Vertebral compression fractures associated with yoga: a case series

The importance of exercise in skeletal health is increasingly recognized by both patients and providers. However, the safety of prescribed or recreational exercise in at-risk populations remains under-reported and under-publicized. Yoga has gained widespread popularity due to its physical and psychological benefits. When practiced in a population at increased fracture risk, however, some yoga poses may increase fracture risk, particularly at the spine, rather than increasing BMD as noted in recent popular press reports.

Nine subjects (8 women) with a median age of 66 years (range 53-87), developed vertebral compression fracture (VCF) one month to six years after initiating yoga-associated spinal flexion exercises (SFE). VCF presented with back pain and occurred in the thoracicspine (N.=6), lumbar-spine (N.=4) and cervical-spine (N.=1). Four patients had osteoporosis by BMD criteria prior to VCF and 2 had osteopenia (median T-score -2.35; range -3.3 to +2.0). Interestingly, all patients had their lowest T-scores at the spine. Three patients had a history of fragility fracture prior to the index VCF. While one patient had primary hyperparathyroidism and another was treated with high dose prednisone, no other risk factors for bone loss including medications or secondary osteoporosis causes were identified in the other patients.

This study identified patients in whom increased torsional and compressive mechanical loading pressures occurring during yoga SFE resulted in de novo VCF. Despite the need for selectivity in yoga poses in populations at increased fracture risk, both scientific and media reports continue to advertise yoga as a bone protective activity. Accordingly, yoga is misconceived as a 'onesize-fits-all' prescription. Instead, the appropriate selection of patients likely to benefit from yoga must be a cornerstone of fracture prevention.