Pilates and Osteoporosis: Safe Exercises and Movements to Modify

By Katherine, Lead Instructor, Certified Pilates Instructor

Pilates can be safe with osteoporosis when your doctor is involved and the exercises are adapted. The main change is limiting loaded forward rounding, end-range twisting and deep side bending of the spine, which several classic mat exercises involve, and emphasizing back extension, balance, strength and posture. Pilates alone has not been shown to raise bone density.

Key takeaways

• Check with your doctor or physiotherapist first, especially after a spinal (vertebral) or other recent fracture. The main exercise consensus calls its own recommendations conditional and notes there is not enough evidence to quantify the risks of exercise.

• Osteoporosis Canada's "Too Fit to Fracture" guidance says people at high fracture risk may need to limit repeated bending and twisting, full forward or side bends, full twists and holding bent or twisted positions.

• Typical mat modifications keep the spine closer to neutral and favour hip hinging, back extension and supported positions.

• The strongest exercise evidence in osteoporosis is for reducing falls. Two meta-analyses, one of Pilates and one pooling Pilates with yoga, found no significant bone density gain.

• Osteopenia is a risk label, not a verdict. Your overall fracture risk, which your doctor assesses, decides how cautious to be.

What does osteoporosis mean for exercise?

Osteoporosis is a disease of low bone mass and weakened bone that raises the risk of fracture (Osteoporosis Canada). Osteoporosis Canada estimates that over 2.3 million Canadians live with it and that at least 1 in 3 women and 1 in 5 men will have a fragility fracture in their lifetime (Osteoporosis Canada). A fragility fracture is a break from a fall at standing height or less, or from an ordinary activity such as bending, twisting or coughing, and many spine fractures are painless and unnoticed (Osteoporosis Canada, 2014).

Exercise advice therefore has two jobs: build the strength and balance that protect you, and avoid loading the spine in ways that stress fragile vertebrae. Our guide to Pilates after 50 covers the wider picture of training as you age. If you have noticed a rounder upper back, our post on rounded shoulders and a hunched upper back explains why a new or worsening curve deserves a medical check.

Is Pilates safe if you have osteoporosis?

It can be, with modifications and your doctor's input, but "safe" has limits. We did not find trials testing Pilates for fracture outcomes in people with osteoporosis. The international "Too Fit to Fracture" consensus panel found there is not enough evidence to quantify the risks of exercise in this group, that few trials exist in people who already have a vertebral fracture, and that its recommendations are conditional (Giangregorio et al., 2014). That panel did not evaluate Pilates.

Osteoporosis Canada's "Too Fit to Fracture" page mentions Pilates once, in a general sentence: activities like yoga, Pilates, walking and dancing should be done in addition to, not instead of, balance and muscle strengthening, with attention to fall risk and spine-safe movement (Osteoporosis Canada). It gives no list of approved or banned Pilates exercises. It also advises seeking guidance from a physical therapist, kinesiologist or exercise physiologist, especially after a recent fracture or if you are at high fracture risk.

At Align & Flow Pilates, we do not diagnose or treat osteoporosis. We adapt sessions to you and work alongside your health care provider, who sets the limits.

What does Osteoporosis Canada say about bending and twisting?

People at high risk of fracture may need to limit repetitive bending and twisting, bending all the way forward or to the side, twisting all the way to the side, holding a bent-over or twisted position for an extended period, and bending or twisting while holding a weight. The alternative is to bend with your hips and knees instead of your spine, using slow, controlled movement (Osteoporosis Canada).

The source does not mention the roll-up, the hundred or the teaser. Connecting them to the principle is our reading, though a reasonable one: many classic mat exercises involve repeated spinal flexion (rounding forward), often with the weight of the legs or arms adding load.

An older study adds support, with caveats. It followed 59 postmenopausal women with spinal osteoporosis and back pain for one to six years. Additional vertebral fractures occurred in 16% of those who did extension exercises (25 women) and 89% of those who did flexion exercises (9 women), with 53% for combined programs and 67% for no exercises (Sinaki and Mikkelsen, 1984). It is small, its groups were uneven, it dates from 1984 and it did not test Pilates, so treat it as a reason for caution about repeated spinal flexion, not proof about any specific exercise.

Which classic mat exercises are typically modified?

What is appropriate depends on your bone density, fracture history, pain and your provider's advice. This table shows how instructors commonly approach six well-known mat exercises. It describes typical practice, not a rulebook.

Exercise	Why it is usually flagged	Typical modification
Roll-up	Repeated, loaded forward rounding of the spine	Hip hinge, pelvic tilt or bridging instead, keeping the spine long and supported
The hundred with the head lifted	Sustained neck and upper-spine flexion	Head and shoulders down, feet on the floor or supported legs
Rolling like a ball	Rounded spine rocked back and forth, with pressure through the vertebrae	Seated or lying knee-hug and pelvic-control work
Spine twist	Rotation of the spine, often at end range	Tall spine, small range, or arm reaches and hip-based movement
Teaser	Deep flexion with the legs lifted, held in a bent position	Shorter levers and a neutral spine, or strength work such as planks
The saw	Combined forward bend and rotation	Hinge from the hips with a long spine, or reach without folding forward

The common thread is direction: anything that combines rounding and rotation, adds load, repeats many times or pushes to end range is a candidate for change. How we adapt these for you starts with a conversation about your bone health.

What is encouraged instead?

• Back extension and posture. In a randomized trial of 80 postmenopausal women with osteoporosis, a simple low-intensity back-strengthening exercise was followed over four months by a 26% rise in back extensor strength (11% in the control group) and a 7% rise in quality-of-life scores that the control group did not see (Hongo et al., 2007). It was a home exercise, not Pilates. Osteoporosis Canada also lists planks, side planks and bird dog exercises for the abdominal and back extensor muscles and posture, which will look familiar to anyone who has done Pilates.

• Balance. Osteoporosis Canada recommends balance training two or more times a week, such as leaning in different directions, unusual walking patterns and reacting to being unsteady, with difficulty increasing over time. We cover Pilates and falls in Can Pilates improve balance and reduce fall risk?.

• Strength with real effort. The same page recommends muscle strengthening two or more times a week at high effort, starting with body weight and progressing to bands or weights. Reformer springs can provide progressive resistance, but a typical Pilates session may not reach the high effort that guidance describes. See Pilates vs strength training for how the two compare.

Can Pilates increase bone density?

• A 2022 systematic review of Pilates in postmenopausal women found only three randomized trials, and only one had satisfactory quality. Pilates showed no significant effect on bone density at the lumbar spine, total hip or femoral neck, and the authors said the few, low-quality studies did not allow safe conclusions yet (de Oliveira et al., 2022).

• A 2021 meta-analysis of Pilates and yoga combined (11 studies, 591 women aged 45 to 78) found a non-significant difference from controls. The authors noted that maintaining bone density when loss is expected could be read as a positive result (Fernández-Rodríguez et al., 2021).

• Exercise in general has a small effect. A Cochrane review of 43 trials in postmenopausal women found a small but possibly important benefit, with progressive resistance training most effective for the femoral neck and combination programs for the spine. It found no effect on the number of fractures, and reporting quality was low (Howe et al., 2011). A later meta-analysis of 80 studies (5,581 postmenopausal women) also found positive effects, with no significant difference between women with osteopenia or osteoporosis and those with normal bone density (Mohebbi et al., 2023).

• The consensus panel found its strongest evidence for falls, not bone density (Giangregorio et al., 2014).

Pilates is best seen as a way to build the strength, control, posture and confidence that support a bone-conscious program, not as a bone treatment.

What about osteopenia?

Osteopenia means a bone density result between normal and osteoporosis, a T-score from -1 to -2.5 (Harvard Health Publishing). Your overall fracture risk matters more than the label: Osteoporosis Canada notes that fracture risk is not based on the bone density result alone, and that some people with a low result may not be at high risk while others with a better result are, because of other risk factors (Osteoporosis Canada, 2014).

Ask your doctor what your fracture risk assessment shows. If your risk is high, or you have had a fragility fracture, the spine-sparing approach above applies in full. If it is lower, your doctor may allow more freedom, though gradual progression and attention to extension are sensible habits either way.

Safety note: This article is general information, not medical advice, and Pilates instruction does not replace an assessment by your health care provider. If you have osteoporosis, a vertebral fracture, a recent fracture, low bone density or a high fracture risk, consult your family doctor or physiotherapist before starting or returning to Pilates, and follow any restrictions you are given. Stop exercising and seek prompt medical care if you have sudden or severe back pain, especially after a fall, a lift or a bend, or if pain, numbness or weakness appears in your back or legs. Also stop and tell your instructor if you feel dizzy or unsteady, and keep a wall or sturdy support within reach for standing balance work. Osteoporosis Canada notes that a loss of height of 2 cm or more, measured over time by a health care professional, can be a warning sign of a spine fracture, so mention any height loss to your doctor (Osteoporosis Canada, 2014).

Bone-aware Pilates with us in Markham

If your doctor has cleared you to exercise with osteoporosis or osteopenia, a Private 1:1 Pilates with Instructor (1 hr) session lets us adapt exercises to your history and restrictions. If you are new to us, the Posture Assessment + 1:1 Pilates Intro (1 hr 15 min) is another place to begin. You can view classes and book online.

Frequently asked questions

Can I do Pilates if I have had a spinal compression fracture?

Possibly, but talk to your doctor or physiotherapist first. The consensus panel noted that few trials exist in people who already have a vertebral fracture, so there is little evidence to guide specific exercises (Giangregorio et al., 2014). If you are cleared, expect a cautious, individualized program.

Can Pilates reverse or cure osteoporosis?

No. Exercise can support strength and balance and may help maintain bone density, but the evidence for Pilates specifically is limited, and the strongest evidence for exercise is for reducing falls (Giangregorio et al., 2014). Osteoporosis is managed through a plan set with your doctor, which may include medication, nutrition and exercise.

What should I tell my instructor before my first session?

Share your diagnosis or bone density result, any fractures, your medications, past falls, pain, and what your doctor or physiotherapist has advised. This helps us adapt exercises within the limits your provider has set.

Is reformer or mat Pilates safer with osteoporosis?

We found no evidence comparing them in people with osteoporosis. How the movements are chosen and progressed likely matters more than the equipment. Our comparison of reformer vs mat Pilates explains how the two differ.

Sources

1. Giangregorio LM, Papaioannou A, Macintyre NJ, Ashe MC, Heinonen A, Shipp K, Wark J, McGill S, Keller H, Jain R, Laprade J, Cheung AM. (2014). Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International, 25(3), 821-835. DOI: 10.1007/s00198-013-2523-2. https://pubmed.ncbi.nlm.nih.gov/24281053/

2. Osteoporosis Canada. Too Fit to Fracture (patient and clinician toolkit). https://osteoporosis.ca/too-fit-to-fracture/

3. Osteoporosis Canada. About the Disease: What Is Osteoporosis? https://osteoporosis.ca/about-the-disease/

4. Osteoporosis Canada (2014). Diagnosis: The Importance of a Comprehensive Fracture Risk Assessment (fact sheet). https://osteoporosis.ca/wp-content/uploads/Osteo.Diagnosis.pdf

5. Sinaki M, Mikkelsen BA. (1984). Postmenopausal spinal osteoporosis: flexion versus extension exercises. Archives of Physical Medicine and Rehabilitation, 65(10), 593-596. https://pubmed.ncbi.nlm.nih.gov/6487063/

6. Hongo M, Itoi E, Sinaki M, Miyakoshi N, Shimada Y, Maekawa S, Okada K, Mizutani Y. (2007). Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osteoporosis International, 18(10), 1389-1395. DOI: 10.1007/s00198-007-0398-9. https://pubmed.ncbi.nlm.nih.gov/17572835/

7. de Oliveira RG, Anami GEU, Coelho EA, de Oliveira LC. (2022). Effects of Pilates Exercise on Bone Mineral Density in Postmenopausal Women: A Systematic Review and Meta-analysis. Journal of Geriatric Physical Therapy, 45(2), 107-114. DOI: 10.1519/JPT.0000000000000309. https://pubmed.ncbi.nlm.nih.gov/33967223/

8. Fernández-Rodríguez R, Alvarez-Bueno C, Reina-Gutiérrez S, Torres-Costoso A, Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V. (2021). Effectiveness of Pilates and Yoga to improve bone density in adult women: A systematic review and meta-analysis. PLoS ONE, 16(5), e0251391. DOI: 10.1371/journal.pone.0251391. https://pubmed.ncbi.nlm.nih.gov/33961670/

9. Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews, 2011(7), CD000333. DOI: 10.1002/14651858.CD000333.pub2. https://pubmed.ncbi.nlm.nih.gov/21735380/

10. Mohebbi R, Shojaa M, Kohl M, von Stengel S, Jakob F, Kerschan-Schindl K, Lange U, Peters S, Thomasius F, Uder M, Kemmler W. (2023). Exercise training and bone mineral density in postmenopausal women: an updated systematic review and meta-analysis of intervention studies with emphasis on potential moderators. Osteoporosis International, 34(7), 1145-1178. DOI: 10.1007/s00198-023-06682-1. https://pubmed.ncbi.nlm.nih.gov/36749350/

11. Harvard Health Publishing (2025). Osteopenia: When you have weak bones, but not osteoporosis. https://www.health.harvard.edu/womens-health/osteopenia-when-you-have-weak-bones-but-not-osteoporosis