is, you stick your butt back, you bend knees. When I started actually doing squat to depth, and I'm one of those people for whom a slightly higher than hips than knees is the appropriate height for me. yeah But that is still a lot deeper. It's 50% more than where I was going. yeah All of a sudden, and i don't know if you ever noticed this, the upper part of my quads suddenly were like, excuse me, I'm supposed, I've just been hanging out here just chilling the whole time. And now I'm supposed to be involved. And we don't emphasize, we 100% do not emphasize physical appearance at all in this course. But what I have noticed in my own body is that I quite enjoy is that now at the top of my legs, the muscle actually now protrudes forward instead of it just being like straight down. So I have visibly increased muscle in my upper thighs and I'm here for it.
00:07:16
Speaker
Yeah. Some women have noted that they feel their inner thighs working more in a deeper squat. Oh, interesting. That's supported by some research looking at muscle engagement in a deep squat versus a partial range of motion squat. It turns out the adductors do probably get to participate more in deep squats.
00:07:32
Speaker
So that was interesting for them to also, without maybe even being familiar with that, to share that. And it's my experience as well. Yeah. So anyway, I just love the progress that I'm seeing, especially with the squat.
00:07:44
Speaker
Before we move on with today's episode, if you are not on our wait list for bone density course, why are you not on it? That's my question. Rhetorical in nature. As your daughter would say, don't know.
00:07:59
Speaker
ah you should be on the waitlist because we give you free stuff. That's number one. So even if you have no desire to take bone density course, you might like the free things you get by being on the waitlist.
00:08:09
Speaker
Number two is it's the only place to get the $100 discount on tuition to the course. So if you do have some inkling that you may want to take bone density course in the spring with us, you want it for that reason as well. Sign up for the waitlist via the link in the show notes.
00:08:23
Speaker
All right. In today's episode, we're taking a closer look at a common, still persistent belief, especially in the yoga and Pilates communities, which is that spinal flexion as a movement the spine can do.
00:08:37
Speaker
for individuals who have osteoporosis is to be avoided because it is potentially dangerous. We're going to get into it. What I've noticed is that, especially in schools of yoga and Pilates, teachers are taught that spinal flexion, bending the spine forward, is something they should discourage students with osteoporosis from doing. It's also sometimes just a movement that's demonized in general. Yes. Everybody should not flex And especially in both of those modalities. Yes.
00:09:03
Speaker
So the reason for the belief regarding not to flex with people for osteoporosis is it is believed that spinal flexion significantly increases the risk of vertebral fracture.
00:09:16
Speaker
Now we know that someone with osteoporosis has low bone mineral density and is because of that at risk for fracture. The question is though, does spinal flexion with no context around the loads being experienced by the spine while flexing, because load and position are different things, if flexion alone minus context is actually risky. This idea that it is has deeply influenced teacher training programs for Pilates, but also for yoga,
00:09:47
Speaker
some of which teach their teachers how to work with students who have osteoporosis in classes titled things like yoga for osteoporosis, Pilates for osteoporosis.
00:10:00
Speaker
Sarah, it bothers me when I see classes titled yoga for osteoporosis or Pilates for osteoporosis, and I'm not going to share why because I want to hear from you. Does it bother you?
00:10:11
Speaker
Laurel didn't say this, I just started shaking my head when she was saying that. It bothers the fuck out of me. part A really specific part of what bothers me is the use of the word for. Because it makes it sound like yoga is gonna help your osteoporosis. Pilates is gonna help your osteoporosis.
00:10:26
Speaker
It's going to take it away Yeah, it's going to make it better. Where we know from research that neither one of them does that. So it's not building bone density. So it's not really for it. What these classes typically are, are kind of cover your ass classes where they're going off of this idea that spinal flexion is dangerous for anyone with any amount of osteoporosis. This is also now including people who have osteopenia, right? Which is that lower level. It's like a precursor to osteoporosis, which if you listen to our episode, are you being DEXA scammed? Which we'll link in the show notes. Osteopenia was actually never supposed to be a diagnosis in the first place, but it is now something that people are being diagnosed and treated for. So those people are also probably showing up in your class. The difference between the bone mineral density of an osteopenic spine And a severely osteoporotic spine is massive.
00:11:20
Speaker
And the kind of people who are severely osteoporotic for whom spinal flexion could actually create a fracture, but so could something like sneezing or coughing or any variety of of moves.
00:11:33
Speaker
First of all, those people are are very likely not coming to your class because they're very likely living at a level of frailty that they may not even be leaving the house. I would hope. yeah It's also deeply problematic to claim any sort of medical condition is going to be benefited by a non-clinical, non-supported in research approach. I don't like it at all.
00:11:54
Speaker
It makes me real mad. Yeah. So I've encountered messaging like this, though, from teachers online, listening to podcast interviews. They've completed these trainings, and it seems to me from my perspective listening to them or seeing their content that they guide their students in a way that...
00:12:10
Speaker
In so many words slash messaging, fear mongers flexion and makes really broad sweeping claims about flexion and the risk to fracture made to entire classes of individuals about these dangers of flexion.
00:12:26
Speaker
And these people are yoga teachers, Pilates teachers. They are not physical therapists or doctors. And this is bad on two levels, okay? One, it causes people to become afraid of movement.
00:12:39
Speaker
Two, it's outside of scope of practice. Do you have any thoughts about the scope of practice part of it, Sarah? Yes, your scope of practice as a movement teacher, right? I think in different ways for the yoga teacher world and the Pilates teacher world, there's this kind of semi-medicalization process.
00:12:59
Speaker
conceptualization yeah of your modality, right? In yoga, I think it comes from this outdated belief that yoga fixes everything, right? And that comes from things like in the Iyengar book, what's it called? tree on light or Light on Yoga. I was like, book on tree on life on yoga.
00:13:18
Speaker
Isn't there one with a tree in it? The tree of yoga. Oh, is that different than light on yoga? Okay. I think it might have been, I don't know. You can take all this out. That's fine. In the Iyengar book, what's it called? In the Iyengar book, light on yoga, there's a whole list in the back of things that yoga supposedly helps or fixes that is basically totally bullshit.
00:13:35
Speaker
um Wildly, wildly. It's, it's, this pose is gonna cure your depression. Right. I'm like, I'm pretty sure it won't. Yeah. Just a, just a guess. Yoga people have this kind of semi-mystical belief in the power of yoga to fix everything. And I'm not saying yoga is not good. Yoga is great. I love yoga. I was a yoga teacher, but nothing fixes everything. Yeah. Right. The Pilates people have like, this because they actually get typically quite a bit more training than a yoga teacher before they're unleashed on the world.
00:14:04
Speaker
They, I think, interpret that as they have a level of knowledge from this training that is up to date, that is accurate, and that is totally fair game for them to then teach. So for different reasons, I think both of these categories of teachers in particular, like you don't see people teaching like spin for osteoporosis, right? Yeah. You don't see it in other movement modalities. And obviously yoga is more than just a movement modality, but we're talking about the movement part of it here specifically. Yeah.
00:14:32
Speaker
So you, in these two groups in particular, there seems to be this idea that A, the thing you're teaching has benefits beyond what it has benefits for, and B, you are qualified to promote or fear monger different types of shapes or exercises based on the training that you got. And you don't, it's outside your scope.
00:14:53
Speaker
So those two big glaring problems aside, Let's now actually talk about this recommendation against spinal flexion. Is the evidence supporting this fear of spinal flexion sound?
00:15:04
Speaker
Should this advice to avoid spinal flexion be given with as much confidence as I often hear it given? Without spoiling the wonderful surprise of this episode. All of the details of the research we're going to talk about. What's your gut check on that, Sarah?
00:15:18
Speaker
This is the TLDR. Yeah, the TLDR is, let's say you have osteoporosis and you're going to your yoga for osteoporosis class and you do an hour of yoga that has no spinal flexion in it. Good fucking luck not flexing your spine the other 23 hours of the day Right?
00:15:33
Speaker
It's unavoidable. Yeah. Like, you're going bend over to pick up some groceries. You're going to flex your spine when you accidentally, like I did the other day, drop your smoothie in the passenger side seat of the car on the carpet floor bit on your way to work.
00:15:46
Speaker
It's a terrible way to start the day. But, like, there's... Why was it on the seat? What was it doing on the seat? Or on the floor? Well, What was it on the floor, Sarah? didn't start out on the floor. I'm blaming you. No. I'm kind of blaming you. Well, so...
00:16:02
Speaker
the you What you should know is that I'm generally racing to work. Even though work is only literally a five minute drive from my house, I massively underestimate the amount of time that I need in the morning consistently. And i try I work on it and it doesn't get any better.
00:16:16
Speaker
Okay. So I have to dig a little deeper. Yes. Yes. I think it's due to some other resistances in my brain. So I'm usually flying through the drive and I do it safely. I ride a motorcycle. I'm constantly scanning. I'm using my peripheral vision, but I go fast, right? I'm not doing it dangerously.
00:16:33
Speaker
But sometimes then you got to brake real hard. So if my smoothie is sitting in my bag of like my little lunch bag. Wait, you're in your motorcycle? No, I'm in in the car. Okay. Picture it. I was in the motorcycle for a second. Oh, no, that's just because I'm saying because I ride a motorcycle, I very much understand the risk.
00:16:49
Speaker
Translate to driving cars. Yes. I'm driving the car, my backpack is on the passenger seat, in front of my backpack is my little lunch bag, often with my smoothie kind of jammed in the top. I brake real hard, that bag goes tilting forwards, the smoothie goes flying, it ends up on the floor. I know, I try i have like wishful thinking like that where i'm like, maybe this backpack is also a cup holder.
00:17:08
Speaker
It turns out no. No, not great. In that instance, the point of this entire story is that sometimes you have to flex your spine. Yes. It's true. Sometimes you have to flex your spine. Before we get into this research, it really reminds me, the paper we're going to look at, of another paper by Lauren Fishman titled... 12-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Okay. The research we're going to look at regarding the risks of spinal flexion in terms of osteoporosis and fracture reminds me a lot of this paper because that Lauren Fishman paper became the paper that every yoga teacher training cited. The paper is weak, exceedingly weak in terms of the conclusions that that are drawn based on how the study was conducted. um
00:18:00
Speaker
I know to you listeners, if you would like to learn more about the paper we're referencing by Lauren Fishman, Sarah and I recently recorded an episode, episode 92, Make Dr. Lauren Fishman Make Sense, in which we dissect a recent email we received from Dr. Lauren Fishman in which he expressed frustration over our past critiques of his study.
00:18:22
Speaker
The study's titled 12-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. In episode 92, we go into a lot more detail about his study, and we also respond to additional claims he made in his email to us. Check out the show notes for episode 92, Make Dr. Lauren Fishman Make Sense.
00:18:38
Speaker
are
00:18:43
Speaker
Similarly, this study that we're going to look at titled postmenopausal spinal osteoporosis, flexion versus extension exercises, and this is a spoiler, is also quite weak and is also a cornerstone reference in teacher trainings and blogs on yoga and Pilates websites and in discussions about exercise safety for individuals with osteoporosis, which makes me conclude that these folks either haven't read the paper or they don't have enough research literacy to understand how weak it is. And look, I am not particularly research literate. I will be completely transparent about that and I am working on it.
00:19:20
Speaker
Hard, in fact. And it's hard work. Okay, is the belief that spinal flexion is dangerous really justified? Does this study that we're going to look at hold up under scrutiny? We're going to look at it, and based on how it was conducted, going to get into the nitty-gritty of that as well as its findings. If it's plausible for yoga and Pilates schools to recommend against spinal flexion as a sort of blanket recommendation, irrespective of whether that's within their scope of practice, whether it medicalizes Pilates and yoga, and if that's an ethical concern, which we believe that it is, but is the recommendation supported by evidence?
00:19:53
Speaker
The TLDR, this study, leaves a lot to be desired, if you haven't already picked up on that, when forming such strong opinions and making such blanket warnings. All right, after we look at the study called Postmenopausal Spinal Osteoporosis Flexion Versus Extension Exercises, which was conducted in 1984, we'll contrast that with another study conducted in 2002, led by the same investigator, Dr. Miersheed Sanaki, which I find very interesting, titled Stronger Back Muscles Reduce the Incidence of Vertebral Fractures, a prospective 10-year follow-up.
00:20:27
Speaker
of menopausal women. So just to plant the contrast in your mind, one study is looking at the risk of exercise, particularly as it pertains to flexion. The other is looking at the benefits of exercise as it pertains to extension. You might then go, oh, flexion bad, extension good, but wait, there's more, okay? This research, the second one, found that just two years of strength training using one single exercise significantly correlated with reduced fracture risk in post-menopausal women eight years after stopping the strength
Study Limitations and Criticisms
00:20:56
Speaker
training. Meaning they trained this one exercise for two years. God bless them.
00:21:02
Speaker
Then they stopped and eight years later in a follow-up, their outcomes were much better than the control group, which did not engage in the exercise intervention. So in terms of bone mineral density and fracture rates, the exercise group was far better off eight years after stopping exercise. And we're gonna, again, make some guesses as to why it's unclear, but it's interesting. Ultimately, when comparing these two studies, we're asking, is the blanket advice for all folks to avoid spinal flexion who have osteoporosis valid?
00:21:30
Speaker
Especially considering its potential to instill fear, to discourage exercise, or maybe more specifically, lead to the avoidance of potentially beneficial strength exercises. Is this type of warning truly sound from a science-based perspective?
00:21:42
Speaker
Is it science-based, given the findings we're looking at, given the way the research was conducted? Or is the real issue here, and I'm sure you can tell what I think, okay, that many women still just aren't engaging in strength training at all?
00:21:57
Speaker
We'll explore how strength training consistently emerges as a protective factor against fracture, against osteoporosis, and why the conversation should shift from fear-mongering to empowering women with the benefits of building strength using research-supported methods, hum not misleadingly calling your classes yoga for osteoporosis or yoga for bone strength. Okay, okay, okay. Let's dive in to the first paper.
00:22:24
Speaker
All right, so this paper is entitled Postmenopausal Spinal Osteoporosis, Flexion Versus Extension Exercises. Okay, so what they did is between 1969 and 1981, these researchers from the Mayo Clinic conducted a study to see how different types of exercise affect the risks of fractures in the spine for postmenopausal women with osteoporosis.
00:22:47
Speaker
At this time, there was not a lot of guidance as far as what to do with someone who has osteoporosis. There was this vague idea that exercise was gonna be helpful, but there wasn't a lot of understanding about what kind of exercise was helpful, what kind of exercise might be less helpful or potentially dangerous.
00:23:03
Speaker
So that's part of what this study was trying to tease out. So there were 59 women in the study between the ages of 49 and 60. They all had osteoporosis, they all had back pain, and then they were divided into four groups.
00:23:18
Speaker
One group was called group E, E stands for extension, which means these people did movements that involved either stretching or strengthening the back muscles so while lying face down or sitting. This group had 25 people in it.
00:23:31
Speaker
Then there was a group called group F. what do you think the F stood for? Fun times. No, it stood for flexion. Okay. And that included sit-ups and stretches for the back. There were only nine people in this group.
00:23:43
Speaker
And that should, and somewhere in your brain, should start to ping a little red flag a little bit. Like, just put a pin in nine people. Nine. Okay. Then we had a group called EF. Guess what they did?
00:23:54
Speaker
Everything fun. No. They did extension and flexion. Oh, okay. Yeah. And there were 19 women in this group. And then there was a group, group N. These people were the no exercise group. They were taught to maintain good posture, whatever that means, during their daily activity. So probably they were told like, bend at the hips when you go down pick something up, don't bend at the spine. Right.
00:24:14
Speaker
Neutral spine. N maybe is standing here maybe more for neutral than no exercise because they were also taught how to do like isometric abdominal contractions. That's like the Miguel Big Three exercise.
00:24:25
Speaker
Yeah. Sort of bracing. Yeah, totally. yeah And here's another group. There are only six people in this group. Oh yeah, six. That's not great. That's the control group. Yeah. So then... Sorry, my cat. You're so loud when you walk.
00:24:39
Speaker
You're supposed to be quiet and stealthy. You're an ambush hunter. Come up here. Okay, you might be need to be locked up somewhere. This is the problem with recording in the living room. it It's hard to escape the wonderful, melodic tone of his meow.
00:24:58
Speaker
As he's gotten older, he sounds so old. oh Sounds like such an old kitty. he's like I think he'll be happy here. want to be cozy. I want someone touching me. yeah I want switches and snuggles.
00:25:09
Speaker
Yes. Okay.
00:25:12
Speaker
okay Okay, so some people, and it's honestly not clear which, if it was just the group N or everybody, were instructed to not lift anything over 10 pounds.
00:25:23
Speaker
It's also not clear, because it doesn't say in the study, how long they did these exercises for. Was it over three months, six months, a year? We don't know. Then there were follow-ups from anywhere between one to six years later.
00:25:35
Speaker
And they used x-rays again, because at the time that was the only available technology, to check if they were if they could see any new fractures. And a fracture in this context means a bone in the spine either collapsing or cracking due to the wheat and wheaten weakened state of the bone.
00:25:53
Speaker
Okay, so here's what they found. Group E, what does E stand for again? Extension. In group E, the extension group, 84% of women had no new fractures, right? So the people doing the extension exercise had the least amount of fractures.
00:26:06
Speaker
This was also the largest group of people that were studied. In the flexion group, who were doing flexion exercises only, can we also break in for a second and say, generally speaking, it's not a good idea to do just one direction of movement exercises for anybody. So this is a mean study setup.
00:26:23
Speaker
Yeah. It's like when they do those balance tests for people who have impaired balance and they put them on ah one of those plates and the plate starts shaking. I'm like, they can't fucking balance when the ground is not shaking. What do you expect?
00:26:34
Speaker
Anyway, in the flexion group, now this is only nine people, which is a very small amount of people. 89% of women had fractures. So this group had the most amount of fractures. In the group E plus F, extension and flexion, there were 19 people in that group.
00:26:48
Speaker
53% had fractures. hat fractures And in the group N, which is no flexion, no extension, and again, there's only six people in this group, 67% had fractures. So that means four out of six of them. If I'm mathing correctly, two thirds? Yeah, okay. So based on this, the researchers concluded that flexion exercises like sit-ups cause more fractures and extension exercises or posture-focused activities quote unquote, were safer for women with osteoporosis. But 67% of the posture-focused activities, the control group, had fractures. That was the second highest percentage of fractures, which makes me think that actually neutral spine is dangerous.
00:27:27
Speaker
so We should write an episode called Neutral Spine is Bad for You. If it's all you're doing, it fucking is. Yes. Okay. Are you picking up on any problems? Yes. I feel like there are several things wrong with this study. Me too. Do you want to go first? Yes, please. Okay. But before I do, I just want to say...
00:27:49
Speaker
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00:28:05
Speaker
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Speaker
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00:28:53
Speaker
There are several things wrong with this study. do you want to go first? Yes, please. Okay. But before I do, I just want to say, because this accusation has been lodged at me and both of us past, that we are not just here to be Debbie Downers, okay? We are not here to go on some rampage to nitpick for the sake of nitpicking. There are real issues with this study.
00:29:14
Speaker
And we hope that, yes, despite our sarcasm and our love of I'm saying silly random things off the cuff that you hear that we are trying to be as objective as possible in pointing out the real problems with this study and the next study we're gonna look at, which we like a lot better. Both studies have problems.
00:29:34
Speaker
Okay, so number one, the big one, the low hanging fruit. There are too few participants. Some of these groups were Tiny with a lowercase t. Even if there was something smaller than the lowercase, that's what the t would be. One point. One point font.
00:29:48
Speaker
One point lowercase t. Group F had only nine women. So group F is the group that is supposedly doing the thing that's dangerous. In a study that is being cited in order to strengthen blanket statements to avoid flexion, nine people.
00:30:04
Speaker
Group N, which is the group that is not supposedly moving their spine somehow, they're maintaining quote, good posture and bracing some of them. They were also told not to lift more than 10 pounds.
00:30:15
Speaker
Okay, maybe because that would have been a confounder. Group N had six people.
00:30:22
Speaker
They're small groups, very small groups, and that makes results much less trustworthy and... Really, it's not a good idea to then apply them to larger populations, which is what a blanket statement in a yoga class does.
00:30:36
Speaker
Right. Here's why. It reduces the power of the study. What does that mean? Okay. Let's say you're trying to run a science-y type experiment in your own personal life and you have this song that makes you so happy. you feel unhappy, then you listen to the song and then you feel happy and you just notice this positive mood change and you're like, I wonder if this is true for everyone or some people or a majority people. So you ask your friends, three of them, to listen to the song and notice if they feel happier afterwards and they say yes.
00:31:02
Speaker
It really helps them feel happier afterwards based on that. you still don't know, you have no way of knowing whether or not it was just a coincidence. That it just so happened that these three people experienced that outcome.
00:31:13
Speaker
So the power of your test is like your ability to know the truth about this song. It's low power. If you only ask a small group, it's harder to be sure. You might miss the fact that the song actually makes most people sad.
00:31:27
Speaker
If you asked 100 people instead of three, and if they weren't all your friends, because that's a bias, it'd be much easier to see the real effect because you'd have more data to work with. So small groups make it harder to figure out the truth.
00:31:39
Speaker
And that's why studies like this one that have very small sample sizes are not as good as ones that have larger sample size. Now, granted, this is a small study. It's not claiming to be a large study. Small studies serve a very important purpose in science. They often drive us, if they have interesting results, to then do a larger study yeah to see if that actually holds out with a bigger study. Especially if they can be replicated yes by other smaller studies.
00:32:02
Speaker
So the other problem, one of the other problems is that there was no random assignment. Instead of the women randomly being placed into the groups, their individual doctors, more than one doctor decided what group they got placed into. This is gonna give us some problems.
00:32:18
Speaker
The first one is a problem called selection bias, because if we don't assign people randomly, the then the groups already may have significant differences that are going to affect the outcomes.
00:32:29
Speaker
So maybe their doctors were like, you know what? Betty is really frail. I don't want to put her in either the extension or the flexion group because I'm worried. I'm worried about both of those. Yeah. So I'm going to put her in the end group, right?
00:32:43
Speaker
Sally. Look, is doing pretty well. She's pretty fit. I'm going to put her in the flexion group, right? Who knows? Because you already have an opinion about flexion. Your opinion is going to bias what group you put the person in, and then that's going to bias the results.
00:32:55
Speaker
Something people have a lot of is opinions. The two of us, for sure, and probably everyone else if you ask them. Especially if you ask them if we have opinions. And their opinions about our opinions. So then you you have a problem...
00:33:10
Speaker
because you have you have to end up with two problems. You can't really establish causation. You can't really say this caused this and this caused not this because we can't say that the groups had a variety of different factors that might change the results, right? That's why you wanna do it randomly.
00:33:29
Speaker
You want someone one in the group that has bunions and you want someone in the group that gets headaches and you have someone in the group who's diabetic so that all of those possible confounding factors like all cancel each other out.
00:33:40
Speaker
Right. Right. So we don't know that. I mean, we know that didn't happen. So we don't know if there are these other confounding factors that would have played a big role in why the results are skewed the way that they are. And then because of that, you can't really take the results and generalize it to the rest of the population. so AKA, you probably shouldn't say to a group of 20 individuals in your yoga class yes that they shouldn't flex their spine. Exactly.
00:34:06
Speaker
All right. We also have the issue with a lot of uncontrolled variables and it's impossible to control for everything, but the researchers didn't track Other factors that could easily have influenced fractures, stuff like diets, medications, how active the women were in daily life, or even whether they stuck to their exercise routines. And if they did track these things, it's unclear as to what extent the research. Sarah's going to talk about this and probably in a second. The way the research is communicated in the paper, it's unclear when you read it what actually happened. leaves a lot of questions. So what this does is it causes what are called confounding, potential confounding effects.
00:34:44
Speaker
So uncontrolled variables called confounders can affect your outcomes. And so then it becomes hard to tell whether the changes that you observed in the results are due to the variables that were studied. So that's the extension exercises versus the flexion exercises versus both versus neither. Whether the changes you observed were because of that or because of all these other possible confounding factors.
00:35:08
Speaker
Yeah. Okay. And so ultimately failing to account for important confounding variables can easily lead to either overestimating or underestimating the effect of the variable being studied, which again is position of the spine.
00:35:22
Speaker
It's also highly likely that the technology they were using during the time that the study was conducted is less accurate and less reliable than technology used today.
00:35:34
Speaker
Yeah. We also have different follow-up times. Some of the women were followed for a year. The others were followed for six years. That's a five years difference. A lot of things can happen in five years. We're not comparing the results in a fair scenario.
00:35:46
Speaker
Right. Also, the exercise descriptions were very vague. They were not clearly defined. There appeared to be no standardization. For example, how many sit-ups did group F do? Were they all doing the sit-ups the same way? We don't know. One of the features of good, at least a good write-up of your results, of your research rather, is that someone else should be able to read it and replicate your study. We don't even know for how long they exercise. Yeah, so I couldn't read this and replicate it. I couldn't tell if they had exercised a week or a year. Who knows?
00:36:19
Speaker
Unclear. They probably, it probably was standardized, and
Exploring Strength Training Benefits
00:36:22
Speaker
we don't know what it was. They didn't tell us they didn't tell us. Okay, so then we get into the question of whether or not this is statistically significant. And this is where your brain might just leak out of your ears, drip onto the floor. But i'm going to try to make it as not confusing as possible.
00:36:36
Speaker
Statistical significance means that the difference between the groups are unlikely to be due to chance, right? So if something's statistically significant, it means that the thing that you're studying is the reason why the groups are different, but it doesn't explain how important that is in real life.
00:36:53
Speaker
which is the effect size. Yeah. So the effect size measures the strength of the relationship between the variable and the outcome, right? Flexion and fractures, extension and no fractures. And that gives us a much more practical, real world level of importance of the findings of the study.
00:37:12
Speaker
Statistical sniff. Why it's so hard for me to say that word. It's a hard word together to work. Statistical significance tells you whether or not the observed effect is because of chance, but just because it is statistically significant doesn't mean it's real life significant.
00:37:28
Speaker
Like for example, Let's say you wanted to take a math tutoring course because you have to take the SATs. And so probably your mom, probably not you, probably your mom is online researching which courses are going to give you the most improvement.
00:37:43
Speaker
So you look on, you look, you research, you go online and you're looking at different programs and you find that one program will take your results from, let's say, 80% to 80.2%. to at eighty point two percent Right?
00:37:57
Speaker
So that may be statistically significant, but they're both still a B minus. yeah Right? So that's effect size, right? right How big of a difference is it really going to make a difference to their SAT t score? Maybe by one or two points.
00:38:16
Speaker
But is that going to then get them into Harvard? Probably not. Just because they say it's statistically significant, part of the problem is that the number of people being studied is so small and there was no randomization, all these other things that we discussed, then makes it very hard to to to say with confidence that this has a meaningful effect in real life.
00:38:36
Speaker
Exactly. We don't know whether this study produced results that were likely due to chance because of such small groups, plus the lack of reduction of confounding factors. We don't know if the results found would have any meaningful outcome on how you should apply that to your life.
00:38:58
Speaker
Right. What's the bottom line? This study highlights that certain exercises might be risky for people with osteoporosis. Its flaws, which include a very small sample size, different size groups, lack of randomization, lack of control of confounding variables. Lack of control group. Lack of control group. That is a huge one. Yeah.
00:39:17
Speaker
There's no control group. We'll just leave that there. This makes it hard to rely on the findings and we'd need bigger, better design studies. We'd need this study to be replicated.
00:39:28
Speaker
We need better design studies, clear exercise instructions that utilize more modern diagnostic tools to truly understand if flexion or any position specifically is dangerous more than others. If some positions are in fact safer for the spine to be in most of the time than others. I have a feeling that the claims made by Pilates and yoga teacher trainings are actually based off of this one study held up as proof that flexion is dangerous for people with osteoporosis. And I think that's a big problem.
00:39:57
Speaker
Yeah. I came across the UK, that stands for United Kingdom, guidelines, right? That's guidelines for England, Scotland, Wales, and Ireland. Okay. around what to do exercise-wise if you have osteoporosis. And the reason I came across it is it looked at this study. It took all of the evidence that they could find, right? That's what they do when they create these guidelines. They they look at all of the evidence.
00:40:19
Speaker
There's nothing in the guideline that says, don't flex your spine, which means they considered this evidence and they trashed it. No, truly, they didn't include it because it didn't meet the standards required to be considered good evidence. If they had more evidence or if this was a stronger study, they may have included that. But they did not. Because there wasn't.
00:40:36
Speaker
Sarah, say you just read the study alone, randomly woke up one morning, had a hankering to read a study, picked it up, read it over coffee. And you had taken into account all of the flaws and...
00:40:51
Speaker
What not? Does it leave you with any questions? It left me with some questions. why I asked. Does it leave you with any questions? Would it have left you with any questions around why the nine people, nine people who did flexion-based exercises, whatever those were and however much time they did them for, why did they have more fractures than the ones who did extension-based exercises? We can wonder about it, right? Sure.
00:41:13
Speaker
We're just guessing. But do you have some possible alternative explanations? Just pulling a few out of thin air? Yeah.
00:41:23
Speaker
Sorry, I went because that's the noise I make when I don't know where to start. We don't... the
00:41:30
Speaker
There could have been something similar in all of these people, because we know that they weren't randomized, that predisposed all of them to have more fractures, separate from having osteoporosis. Maybe they were genetically more predisposed to having it. they're just I just keep getting stuck on the fact that the sample size is so small that you can't generalize anything from it. There's a million alternative explanations, because we haven't created a scenario where we've ruled out as many as possible of them. Good. All right, next study. Let's zoom out though. We looked at a study just moments ago that looked at the risk
00:42:03
Speaker
behind exercise as it pertains to osteoporosis. Now we're gonna look at another study that is instead looking at the possible protective effects of exercise for women and how that relates to osteoporosis and fracture. So this one is called Stronger Back Muscles Reduce the Incidence of Vertebral Fractures, a Prospective 10-Year Follow-Up of Post-Menopausal Women. The same investigator conducted this study through the Mayo Clinic, Murshid Sanaki.
00:42:31
Speaker
This study was conducted in 2002 and it explored whether stronger back muscles could reduce the risk of vertebral fractures in postmenopausal women. The study followed 50 healthy postmenopausal women who at the end of the study were aged 58 to 74. So keep in mind, this was a 10 year study.
00:42:51
Speaker
The study followed them for a decade after they participated in a two-year randomized control trial. So 10 total years, two years of the trial, then eight years goes by and there's a follow-up.
00:43:03
Speaker
They participated in this controlled trial of back strengthening exercises. So to start, the women were divided into two groups. They were randomly divided into two groups.
00:43:16
Speaker
27 women performed back strengthening exercises, which we will describe in a moment. They did this for two years. 23 women served as controls, meaning they did not follow the exercise program. So this is good because now we have randomization. We have groups that are closer in size and we have a control group. We're on the right track here. Yes.
00:43:36
Speaker
The back strengthening regimen involved lifting a backpack with weights equivalent to 30% of their maximum back strength. There's a picture included in the study. Sarah, can you describe what the exercise looks like?
00:43:50
Speaker
Yes. This is just color commentary, but it reminds me a lot of a book that I have from like the seventies. That's all about it. I think it's called 28 day yoga exercise program or something. And it's a lot of pictures of women in leotards and tights. had a couple of those books. It's the greatest. So this woman is lying on her belly and it appears that they have placed, it looks like a folded up pillow or something under her hips. I'm assuming that is to either make it more comfortable or decrease the amount of lumbar lordosis when they're on the ground. It's not totally clear, but anyway, they've got a pillow under their hips.
00:44:22
Speaker
And until I understood that this person was wearing a backpack, I wasn't sure. It almost looked like she had a ah plate, like a 25 pound plate on her back or something. But it's actually a backpack with weight in it.
00:44:33
Speaker
And she is doing, she's got her arms down by her sides. She's doing spinal extension. It's like shalabhasana with your legs With your legs down, right? So she's not lifting her legs. She's keeping her legs down. She's got her arms reaching back and she's doing however much extension she can do from that position.
00:44:48
Speaker
Yeah. Okay, so over time, as these women's strength increased, the weight was adjusted to be heavier. So here we have progressive overload, but the weight could never be above 50 pounds. Apparently the backpack couldn't hold more than 50 pounds.
00:45:01
Speaker
And that's just information that was included. We never found out if some women topped out and then were unable to continue to progressively overload their strength. They're just letting us know that this backpack only held 50 pounds. So the exercise using this bag was done at home. And this is really, my eyebrows went up.
00:45:16
Speaker
This exercise was done five days a week. This one exercise. Now, here's the thing. We don't actually know how many times they did this exercise in a day. I don't believe that was included, like how many sets they did. It was probably isometric. Mm-hmm. Then every four weeks, both groups had their strength and physical activity levels assessed and proper posture techniques were reviewed. Maybe it was like form checks. Okay, just let's make sure you're doing the exercise correctly. And that happened every four weeks, which is good. So there is this attention being paid to whether or not the exercise is being performed as intended. Okay.
00:45:52
Speaker
Also their strength is being assessed to determine whether or not they need to increase load. We believe that their strength is being assessed via some type of dynamometer and that they're looking at maximal isometric contraction or just isometric contraction. Okay. At the end of the two years, the exercise group stopped the program and were not monitored for the following eight years. So in other words, they were free to go and do whatever they wanted to.
00:46:20
Speaker
They were given no restrictions and no guidance. All participants returned. That's actually pretty impressive. It is impressive. I think all of them returned. Okay, hopefully I didn't get that wrong. For a follow-up 10 years after the start of the study, and here's what they found. We're gonna discuss some key findings from this study. Yeah, so here's some significant things that they found.
00:46:40
Speaker
In terms of muscle strength, The exercise group's back extensor strength at the start of the study was an average of 39.4 kilograms. It then peaked at 66.8 kilograms after two years of doing this exercise.
00:46:55
Speaker
Then at eight years later, it dropped back down 32.9 kilograms. kilograms Right? Because they had stopped doing the resistance training using the backpack for then that eight year period.
00:47:05
Speaker
The control group who did not do these any exercises for back extension strength, they started at 36.9 kilograms. So a slightly lower baseline and it improved slightly to 49 kilograms after two years of not doing resistance training. They determined this to be coincidental the paper.
00:47:25
Speaker
But then it fell again to 26.9 kilograms at that 10-year mark, which was six kilograms lower than the study group. So something to note both groups started at a lower level of strength than they ended at after two years.
00:47:42
Speaker
But after 10 years, we're at a lower level of strength than they started with initially. Yes. But- Despite the decline, the exercise group maintained strength levels that were considered significantly higher than the control group a decade later. There was roughly a 20% difference in their strength.
00:48:00
Speaker
At 10 years? At 10 years. Of course they were much stronger after 2. Right. We would expect that. Yes. The surprise is that they were actually quite a bit stronger after 10 as well. Yes. All right, regarding bone mineral density, although bone mineral density decreased similarly in both groups over 10 years, it decreased an amount considered by researchers to be a normal decline due to aging.
00:48:23
Speaker
The exercise group's bone mineral density was significantly higher at the 10-year mark. compared to the control group. But the change over time was not enough to claim that the exercise intervention built bone. It may have slowed bone loss.
00:48:41
Speaker
We're going to talk about this. yeah I also want to say something about this. The difference in bone mineral density pre-exercise intervention and then two years later was also not significant. In other words, the exercise intervention did not build bone density at any point.
00:48:58
Speaker
But bone mineral density levels were significantly different after 10 years. Regarding fractures, the control group experienced 14 fractures across 322 vertebrae, while the exercise group had six fractures in 378 vertebrae.
00:49:19
Speaker
So the exercise group had fewer fractures across more vertebrae, so a much lower percentage. It breaks down to the control group's relative risk of fracture was 2.7 times higher than the exercise group's. Yeah. And so this speaks to a couple of things. The study itself wasn't saying, let's see if this exercise increases their bone mineral density. Which is really important to constantly remember.
00:49:45
Speaker
Yeah. It was saying, let's see if this exercise reduces their risk of fracture. And it did. Which also speaks to when people say anything is better than nothing. Yes, it is a it is a, what's the word I'm looking for?
00:49:58
Speaker
Yes, but with some restrictions around the yes, in the sense that it may not be doing anything for your bone mineral density, but it may reduce your risk of spinal fracture, which is important. Don't get me wrong. I still think heavy lifting is the most appropriate intervention, but this just points to maybe the sort of why of people say anything's better than nothing. It's true for all exercise for any reason.
00:50:19
Speaker
It's true in some ways. What we're going to see, though, possibly, and this is, again, conjecture, but not based on nothing, that yes, while something is better than nothing, what this study might suggest, and we're going to get into it, is that strength, specifically, progressive overload, right, specifically creates a cascade of behaviors and changes in a person's life that causes them to be more physically active, which reduces bone loss. Yeah, possibly.
00:50:49
Speaker
Notice how much caution and qualifier type language we're using in making these statements. We're not saying everyone with this thing should avoid this thing with a high level of confidence, because that is just not a science-based way to communicate at baseline.
00:51:06
Speaker
And this study, and any study really, never fully supports a high level of confidence because it's usually just looking at one piece of a puzzle That's why when people say something with high levels of confidence, I'm immediately suspicious. Red flag.
00:51:22
Speaker
Yeah. I'm staying skeptical. That's a new t-shirt in the store, folks. It is. It's stay s skeptical. Yeah. Movement logic. That's right. That's right. It's a cute little tank top. It is. It can also be a t-shirt or a muscle tank. Anyway.
00:51:36
Speaker
So in terms of physical activity, it was found that initially both groups had similar physical activity levels. Obviously during the two year program, there was increased activity in the exercise group. But at the 10 year follow up, activity levels had decreased in both groups, but remained higher in the exercise group.
00:51:52
Speaker
So what we're seeing is that the exercise group remained more physically active. They still had a higher bone mineral density and a lower risk of fractures. Eight years later.
00:52:03
Speaker
That's cool as fuck. I love that. The first study had a lot of problems and limitations. Like so many. Oh my God, you guys like so many? Like so many.
00:52:14
Speaker
This study is not free of problems and limitations either. We are going to look at some of the problems and limitations with this study as well. I think it has far fewer, but they it does have some.
00:52:29
Speaker
I just want to interject to say I think it's almost impossible to create a study that has no problems or limitations. Yes. Yes. We have small sample size again. We have like 27-ish people in both groups. Yeah.
00:52:43
Speaker
It's not a large study. Only 50 women completed the study. Okay. That limits our ability to generalize the findings. And there was a lack of monitoring. I think for the most part, these women were exercising alone. They had four week follow-ups.
00:52:55
Speaker
Additionally, after the initial two years, neither group was monitored. They were given no restrictions. And if they were, okay we don't know exactly how they were then able to remember what their physical activity levels were like.
00:53:09
Speaker
over the course of eight years? Were they given a diary? Were there ways that they were recording their physical activity levels? Because at the end of the day, i have no fucking clue really what happened yesterday. So asking people, we'll get into it, but like asking people to tell you what their physical activity levels were like over eight years is...
00:53:26
Speaker
ah ah yeah like I mean, I don't think it says in the study if they were given ways to track their general activity and over that eight year period. Yeah, it was self reported somehow. Right.
00:53:38
Speaker
So either at the end of the eight year period, they had to think back and determine whether they had been more physically active or not. That's a long time to try to remember anything. Also, we're very bad at estimating.
00:53:49
Speaker
Like whenever you have someone do a food diary, let's say, and you're because you're looking at their nutrition, when people write down what they're actually eating versus what they thought they ate, it's wildly different. Oh, I just had this. No snacking. What are you talking about? So that's a hard thing. That's a hard ask.
00:54:04
Speaker
and to say yeah It's very unreliable to ask people to just remember and then self-report and just take that as objective truth. One thing I'll say, though, is that the study did specifically mention that the people who reported that they were more physically active from that exercise group were able to stay in their jobs longer. slash or had more physically demanding jobs. So this is conjecture.
00:54:28
Speaker
Is it possible, question only, that the exercise they did do for two years that was progressively overloaded and that made very significant change to their back strength, made it so that they were able to have more physically active jobs, which in turn caused them to have higher baselines of capacity at the 10-year mark. Slash didn't make them able to stay in their jobs for longer. Questions only, but it would be a plausible thing to have happen. Yeah, I agree.
00:54:56
Speaker
All right. Bone mineral density.
00:55:00
Speaker
Okay. So issues with the bone mineral density findings. The difference in bone mineral density between groups was not significant at the start or after two years. Well, it's good that it wasn't different at the start.
00:55:12
Speaker
Yes. Okay. And it's... understandable why it wasn't so different after the two years, because bones just aren't going to probably respond all that impressively 30% of load. Okay.
00:55:27
Speaker
okay It only becomes significant, the difference in bone mineral density at the 10 year mark. This makes it unclear if the exercise intervention directly caused that improvement or change. I don't think it did.
00:55:38
Speaker
yeah Because when you take an exercise away, stops benefiting you. But I suspect, and this is something we've hinted at a lot, that the back extension exercise wasn't, while it wasn't high enough in terms of magnitude of load, it was high enough to cause increases to strength that caused that group to be able to engage in more physical activity.
00:55:57
Speaker
And then the last thing is the study didn't account for other possible confounding factors like diet, medication, hormone therapy, and more, all of which can influence bone health and muscle strength. We don't know about confounding factors during the two years or over the following eight years. I think that some people were excluded for things like hormone therapy and disease, but I don't think that they...
00:56:20
Speaker
were able to continue tracking that for the entire 10 years. They didn't say specifically, hey, in the next eight years, definitely don't start hormone therapy. And of course they can't say that, right? All right. So what are some key takeaways? What can we take away from this practically? What can we glean from this research? I think, number one, that this study underscores that strength training is beneficial. Being stronger is beneficial in reducing fracture risk.
00:56:47
Speaker
even if it's done for a limited amount of time in the distant past. ah Sorry. The benefits of that can carry forward in other ways because of the ways that temporary strength relative to how you started changed the way you live your life, changed the activities you decided to participate in. We talk a lot about how it's a self-reinforcing cycle, so to speak, where We stop participating in the activities of our life because we lack the strength, which causes us to decrease our strength levels, which causes us to discontinue participating in even more activities of our life. And it's this downward spiral, but the converse is true. We start strength training. We start participating in more activities in our life. We get stronger and more capable because of that. And that is that upward positive spiral. Yeah.
00:57:42
Speaker
The other thing that it underscores is that it's use it or lose it. The women stopped strength training after two years and lost all of their strength and ended up at 10 years with lower levels than they began with because of age-related declines, probably. And also not doing the exercise.
00:57:59
Speaker
And not exercising. Right. Which we can actually go a long way toward reducing age-related decline with, which is why exercise is the real, true fountain of youth. Yep. but So while the benefits of strength training persisted, seemingly, for eight years because they the exercise group had better outcomes at the 10-year follow-up, the greatest improvements, the greatest measurable improvements, were during those two years that they were actively training. So consistent exercise over time would have been likely much more beneficial than stopping for eight years.
00:58:32
Speaker
But it's also true, to say it again, that even just a little bit can go a long way. This is why the all or nothing mindset that we tend to walk around with, black and white thinking, if I can't do a little, I might as well not do any. If I can't do it forever, i might as well stop, is really unhelpful because even a little bit can be life-changing and life-prolonging.
00:58:54
Speaker
Sarah, we talk a lot in Bone Density Course about getting back on the wagon. How does that relate to a little bit goes a long way? Let's say they started the course, they did it for two months, and then as has happened for several people, because life is lifey,
00:59:08
Speaker
something gets in the way. There's some sort of family event. There's somebody is now out of work. We've had multiple people impacted by the fires in California, right? None of this is predictable.
00:59:19
Speaker
we One of the things that we use the Facebook group for is to create some community. And I even jokingly created something called the Month Behind Club. which is a bunch of people who are just working a month behind everybody else, but now they also feel like they have a group, right?
00:59:36
Speaker
We need support, and we especially women. We really like community and we like support. yeah And so while it would appear that Let's say someone participated in the course for two months and then stopped and never did anything again. That would still be beneficial to their life overall.
00:59:52
Speaker
There's so much more benefit to be accrued by continuing to work. So even if then there was like a year pause and then let's say you started it up again, that's fantastic. It's very hard to do to self-motivate in that way. Yes.
01:00:05
Speaker
But I know women who are doing that. yeah they they They signed up last year yeah didn't do it yeah with us, but they're doing it now. They're doing it now. Although I would say that takes a lot of discipline. It does. I know a woman in particular who has roped her all of her friends that live near her to do it with her. That's brilliant. Which fantastic. She's made her own community. yeah I love it. yeah I love it.
01:00:23
Speaker
And the community is also the accountability. yeah right That's why I was like, oh, you guys are the month behind group because you guys will keep each other accountable. yeah right Which leads to a problem of this study that you're going to talk about too, which is that lack of community. Right. That these women participating in this exercise. Right. We're doing it on their own homes. Right. And so just doing one exercise five days a week. Yes. it It's not the most interesting exercise program. It's a decent study design. Yeah. But those are two different things. Yeah. But yeah, I would be bored as hell if that was the only thing. I'd be like, two years are done. Thank fucking God. Yeah, seriously. i might be I might even be somebody who like bows out at month three. I'm like, I'm done with this.
01:00:59
Speaker
right This is so dull. But yeah, if you're not someone who's done a lot of exercise in your life and you start a program and you get a month into it and something happens or you get a month into it and you're just like, oh, this is a lot of work.
01:01:11
Speaker
It's very easy to adopt the mindset of, oh, this is not for me. That all or nothing mindset. I i apparently I just can't stick to anything. I'm not the kind of person who does. I missed a month. I might as well miss a lifetime. Exactly.
01:01:23
Speaker
And what this study is telling us is that even having done it a month might be useful. Right. And also getting back on the wagon at any point. Well, that that's not what this study says, but getting, we know from a lot of other research that getting back on the wagon at any point, starting resistance training at any age, including our friend, the oldest old is always going to be beneficial.
01:01:43
Speaker
Yeah. And that is, I think, ultimately the reason for being for us with Bone Density Course, yeah which is not just to help women get strong as fuck, not just to serve a group of people who have been marginalized in terms of the fitness industry and specifically the type of fitness that involves lifting heavy weights. Women, older women specifically, middle-aged older women.
01:02:06
Speaker
But yes, we do that. I think more than anything, at least I'll speak for myself, is that I want to help this become a habit. Yes. I want to help people see strength training like teeth brushing, like flossing, like cleaning their house, like showering, which is that sure you might miss a few days. I sometimes go whole days without brushing my teeth.
01:02:32
Speaker
But guess what? I get the fuck back on that wagon. I don't have the all or nothing like, oh, i missed a day. Might as well miss a lifetime.
01:02:43
Speaker
I think it should be the same way with strength training, frankly. I too do. I do too. i I do too. i do I do too.
Ethics in Movement Teaching
01:02:52
Speaker
I do too. Good. Okay.
01:02:53
Speaker
Now what you going to say? You mentioned that this is a ah group women in their mid to later life that have been marginalized or left out of strength training. That's still the norm now. It was absolutely the norm then. This is a study from the early 2000s, but it was more so a thing in the early 2000s than it is even now. yes that women are discouraged from participating in in heavy resistance training. Well, this wasn't heavy even. So it's very revealing that their like form of strength training was a backpack at 30% intensity. So different from the Liftmore trial.
01:03:24
Speaker
Yes. So different. Yes. Which was? Barbells. No, which I was going to say was a mere decade and change later. it's like big change like Big changes have happened. That's encouraging, right?
01:03:34
Speaker
Yes. What were you going say, though? Something. I was just going to say, that that's what I was going say, that the societal norms from 20 years ago and today are still somewhat similar, although it is getting better in terms of we're seeing more women lifting barbells. We also have, like it or not, social media. So there's a lot more opportunity for women. They don't have to go to a gym and find the one woman, maybe, who's lifting barbells. Right. They can scroll on social media and see women from all over the world.
01:04:01
Speaker
Yeah. And that's a huge thing for people to do something is seeing other people that look like you doing it. Yeah. We're also often blind to the algorithm that we are trapped in. And for us, of course, the algorithm is feeding us all of these positive images of women lifting barbells. right But I'm pretty sure for most of the females in my family, that is not what the algorithm is feeding. That's fair. Because that's not necessarily where their interests lie. I don't think things have changed as much as we would like to believe they have based on what we're seeing on Instagram. But I do think what you would have seen on Instagram in 2002, if it existed, compared to what you are seeing now, there would be a very big difference. And that potentially is somewhat reflective of how society has changed as well. But I always try to be mindful of the fact that Instagram of course is a very strong filter. Yes.
01:04:51
Speaker
No, that's true. On reality. That's true. But let's say you were like, oh, i can do women lift barbells? Right. And you wanted to be like, I don't know, let me do a search, women and barbells. Right. Lots of them. Yeah.
01:05:03
Speaker
Which is great. Fantastic. Yes. It's one of the things that I think social media is really good for is exposing people to ideas that they would otherwise not be exposed to. Right.
01:05:14
Speaker
Okay. What's your takeaway? My takeaway from these two studies when compared are that, okay, on one hand, we had a very flawed study that concluded that flexion exercises were dangerous and spinal flexion could lead to fracture in body weight exercises.
01:05:30
Speaker
And therefore, flexion should be avoided even in body weight exercises or just always. We know that this has led to yoga and Pilates teachers teaching whole classes called yoga or Pilates for osteoporosis and problematizing flexion, fear-mongering flexion,
01:05:47
Speaker
recommending outside of scope against flexion to their students. We feel that's deeply problematic. But we also know from comparing these two studies that we have this other less flawed study showing that strength is protective. And we have many more studies showing that as well.
01:06:01
Speaker
And it was protective even after a decade of stopping strength training, maybe because being strong in the past led to more physical activity. that carried these people forward into the future and that physical activity left them in a better place. So there's lots of questions still, but I want us to address some ethical questions that arise for me in looking at these two papers, specifically for movement teachers.
01:06:24
Speaker
Should we be so confident in our warnings against certain positions? Warnings that tend to be worded in a way that create fear, fear avoidance of exercise in our students.
01:06:38
Speaker
based on this one paper, the first one we talked about, which constitutes weak evidence if you look at the study design and how flawed that was.
01:06:51
Speaker
Do you have any thoughts there? Yes. we be so confident? No, we should not. Because look, fear mongering against any one particular movement, like spinal flexion, is not useful.
01:07:07
Speaker
for your students because perhaps you have now put the fear of god into them of ever doing any spinal flexion movements and ultimately that might be reducing their general physical activity might they might be really focused on never letting their spine move at all which is going to cause them to decline If you're never bending, flexing, side bending, rotating, even against the weight of your body weight, you're gonna get weaker.
01:07:35
Speaker
But Sarah, are you saying that flexion is always safe for people with osteoporosis then? Is that what you're saying? no I'm not saying that. But I'm also saying it's not automatically dangerous for everybody.
01:07:47
Speaker
Good. It's nuanced, right? Yes. It depends. It depends, which is an answer that people hate. but It may not be your job to make that decision for your students. Exactly. Exactly. It's definitely, you know what? I'm going to go ahead and say it's not your job to make that decision. And if you have, if if you're listening to this and you're like, fuck, I took a class called yoga for osteoporosis. Okay. How to teach yoga for osteoporosis. How to teach yoga for osteoporosis. I took the training. I paid the $2,000. And now I was like, I've been teaching a class called yoga for osteoporosis. But now I feel like maybe that's not the best.
01:08:19
Speaker
And I'm feeling shitty about it. That's okay. I'm sorry about the money spent. But lots of us have spent lots of money on things that we then discovered aren't either aren't great or that we don't use.
01:08:30
Speaker
Look in my closet, for examples. Yes. Right? Like, we all... We've all done lots of trainings that we like, you know, upon reflection, perhaps didn't give us the most relevant and the most accurate information.
01:08:48
Speaker
so I mean, i i would be I would be so on board with someone teaching a class that has a super long title. And maybe this is something they'd have to fix. But it would be called something like, come do yoga with me if you have osteoporosis. Some of you should be totally fine with flexing.
01:09:05
Speaker
Some of you might not. You're going to figure that out for yourself. We're going to have a great time. You're going to figure that out for yourself, hopefully not by fracturing. Well, but you signed my waiver. Hopefully you've seen a doctor. Hopefully, yes. person has cleared you for exercise.
01:09:18
Speaker
you for I was trying to keep the title a little shorter, but there's so much more nuance to it that is not afforded in a name of a class called yoga for osteoporosis. Here's the thing. I don't think you need to say a disease name in the title of your yoga class. yeah I don't think you should say it unless you are potentially some type of clinician who has within their scope of practice, the training to address the questions and concerns of people with a particular disease or condition. Yeah. I've i've taught workshops that had titles like relieve your back pain or relieve your neck pain and I've taught them and I am a physical therapist and even within that people come to class and they'll say they'll put up their hand they'll say why does it hurt when I turn my neck to the side and I will say i have no idea because I don't it would be irresponsible of me to claim that I do yes I think that whenever we use medical terminology in our marketing as movement teachers who are non-clinicians
01:10:13
Speaker
we are overstepping. I agree. Medical terminology includes something like this will take your XYZ pain away, back pain. Yoga for back pain, problematic. Yoga for osteoporosis, problematic. Yoga for cancer, problematic. Now, how could we change these titles to make them within scope?
01:10:30
Speaker
If you are teaching a type of yoga that might be more accessible to people who have undergone chemotherapy, what could we call it to make it so that it doesn't sound like your yoga is a treatment for cancer? Or same for osteoporosis.
01:10:43
Speaker
What could we call it if somebody really shouldn't be flexing their spine? I don't know. i have no good answers. It's possible that somebody who shouldn't be flexing their spine shouldn't be doing yoga in a group class. yes They should be maybe doing it with supervision from a clinician. Yeah, I agree with that completely.
01:10:58
Speaker
I think there is a way to talk about what you do and note that you are able to help a wide variety of people walking around with a wide variety of concerns and issues within scope of practice without using terminology that leans toward medicalizing your services, that leans toward suggesting that you have some type of medical insight that you don't.
01:11:21
Speaker
And I don't have any clear, straightforward guidance on that. I know I work with a ton of people who have medical concerns, and I'm able to help them for sure, but I can do it without suggesting specifically that what we're doing together is a treatment, a diagnosis, some type of assessment that pertains to their condition.
01:11:42
Speaker
Because at the end of the day, exercise helps a lot of things for general reasons. yes So I want to talk about two terms that I think are really important to have in your vocabulary. I know one of them I didn't have in my vocabulary until I researched for this episode that I think illustrate a little bit about what we're talking about here when it comes to the ethics of giving really direct and specific guidelines around what someone should or shouldn't do who comes to you with a condition.
01:12:06
Speaker
Okay, the first term is called medical paternalism. So medical paternalism refers to a situation in healthcare care where medical professionals make decisions for a patient without considering or prioritizing the patient's own preferences, the patient's autonomy, or something called informed consent. Medical paternalism operates under the belief that the healthcare provider knows what is best for the patient. This is often based on their expertise or their experience, and that their judgment should override the patient's wishes or choices.
01:12:39
Speaker
This is in contrast with that phrase, informed consent. So in contrast to medical paternalism, informed consent is a fundamental principle in healthcare care and research that ensures that individuals have the right to make voluntary educated decisions about their medical care or their participation in studies. It is the process by which a patient or a research participant is provided with sufficient information about a procedure, a treatment, or a study so that they can understand its risks, they can understand its benefits, if there are any alternatives, and what the potential outcomes could be. And this all enables the patient to be able to make an informed choice.
01:13:21
Speaker
So here's the deal. No matter where advice is coming from, whether it's from a doctor or a movement teacher of some kind, When you give overly restrictive advice, especially when it's based on weak evidence and especially when it's delivered with a high level of confidence, this removes agency from the people you're serving. And in many cases, when we're talking about yoga and Pilates, this is removing agency from women.
01:13:46
Speaker
a more ethical approach would be to first share the limitations of what you are able to do, the limitations of the evidence out there that you're knowledgeable of that might be informing how you teach, and instead to help women make informed decisions about what they're gonna do in your class.
01:14:06
Speaker
based on what they share with you and based on what your class entails. You had something smart to say in our talk through before this episode about medical paternalism and about like that yeah female dynamic. youmona One of the things that I think is fascinating about the term medical paternalism is that it's not medical maternalism, right? So it's this sort of 1950s idea of doctor knows best.
01:14:28
Speaker
Right. Doctor is a man. Now, it's not to say that women, female doctors do not practice medical paternalism. Lots of them do. But i i that's just sort of like a linguistics thing that I thought was kind of interesting. yeah Also, what what might informed consent look like for a yoga or Pilates teacher who's getting ready to start their class and they have a student come up to them and say, i have osteoporosis. Yeah.
01:14:52
Speaker
Let's say they just say that. Then let's say they say, another example is they say, I have osteoporosis. What movements should I avoid? Yeah. What would you say to the first student? I have osteoporosis. You're a yoga teacher or a Pilates teacher. I would say, thanks for letting me know.
01:15:06
Speaker
Are you cleared for yoga or Pilates or whatever exercise it is? Or are you cleared for all exercise by your doctor? And hopefully the answer to that is yes. If the answer to that is no, or I don't know, then I would say something like, okay, I then cannot advise you specifically on what poses to do or not do.
01:15:24
Speaker
Based on that, I can't advise you specifically on whether or not you should be in this class. You being in this class is going to be you taking responsibility for the movements that you're doing. And you signed the waiver.
01:15:35
Speaker
Great. The second person who says, i have osteoporosis, what movements should I avoid? I would say, again, have you been cleared for exercise? And then I would also say, it's beyond my scope to really tell you that you should do this and not do that because I am not a clinician. And I don't know the details. I don't know how severe your osteoporosis is.
01:15:55
Speaker
Even if you then come at me with some T scores, I'm not working with me personally, Sarah, I'm not working with people based on their T scores very much as far as whether or not they do an exercise because frankly, they're not the frailest, oldest, old people that are coming in to the clinic where i work with them and doing barbells.
01:16:13
Speaker
The other thing too is, What I'll often ask if no information is given about it is whether or not there are certain movements you've been told to avoid or that you've learned you should stay away from. And then I step well within my scope of practice.
01:16:27
Speaker
And I think about the sequence that's coming or the class that's coming. And I have an understanding of human movement that is expansive enough to know about the ways joints can move, which I think is the number one thing you should know as a movement teacher is how do the joints move?
01:16:42
Speaker
And I know what they're called and I know where they show up in the practice. And if this person tells me that there is a particular position that they should stay away from, for whatever reason, osteoporosis or back pain or whatever it is, I can definitely let them know and give them a heads up that those positions are going to be explored in the class and then invite them to not do them and instead do this instead, which will be not that position.
01:17:06
Speaker
or to simply make them feel completely comfortable and at home in your class doing whatever the fuck they need to at any point. In other words, I am not going to be requiring you to do exactly what I say all the time at any point in this class. In fact, I encourage the opposite. I encourage you to do what is going to best serve you in your body, given everything.
01:17:31
Speaker
what you're working with. Please feel comfortable to do that. Please don't feel like you are disobeying me or breaking the rules. That is not how this works. So take care of yourself. Yep. All right.
01:17:43
Speaker
Well, I hope you liked this episode. That's segue. It's always that segue. I know. It's always like, and bye. And scene.
01:17:56
Speaker
That's the episode. So thank you for listening in all seriousness. Thank you for joining us for this episode. of the Movement Logic Podcast. We hope that you found the questions, the studies, the different directions at which we looked at this issue interesting that it informed your thoughts and your teaching in some positive way, that you were not only left with hopefully a higher level of skepticism around what often comes across as advice to avoid movement,
01:18:32
Speaker
from people who are probably stepping outside of scope, delivered with a high level of confidence, that you have some healthy skepticism around whether that's ethical, whether that advice is based on any solid research, but also that you step away from this episode with some actionable tips of what you can do as a movement teacher when potentially you are approached as though you are a clinician and you should be giving medical advice.
01:19:02
Speaker
around what movements are safe and unsafe for people with osteoporosis or any type of condition. And you have some actionable ways to address that conflict that we we often do face as movement teachers.
Conclusion and Call to Action
01:19:13
Speaker
And we hope that you check out the show notes for links to references that we've included, including the studies and other studies that were mentioned, and that you get on the wait list for bone density course, Lift for Longevity. We're launching at the end of May, and we're really excited for round three.
01:19:28
Speaker
Yeah. Rate, review, and subscribe. Reviews just help us, okay? Please leave us a review. We hear from you all the time in like DMs on Instagram, emails. Hey, I'm listening to the podcast. I love your podcast. You guys are doing such amazing work. We believe in the work you're doing. I also felt this or that way about that topic that you recorded an episode.
01:19:49
Speaker
You know what you can do? You can copy paste that email or that DM and put it into Apple Podcast Reviews. All right, we need a song, remember?
01:19:59
Speaker
You said we're gonna do it to a song. Okay, we're gonna say see you in two weeks to another favorite song. Okay. Earth below us drifting, falling, floating weightless. See you
01:20:19
Speaker
That's not...