The Clinical Foundation
What osteoporosis is and
why exercise matters.
Bone is not inert tissue. It is a living structure that is continuously remodelled: old bone is resorbed and new bone is formed in a cycle governed by the mechanical demands placed on the skeleton. When the demands are sufficient, bone formation keeps pace with resorption. When they are not, resorption outpaces formation and bone mineral density declines.
The type of load matters as much as the presence of load. Exercises that produce the right mechanical stimulus build bone. Exercises that produce excessive compressive or shear force at a compromised vertebral body risk fracture. The programme must deliver the former and avoid the latter.
Exercise matters because mechanical load is the primary stimulus for bone remodelling. When the skeleton is loaded above the threshold required for remodelling, bone-forming cells are stimulated and density is maintained or increased. This is why weight-bearing and resistance training are the most consistently evidenced interventions for bone health in older adults.
One in three women over 50 will sustain an osteoporotic fracture
The sites most affected are the vertebrae, the hip, and the wrist. Vertebral compression fractures can occur simply from the load of standing and bending in a spine whose structural integrity has been sufficiently compromised.
Load above the threshold builds bone. Load below it allows loss.
The programme is designed to deliver load above the remodelling threshold at the hip, spine, and lower limb, progressively increased as the client’s capacity develops, while staying well within the fracture risk boundary.
Both require adapted programming. Earlier is better.
Osteopenia is below-normal bone mineral density that has not yet reached the osteoporosis threshold. The same loading principles apply. Intervention at the osteopenia stage is more effective than waiting for the threshold to be reached.
What Pilates Offers
What Pilates offers
for bone health.
Pilates provides two of the three exercise types most evidenced for bone health: resistance training (through the spring system of the Reformer, Cadillac, and Wunda Chair) and functional weight-bearing (through standing apparatus exercises that load the spine and hips in controlled upright positions).
The Pilates apparatus offers a specific advantage for osteoporosis: the spring resistance is adjustable and progressive. Loading can be increased precisely as capacity increases. It can also be reduced for a more cautious starting point.
Progressive resistance training
The spring system of the Reformer, Cadillac, and Wunda Chair provides controlled, adjustable resistance that delivers the mechanical stimulus bone remodelling requires. Load increases with capacity. The osteogenic stimulus is maintained across the programme.
Functional weight-bearing
Standing apparatus exercises (Core Align, Reformer standing, Wunda Chair) load the spine and hip in controlled, aligned positions. Axial loading through neutral spine is the most osteogenic loading pattern for vertebral and hip bone density.
Postural strength and fall risk reduction
A denser bone is still at risk if the person carrying it falls. The programme addresses both simultaneously: the osteogenic stimulus and the balance, postural strength, and neuromuscular speed that reduce the probability of the fall that would make the bone density relevant.
What Cannot Be Done and Why
The movements that are
contraindicated and why they matter.
Standard Pilates repertoire contains movements that are specifically contraindicated for clients with significant bone density loss. Some are foundational classical Pilates exercises that appear in every group class. A general senior Pilates class that has not been adapted for osteoporosis may include them. A private programme built for this client does not.
This is the primary clinical reason a private programme matters for clients with osteoporosis. The instructor must know the client’s bone health status to design a safe programme. A group class cannot.
Loaded Spinal Flexion
Forward bending of the spine under load places compressive force on the anterior vertebral bodies. In a spine with significant bone loss, this can produce a vertebral compression fracture. Classic exercises involving rolling up, spinal curling, and abdominal work with head and shoulders lifted are modified or removed.
Rotation Under Load
Rotational forces place torsional stress on the vertebral bodies. In the osteoporotic spine, combined flexion-rotation movements are a fracture risk. Gentle, supported thoracic rotation within a neutral spine may be included. Combined flexion-rotation is avoided.
High-Impact Loading
The impact forces of jumping and high-impact exercise exceed the loading capacity of the osteoporotic spine. The programme uses controlled spring resistance rather than impact to provide the osteogenic stimulus.
What this means in practice
The programme is not a restricted version of a standard Pilates class. It is a specifically designed programme that works within safe loading parameters to deliver a meaningful osteogenic stimulus. There is a great deal it can do.
What the Programme Builds
Four components.
Safe. Progressive. Osteogenic.
Axial Loading for Bone Stimulus
Standing apparatus exercises (Reformer standing, Core Align, Wunda Chair) that deliver axial compressive load to the spine and hip in controlled, aligned positions. The load is progressive: as capacity increases, spring resistance and exercise demands increase to maintain the stimulus above the remodelling threshold.
Postural Strength and Spinal Extension
The thoracic kyphosis of osteoporosis increases anterior compressive loading on already-compromised vertebral bodies. Building the thoracic extensor and scapular retractor strength that maintains upright posture reduces this load. The Cadillac and Ladder Barrel provide supported thoracic extension work without contraindicated spinal flexion.
Hip and Lower Limb Strength
The hip is one of three primary osteoporotic fracture sites. The programme builds hip abductor, extensor, and lateral rotator strength that reduces fall risk and provides the functional lower limb loading that stimulates hip bone density. The Wunda Chair’s single-leg work loads the hip under controlled resistance in a weight-bearing position that provides both the bone stimulus and the balance challenge.
Balance and Fall Risk Reduction
Bone density management addresses the consequence of a fall. Balance and fall risk reduction addresses its likelihood. The programme integrates both: the same sessions that build the osteogenic stimulus also develop the proprioception, dynamic stability, and neuromuscular speed that reduce the probability of the fall that would make the bone density relevant.
When the Physio Team Is Involved
Clinical input when the
programme needs it.
Most clients with osteoporosis or osteopenia who begin this programme are managed within the Pilates programme. The instructor is trained in osteoporosis-specific loading and contraindications and builds the programme within appropriate parameters.
Physiotherapy at Core Fitness is eligible for insurance claims through most major insurers. Private Pilates sessions are not claimable under insurance.
After an osteoporotic fracture
Clinical assessment needed before loading decisions are made and the programme is designed.
Significant spinal changes on imaging
Loading parameters require clinical input before the programme is established.
Pain suggesting a clinical episode
Where the presentation requires physiotherapy management before the programme continues.
DEXA scan review and guidance
Clinical review of DEXA results and specific guidance on appropriate exercise parameters for the bone density category.
The Core Fitness Model
Same practice. Shared context. The Pilates programme resumes without starting over once the clinical episode is resolved.
Your Questions
What clients ask before they book.
I have osteopenia but not osteoporosis. Do I still need a specifically adapted programme?
Yes. Osteopenia means bone mineral density is below the normal range but not yet at the osteoporosis threshold. The same loading principles apply: the programme should include appropriate weight-bearing and resistance to provide the osteogenic stimulus, and should avoid loaded spinal flexion and rotation. The adapted programme for osteopenia is less restrictive than for osteoporosis, but the principles are the same. Early intervention is more effective than waiting until the osteoporosis threshold is reached.
I have been told not to do crunches or sit-ups. What can I do for core strength?
A great deal. Core strength in Pilates does not depend on flexion-based abdominal exercises. The deep stabilisers of the trunk (the transversus abdominis, multifidus, and pelvic floor) are trained through stabilisation exercises in neutral spine positions that provide significant core benefit without loading the vertebrae in flexion. The programme builds a strong, functional core through these methods.
My doctor has cleared me for exercise but has not given me specific guidance. Where do I start?
The movement assessment at the first session at Core Fitness establishes the specific loading parameters appropriate for your bone health presentation. If a DEXA scan result is available, bring it to the first session: it informs the programme design. If physiotherapy input is needed to interpret the clinical picture before the programme begins, the physiotherapy team is available internally.
Is there a risk of fracture from Pilates?
In a correctly adapted private programme delivered by an instructor trained in osteoporosis-specific loading, the fracture risk is extremely low. The contraindicated movements are removed. The loading is progressive and within safe parameters. The risk comes from generic or group programmes that include contraindicated movements without knowing the client’s bone health status. The private format at Core Fitness is specifically designed to avoid this.
Are sessions covered by insurance?
Private Pilates sessions are not claimable under insurance. Clients requiring insurance-claimable treatment are directed to the AHPC-registered physiotherapy team. See the price list page for further detail.