Many of my clients tell me about a “really great morning stretch routine” they’ve discovered that “increases thoracic mobility and range of motion”. However, when they demonstrate these routines, I often notice they include the spine twist. These are unsafe for them due to their either their osteoporosis, osteopenia or low bone density. In this post, I’ll show you two alternative ways to safely perform the spine twist (sometimes called the “t spine twist”, “torso twist”, or “thoracic twist”).
Spine Twist
The spine twist can help improve the mobility of our rib cage. However, when you have osteopenia or osteoporosis, doing a spine twist in sitting or standing can increase your risk of a vertebral compression fracture.
It’s important to note that while most of the rotation during the spine twist occurs in the thoracic region of your spine, there is also rotational movement happening in the cervical (neck) and lumbar (low back) regions of the spine.
Avoid the Standing Spine Twist and Sit Twist Exercise
It’s impossible to completely avoid twisting your spine during daily activities — turns and rotations are natural parts of everyday movement. However, if you have low bone mass, osteopenia, or osteoporosis, you should avoid doing full twisting motions while sitting or standing.
This is particularly important when you twist only from your spine without moving your pelvis or feet. These isolated spinal twists can put extra stress on weakened bones and potentially cause a vertebral compression fracture.
Later in the post, I have a video where I demonstrate how to do common activities of daily living without incorporating a spine twist.
Standing Spine Twist
When you stand straight, your spine supports the full weight of your head, shoulders, and arms. Adding a twisting motion creates what’s called a “loaded twist motion” — you’re twisting your spine while it’s under pressure. For people at risk of a vertebral compression fracture, this combination of uneven load and twisting, significantly increases the stress on your spine and can cause a compression fracture or worsen an existing injury.
You might think this doesn’t apply to you if you don’t have a compression fracture. But here’s an important fact: studies show that about 70% of people with osteoporosis actually have compression fractures they don’t know about.
Many of these fractures happen with little to no pain, so you may not realize you have one. The problem is that the spine twist and other risky movements can make existing compression fractures worse or cause new ones in nearby vertebrae.
Sit and Twist Exercise
Most people do not realize that when you do the spine twist you potentially create 40% more load on your spine than standing! My advice: Avoid the sit and twist exercise if you have osteoporosis, osteopenia or low bone density.
Spine Twist and Vertebral Compression Fracture Risk
Vertebral compression fractures most commonly occur in the middle portion of the thoracic spine, (T6, T7, T8) though they also commonly occur closer to the low back, most commonly at T12 and L1. Compression fractures rarely occur in the cervical spine (neck area).
The problem for people with osteoporosis or osteopenia is significant. The movement involved in the traditional spine twist performed while standing or sitting (often found in Pilates, yoga and aerobic exercise classes) puts them at much greater risk of vertebral compression fractures compared to the general population.
Unfortunately, most fitness, Pilates, and yoga instructors aren’t aware of this risk. Even more concerning, many people don’t realize they’re at risk for compression fractures until they’re actually diagnosed with one.
Let’s explore two much safer alternatives for performing the spine twist. In both cases, we do a supine spine twist lying on the floor.
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Supine Spine Twist and Mobility: Option #1
Before trying any new stretch, I highly encourage you to get a recommendation from your physical therapist about whether the supine spine twist is safe for you.
This safer approach uses two key modifications: first, we’ll use a towel at the waist to support your lumbar curve and the space between your pelvis and ribs. Second, we’ll place a pillow behind your back. The thickness of this pillow depends on your flexibility level.
This supine spine twist is actually a modified Feldenkrais movement called the shoulder spine integrator.
Supine Spine Twist Setup and Execution
Start by lying on your side with the towel positioned in the hollow of your waist. Position your arms out at 90 degrees from your body, creating a straight line with your shoulders and pelvis. Your knees and hips should also be at 90 degrees.
From this position, sweep your top hand across the forearm of your bottom hand and bring it to rest at your breastbone. Then reach back toward the pillow. The pillow should provide enough support that you can feel it and rest into it comfortably. If it doesn’t offer adequate support, adjust accordingly.
Take a deep breath in, then exhale as you rotate back into the pillow.
Supine Spine Twist Hand Placement Options
There are two reasons I recommend bringing your hand to your breastbone rather than extending your arm fully. First, depending on the health of your neck, you have an alternative: you can bring your hand to rest on your bottom ear, transitioning it to your top ear as you rotate.
The second reason is crucial for safety. If I allowed you to bring your arm all the way back, the movement would shift from active rotation (using your own muscles) to passive rotation (where the weight of your arm pulls you down). This means your body would go beyond its active limits, which isn’t safe.
By keeping your hand either on your bottom ear or at your breastbone, you maintain control while still achieving excellent rotation. Most of this rotation occurs through the thoracic spine — the part of your spine with ribs attached.
Lying Twist Stretch and Mobility: Option #2
If you want to focus slightly more on the lower lumbar spine area (though most rotation still happens in the Thorcic spine), here’s another safe alternative. You can use a pillow for this variation.
Lying Twist Stretch Setup and Execution
Lie flat on your back and continue using the towel support at your waist. This time, place the pillow down beside your knees. You can open up your chest, which creates a nice variation of the stretch.
Shift your hips about an inch away from the side you’re going to rotate toward. Take a breath in, then exhale while dropping your knees to that side, creating a gentle rotational stretch.
Without the pillow, you would be “hanging” in the stretch, which creates a greater twist.
However, since I don’t know each person’s individual situation—and many people might have compression fractures without realizing it—I’m not comfortable suggesting that everyone can safely do the more intense version.
This is why it’s always best to check with your individual therapist.
Lying Twist Stretch Proper Positioning
- Breathe in and exhale as you lower your knees to the side
- Position the pillow close enough to support your thighs so you can relax into the stretch
- Focus on breathing deeply into the stretch
- Remember to always roll over onto your shoulder when transitioning back up to a sitting position.
How to Safely Twist Doing Activities
I demonstrate how to modify your activities of daily living so that your twist and rotation movements are safer.
Conclusion
One of my main motivations for creating these educational posts is to help you avoid compression fractures or arthritis flare-ups in your back. I receive too many emails from people saying, “But I was just trying to help myself”—people who were simply doing exercises or following along in fitness classes.
If you know you have osteoporosis or severe osteoarthritis, please make these modifications to keep your spine safe. Your long-term spinal health is worth the extra precautions.
Margaret Martin
Further Readings
References
- Takano, H. , Yonezawa, I. , Todo, M. , Hazli Mazlan, M. , Sato, T. and Kaneko, K. (2017) Biomechanical Study of Vertebral Compression Fracture Using Finite Element Analysis. Journal of Applied Mathematics and Physics, 5, 953-965. doi: 10.4236/jamp.2017.54084.
- Wiklund P, Buchebner D, Geijer M. Vertebral compression fractures at abdominal CT: underdiagnosis, undertreatment, and evaluation of an AI algorithm. J Bone Miner Res. 2024 Aug 21;39(8):1113-1119. doi: 10.1093/jbmr/zjae096. PMID: 38900913.
- Li, Y., Yan, L., Cai, S. et al. The prevalence and under-diagnosis of vertebral fractures on chest radiograph. BMC Musculoskelet Disord 19, 235 (2018). https://doi.org/10.1186/s12891-018-2171-y
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