Building Better Bone Strength with Rebekah Rotstein

[00:35] Jennifer Milner: Welcome to Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes. This is co-host Jennifer Milner here today with Dr. Linda Bluestein. Before we introduce today's special guest, please remember to subscribe to the Bendy Bodies podcast and leave us a review. This really helps grow the audience and increase awareness about hypermobility and associated disorders. This podcast is for you.
[01:15] Today we have the great pleasure of speaking with Rebekah Rotstein, an industry leader in Pilates, bone health, and movement education. She's the creator of the medically endorsed Buff Bones system with trained instructors in more than 30 countries. She presents throughout the U.S. and internationally at conferences in the Pilates industry and beyond, including the International Osteoporosis Foundation Worldwide Conference. She pursued her love of anatomy training in Pilates at the Kain School in New York City under the tutelage of Kelly Kain, where she later joined the teacher training faculty. When she was diagnosed with osteoporosis at age 28, her focus took on a new direction to share insights and options with those with low bone density and exercise professionals caring for them. Her work in the field of osteoporosis led Hatherleigh Medical Education to invite her to write an evidence-based continuing education paper on osteoporosis and exercise, which later encouraged her to develop the Buff Bones exercise system for bone and joint health.
Rebekah serves as a longstanding ambassador for American Bone Health and worked as a partner of the U.S. Department of Health and Human Services. She's a longstanding visiting instructor at the online studio Pilates Anytime. Rebekah, welcome to Bendy Bodies.

[02:33] Rebekah Rotstein: Thanks for having me. I'm excited to be here with you both.

[02:36] Jennifer Milner: Well, we are so excited to have you, right, Linda?

[02:39] Dr. Linda Bluestein: Oh yes, super excited to chat with you.

[02:43] Jennifer Milner: And I should say also at the outset that Rebekah and I have been friends for about 15 years — maybe more than that. I was one of Rebekah's Pilates teacher trainers. So I trained Rebekah to be a Pilates teacher. And then we have been fortunate enough to stay friends through the years, and I'm so proud of what you have accomplished, Rebekah. So proud.

[03:09] Rebekah Rotstein: Thank you, Jen. I think it's actually like 18 years now.

[03:13] Jennifer Milner: Oh, thank you. I feel much better. Wow.

[03:17] Dr. Linda Bluestein: That's incredible.

[03:19] Jennifer Milner: It is incredible. So Rebekah, you have been a pre-professional dancer. You have hypermobility and you had some serious injuries and were diagnosed at an incredibly early age with osteoporosis. So let's start at the beginning. You're dancing. You've got a wonky body, you get injured. Tell us about that.

[03:40] Rebekah Rotstein: The first time that I really realized that there was something going on was at Boston Ballet School. I was having a lot of problems with my Achilles, and I went to the company doctor and started seeing their physical therapist. Then it just continued onward from there — same thing at San Francisco Ballet School. I kept going on and discovering that these ankles were causing me a lot of problems. It was diagnosed as chronic Achilles tendonitis, and that's why I quit. But then I learned later that it was far more than that. That was really just the symptoms of it.
[04:24] It all stems from the joint hypermobility throughout my body, but I never thought of it that way because I never had amazing extensions. I didn't have these incredible feet. I just seemed to have pain. I didn't think I was hypermobile. I just thought that I had more laxity than the average person, but looking back, there are so many signs going back even prior to that — when I was an ice skater, where you see pictures of me at 3 years old and my ankles are totally collapsing inwards. With all the others who seem to have straight parallel feet and well-aligned structures. So this has been a lifelong thing. I just didn't realize it at the time.
[05:10] So I ended up quitting. I got to the point where at North Carolina School of the Arts, I was sitting out for most of class and only joining rehearsal — essentially so that I could perform. And I decided I was about to quit when I was considering this offer where Fernando Bujones was creating a new company down in Southern Florida. And I thought I would go that route, but then I just realized I'm in so much pain and I'm done. So I decided to quit dancing and I went to college instead.
[05:51] And then that took me on a very different route where I began working in the sports medicine department of my college, thinking I'd go to physical therapy school. I still was surrounding myself with injuries — they just weren't my own. And I thought that would be my path, and then I decided I just needed to get away from the body completely and never deal with it again.

[06:21] Jennifer Milner: How did that work out?

Rebekah Rotstein: It lasted a couple years. The first, I'd say, 5 years after I graduated college and moved to New York, I wasn't working with anything body-related, but I was seeing one of the big dance medicine physicians there who dealt with the Joffrey for my injuries. He started doing injections — prolotherapy — which was extremely excruciatingly painful, but it turns out that was coming from my sacroiliac instability. So that was part of what was leading down to the discomfort and pain through my ankles.
[06:58] So that was the first indication to me that the symptoms are not necessarily the source of the problem.

[07:10] Jennifer Milner: That's such a huge thing for you to learn. Hopefully some people learn it while they're still dancing, but not everybody does, you know. But a benefit of the injury process was that it introduced you to Pilates, and started something that has, I think, really had an impact on the exercise world with what you're doing. You were always a very gifted Pilates teacher — I should know. But I know that the diagnosis at age 28 of osteoporosis absolutely reshaped your teaching and your focus. So talk about how you got that diagnosis. Why were people even looking for that, and what happened immediately afterwards?

[07:57] Rebekah Rotstein: Sure. Well, thanks to you actually, Jen. My interest in special populations that I'd already had from my own injuries led me to teach the special populations curriculum at the Kain School. So I was already teaching about osteoporosis — I had some knowledge about it. And then I started taking some additional workshops at conferences. I was interested in it.
[08:28] And then when I was diagnosed, I was shocked. The reason I even got a DEXA scan — a bone density scan — in the first place was because one of the workshops I had attended had pointed out a staggering statistic. The statistic was that 98% of your bone density is developed by the time you're 18 to 20. It varies a bit, but the majority of your bone density you develop in your teenage years. And when I was dancing, like many dancers, I had stopped menstruating. I had weighed a very, very low amount — I weighed 82 pounds throughout my whole dance career. Granted, I'm only 5 feet tall. But still, I was very small and I'd only menstruated for one of those teenage years.
[09:16] So I knew from everything I was learning that I was predisposed for osteoporosis. It ran in my family. Both parents had it. And so I decided, let me just get a bone density test as a baseline — for once I hit menopause later. And it just came back with very disturbing, shocking results, which were that I already had osteoporosis according to that classification.
[09:45] So I got very depressed. I got very upset, partly because I still identified as a dancer — and you're never going to not be a dancer in your mind, no matter where your life takes you. And so I identified so wholeheartedly with my body. It had so many ramifications: from the idea that I would fracture, to the idea that from all I had learned and studied, I knew I was going to have to completely alter my Pilates repertoire and my personal practice, because I already knew what movements were contraindicated for osteoporosis.
[10:30] So eventually I took action after I allowed myself to grieve, as was needed at the time. I started talking to physical therapists I knew, reached out to other physicians, and I started doing my own research and finding out what I could do for myself. I visited an endocrinologist, and that gave me a lot of information that I think is critical for people still now — information that gets overlooked by the oversimplified version of a diagnosis. You have it, you have to treat it, and these are the ways you do it. And I think there's a lot of gray area in there that is dismissed, unfortunately.

[11:16] Jennifer Milner: So you started researching. First you got sad, then you got angry, and then you started researching, trying to figure out what you were going to do. And you chose to go see nutritionists, endocrinologists. You kind of pieced together your own plan, right? Because as you said, options for treatment right then weren't really covering a lot of that gray area. They were more, as you said, here's what you have, now it's time to treat it. And my guess is that what they talked about as treatment wasn't necessarily what you thought should be the start and end of the conversation. So talk a little bit more about that.

[11:57] Rebekah Rotstein: So in the medical world, treatment equates to medication — certainly in the osteoporosis world. And so the first thing I was told by the treating physician was, "All right, the bad news is you have osteoporosis. The good news is there's medication that you can take." That pretty much sent me into a complete sob story right there.
[12:24] But the more I looked into it, I started learning about the medications. Not a single one had been tested on premenopausal women at the time. So I was in childbearing years. What are the ramifications and possible side effects that had been completely ignored? Let alone, the more I learned about osteogenesis and bone resorption — the metabolism of how your skeletal system works — the predominant medications, except for one, all suppress your bone turnover. What they do is halt bone breakdown. But it turns out, as I learned through blood and urine tests, I wasn't having a problem of bone breakdown. So the mechanism by which these medications would have treated me would not have been logical.
[13:23] It turns out I had a vitamin D deficiency. Now everybody talks about vitamin D, but back in 2004, clinically and definitely in the mainstream, you didn't hear about vitamin D deficiencies. So I was able to get certain blood markers and urine tests to identify whether there was anything else underlying — anything going on with my endocrine system, which is very common. Check, that was not the case. Was there celiac disease? All these other things that can be secondary causes of osteoporosis.
[14:12] But what we did identify — the only thing we really identified — was that I had a vitamin D deficiency, and remineralizing my bones through vitamin D alone increased my bone density. At the same time, I also changed my diet, and I sought out the assistance of a trainer. Deb Goodman put me in touch with Jeff Bell, who became my longtime trainer from probably 2005 until I moved away in 2019.
[14:55] So the interesting part is that there are a number of other factors that have to be identified and ruled out on the course to treatment, on the course to an identifying plan. And back then — and I think still very frequently — these other factors are not looked at and considered.

[15:20] Dr. Linda Bluestein: That's super interesting. Almost at the exact same time — 2004 sounds like about when I got a diagnosis of osteoporosis. I'm older than you, so I was older than 28 by a fair bit, but I literally got a voicemail from the nurse — not even my doctor. They called, they left me a voicemail: "You have osteoporosis. You can choose drug A or drug B." And that is literally all they said.
[15:45] And I had been asking for years to test my vitamin D level because I was aware of some of the research — not necessarily even for bone health, but for mood, pain, and sleep. So it's really fascinating, the parallels. I totally agree with you, and I think part of that is because the healthcare system is so dysfunctional and it's all about time. It's quicker to just say, "You have this, you can do this or this," done.

[16:19] Rebekah Rotstein: And it's still, unfortunately to this day, very myopic. I went with my mom to one of her physician appointments probably about 4 years ago. She has osteoporosis. She had been on the bisphosphonate medications, which are the most commonly used to treat osteoporosis. Actually, it's changing now — I should say not necessarily just bisphosphonates, but antiresorptive medications more broadly, which is the larger classification of stopping bone breakdown. And my mom said at the time, "Well, what about exercise?" — with me there, her daughter who specializes in this. And the doctor said to her point-blank, "Exercise won't help."
[17:02] I had to pull myself back. Because this is still to this day very frequently stated, even though there's actually much greater evidence than there was then — and even then there was more evidence than there had been back in 2004 when I started investigating this. To say that there's no evidence is a complete fallacy.
[17:27] And I can share some challenges with the shortcomings even of research and the approach in the medical world, where we have so much emphasis on bone density — and yet they've identified that there are more fractures occurring in osteopenia, which is the precursor to osteoporosis, than in actual osteoporosis. More fractures occurring at a higher bone density. So that points to some kind of shortcoming in our diagnoses, in our outlook on this condition.

[18:14] Jennifer Milner: That is so interesting. And I see a lot — because you have hypermobility, I have hypermobility, Linda has hypermobility. We're all somewhere on the spectrum. I'm somewhere on the EDS/HSD spectrum depending on which labels you're looking at, and have fought with low vitamin D my whole life. At one point just a couple years ago, I switched doctors and she ran a test we hadn't done for a couple years, and my vitamin D was 12. Yes — 1, 2.
So I've seen with my hypermobile dancers, you know, dancers are very prone to having low vitamin D. Everybody talks about that now, which I'm so grateful for. But especially in my hypermobile dancers, I've seen — without any research to back it up — that they have a harder time maintaining it. I don't know, Linda, if people on the spectrum have a harder time absorbing minerals in general. Have you seen anything like that?

[19:11] Dr. Linda Bluestein: That's a good question. There are definitely gut issues that lead to more difficulty with absorbing. Gut function is impaired in a lot of people on the spectrum — which I think is a good way to think of it. Of course, when you say "on the spectrum," a lot of people think the autism spectrum, but here we're talking the hypermobility spectrum. Because of course, everything we talk about is hypermobility.
[19:35] So yes, I think that's definitely the case. There are also some genetic markers we can look at that have to do with vitamin D incorporation and how well we process vitamin D. There could be genetic differences as well. That pertains specifically to SNP testing — single nucleotide polymorphisms. Anyone who has had something like 23andMe done can actually pay a little bit of extra money to have them look at some of these SNPs. There's a lot of great information, so stay tuned for that as well.

[20:20] Rebekah Rotstein: Yes, absolutely. So — you've got hypermobility, you have osteoporosis, you're young, they've told you to start taking drugs, and you are not finding a lot of compelling research at the time that says do exercise instead, right? So what made you pursue exercise? Was that just because that's what you knew and what you felt good doing? What made you seek Jeff out and start building that?
[20:49] Well, the thing that's interesting is there was evidence to show that exercise can improve your bone density. The medical community was just hesitant to adopt it. The reasoning, as far as I can tell, was that it was limited in terms of needing longitudinal studies. But there was the famous Erlangen study that had looked at this — there was compelling research, but you needed more. You needed greater systematic reviews and more meta-analyses to make the case. But there definitely was evidence.
[21:33] And then we already know from Wolff's law that bone responds to outside forces — that you can strengthen bone by loading it. So to me it was a no-brainer. And just going back to my personal history, something that I think may have been a savior for me with my hypermobility is that I had started ice skating when I was 3. Pretty much as soon as I could walk, I was ice skating. And with ice skating, there's a lot of load and force — way more than with dancing, because you have velocity compounded in addition to gravity and height, so more impact going through your bones. I haven't looked at any research done on ice skaters, but I believe that helped my connective tissue system. The fact that I had had so much force generated when I was younger, prior to even dancing, I think actually strengthened my joints more than would have happened without that.
[22:58] But I had not been very intensely involved in progressive resistance weight training — high-intensity loading as well as velocity training. I had worked out throughout my 20s and gone to the gym, but I'd never officially had a trainer. And so that made me think, all right, I'm going to take this next path.

[23:34] Jennifer Milner: I remember watching you as you went through the diagnosis and then as you did your research and started working with Jeff. I remember seeing a clear difference in you physically as you seemed to take on muscle for sure, but you also inhabited your body in a different way — looked stronger, looked more assertive physically in your frame. I love that it did something for you, but then you also thought you wanted to take that and do something for other people. So we know that your personal struggle led you to develop Buff Bones. What made you feel like the world needs this program and I'm going to put it out there?

[24:22] Rebekah Rotstein: I really didn't. That's the funny part. Somebody else told me they did. Initially we had just created this workshop for osteoporosis as I was doing all this research, and I thought, let me share some of this information. This coincided with the same time I was creating a workshop on hypermobility. So I was simultaneously researching these two very different diagnoses. And at the time, this was when it was still called "benign joint hypermobility syndrome." I remember thinking, well, I guess it's benign because it's not affecting my organs, but this sure doesn't feel benign to me.

[25:01] Dr. Linda Bluestein: Yeah.

[25:02] Rebekah Rotstein: So I was simultaneously looking at both pathologies, if you will, and I had created this workshop. About 2 years after I created it, I was invited by Hatherleigh Medical Education to create a continuing education lesson and paper for exercise professionals about osteoporosis. They were building out this whole other arm for exercise professionals in addition to their CME division for nurses and physicians.
[29:44] So I did a whole literature review — that's how I started really delving into all the literature, looking at all the evidence that was out there about exercise. And it was bountiful. Despite what people were thinking, there was plenty out there. Even if you look now, you'll see citations in current literature that reference things prior to 2004, even prior to 2002. But it was a matter, I think, of the word not spreading and reaching the ears it needed to reach.
[29:44] Then, probably about a year afterwards, one of my colleagues who had taken my osteoporosis workshop said, "Why don't you put together a whole program? Not just all the science and the bone metabolism and medications and nutrition and movement — why don't you take the movement part and actually create a whole program for it?" And at first I thought, well, why does anybody need that? I said, I've just given you the tools to do it yourself. She said, "People actually want you to implement something." So that's how it came about.
[29:44] It became a whole methodology and system that follows certain protocols — essentially my belief of how you approach the body, which comes from my hypermobile mind, my attitude toward the way I treat my own body with hypermobility and the way I worked with every single client. I took that approach and put it into this system for bone health, and it works magically.

[29:44] Jennifer Milner: So who is your target audience for this? Is it people who have already been diagnosed with osteoporosis, people who just want a good workout? For whom do the benefits come?

[29:44] Rebekah Rotstein: It's really evolved much more than my initial intention. My intention initially was to help people with osteoporosis, to help people prevent osteoporosis, but also part of the mission statement was to help future generations and spread the word about this epidemic that is growing. Statistically, the numbers were showing that future generations were going to have larger experiences of osteoporosis than already existed.
The actual Buff Bones system itself was initially really just designed targeting early postmenopausal women who were far more capable of doing many different types of movements — getting up and down from the ground — and more capable than the simple seated exercises with weights in their hands that was really all that existed before. There was a huge gap I felt a need to fill for women who are, say, 40s to 60s. My mom is 74 now and she's part of that demographic that can get up and down from the ground, is not elderly, is not what you think of as the senior or fragile population. And yet these people don't want to be doing boot camps. They're not trying to flatten their stomach. They need to be functional and they need to be strong.
[29:44] We're doing them a disservice by saying, well, you either go do burpees or you do exercises where you sit down and tap your toes. I realized there's a huge population that is being underserved. And even though chronologically I didn't fit into that demographic, I did in terms of what my body needed to be doing. So I created a system that felt good on my body — I was my own guinea pig to test it. Then I tested it on a number of people and found it served them very well, and the results were pretty outstanding.
[30:00] So it's become something that's not just for osteoporosis. It's safe for anybody with osteoporosis, and the system is designed with bone loading approaches, yet it also integrates so much more — considerations of fascia research, how we can release restrictions in the body and then build from there once we've removed those restrictions, so that then we build in the strength and bring in the mobility and coordination. A huge component that I don't talk much about with the public is motor control. There's a lot built upon motor control in this — the general public probably isn't as interested in hearing about the sequencing, but it plays an important role.
[30:43] As a result, it's been great not only for people with osteoporosis, but also for people with osteoarthritis, neck pain, shoulder pain, back pain, hip pain, and especially hypermobile folks. Because what we're doing is releasing the areas where there are fascial challenges so we can restore the gliding, and then you start to change the sensation and the proprioceptive feedback, and then we bring it all together. At the end is when we bring in some of the loading from outside forces, and then the body knows how to respond and it really integrates as a whole.

[31:31] Jennifer Milner: So your hypermobility did not feel like it was being challenged while you were starting to do your strength training. The work you were doing actually felt good for your hypermobility and felt like it was helping you rein it in and get control over it. Is that what I'm hearing?

[31:50] Rebekah Rotstein: Yes, although I still had to do it my way, essentially. And that was one of the beautiful things that Jeff and I created together — this technique of hands-on work, because I definitely needed the additional load and resistance. That made such a difference for my body. But for me to do seated rows and lat pulls where my shoulder is not fully connected — where I can feel it's not congruent — I felt nothing in my posterior delt ever, until I worked with him and basically told him where I needed his hands to give me feedback so that I could get the joint congruent and get the joint stability. And then I could get the muscular activation where it needed to be. But until we did it that way, it still wasn't enough for me.
[32:50] So my answer is that weight training has been a game changer for me, but still today the joints are so lax that I still need the hands-on assistance that makes the difference so that I can actually get the proper loading forces and the proper activation where it needs to be.

[33:12] Dr. Linda Bluestein: Very, very interesting. And I think this is a great concept because we talked about medications and the challenges with that. When it comes to writing a prescription — and basically when we give a plan to somebody, we're writing them a prescription — writing a prescription for exercise in the general sense is so much less useful than saying, "This is a specific program that you can do." If we don't make it specific, people don't follow through. Even when we do make it specific, it's easier to pop a pill. So I think when people understand the why, they're much more likely to actually do the how. And for you, you really understood it at a deeper level. So you were really motivated to actually follow through with the exercise.

[34:24] Rebekah Rotstein: It's true. And interestingly, when I was in New York in my practice, I had a prominent sports medicine physician who would refer patients to me. Two interesting things about that. Almost every single one of the patients referred to me was there because the diagnosis was "there's nothing wrong with them, they just need to strengthen." And almost every one of those people passed the Beighton scoring. So usually the situation was that there was underlying hypermobility, and that's what we were really working with — getting them stronger, incorporating strength training concepts along with Pilates and other movement modalities.
[35:18] But the other interesting thing is that many of the people who came to me were not compliant even with that when they were told by a physician that they had to come. The ones who stuck around more often than not were the ones who had found me on their own — their own volition, their own determination, not being told by an outside source that this is something they need to do. They had their own internal motivation. They were willing to do whatever they needed to do to get themselves out of pain. Or, in an osteoporosis scenario, they are people who are so determined that they are going to take charge of their health. And that's the biggest factor in the whole compliance idea.
[36:07] And with my trainer, I would have him help me stabilize the joint in order to produce force, because without that I wouldn't get the force production directly through the joint in the way I needed. So thinking about the pathomechanics, it becomes really evident that with those who are hypermobile, you're not going to have the exact same force production, distribution, and transmission through a joint as you would with the standard patient.
[36:54] But I also think there's another important component — in terms of bone density and therefore possibly vulnerability to fracture — and that's the collagen makeup. The actual component of what comprises the bone. Most people think of bone as a skeleton, or as hard and stiff and calcium, forgetting about the collagenous component that gives it resiliency. A strong bone is resilient. One of the goals I have with Buff Bones is to make strong bodies that are resilient.
Technically, with Buff Bones, we're not getting enough loading force into the bones to truly make a big impact on osteogenesis and changes in bone density — although clinically I've seen it. But technically we shouldn't really be. What we're doing is preparing the body to then go do the other components: high-intensity progressive resistance training, velocity, these other things that evidence has shown — even at 85% of your one rep max — can increase bone density in ways that were previously not believed possible. So I believe Buff Bones is part of a bigger system, not everything.
But there's also the idea that you're loading the bones while having to acknowledge the chemical makeup and the collagenous component. And so if there is a deficit or some impairment in the collagen in people with, say, EDS or hypermobility spectrum disorders, then it makes sense that the collagen comprising the bone might also be altered — perhaps responding differently at a genetic level. So it makes total sense to me.
And one thing I also want to quote you on, Linda — I was listening to one of your past podcasts and you said something I love, which is that the exact label is not as important as the symptoms. I love that because I think that's a big factor when we're talking about osteoporosis too. People freak out that they've been diagnosed with osteoporosis. It's not the same as being diagnosed with cancer. Osteoporosis itself is never a cause of death. It's pneumonia or blood clots that it can lead to from a fracture — especially in the elderly — that is the relationship to mortality. People in the healthcare system are so concerned about osteoporosis in the elderly population because of that relationship to mortality from blood clots or pneumonia after a hip or rib fracture when a person is immobilized. But osteoporosis itself is not going to kill you, and many people live very long, healthy lives with osteoporosis and never fracture.
[40:41] There's also another component, which is that osteoporosis was originally supposed to be diagnosed — let me rephrase that. The World Health Organization originally created its classification of osteoporosis based on low bone density as well as changes in an inability of the bone to self-repair itself — changes in architecture. But for some reason, we're not looking at the secondary portion of that classification. We just look at low bone density.
[41:17] So as my original endocrinologist said to me: "You are tiny. You are 5 feet tall and you weigh very little. Look at the size of your wrists. You're not going to have much mass there. You are automatically predisposed to having low bone mass because you have little bone mass." And so I think we have to keep that in mind. That plays out for dancers certainly as well — they're going to be small-boned. Ballet dancers are generally small-boned, and they're going to probably be predisposed to a classification of osteoporosis based on having low bone mass. That doesn't necessarily mean they're going to fracture. And that's an important thing we all have to keep in mind — bone mass has to be considered, but let's be careful with our labels as well.

[42:09] Dr. Linda Bluestein: That makes sense. And have you found a difference in how people who are hypermobile progress through the Buff Bones course, or how they respond to exercise as compared to people who are not hypermobile?

[42:31] Rebekah Rotstein: That's a really interesting question. I have not done enough of a clinical analysis to identify, but I would like to. I think those who are hypermobile respond differently. Here's the thing — we're usually talking about postmenopausal women who are coming to our classes or to me as clients because of osteoporosis. Not always, but if we look at that subset, we generally know that with hypermobility, most people tend to become a little bit stiffer as they get older. The Beighton scoring lowers at certain ages — I think it's 4 after age 50, versus 5 for the number of joints that have to be classified prior to that. People are getting stiffer. As they're getting stiffer, they're also having more fascial restrictions and tightening, also trigger points and such.
[43:42] So I think the release work that occurs early on in the program benefits them, and the motor control benefits them, so that when they add the load later and they're doing more full-body integration, it makes sense in their bodies. Not necessarily cerebrally, but their bodies automatically are saying, "Ooh, okay, wait — I'm getting this. I'm starting to congeal." Those who are not hypermobile are still benefiting from the stretch components and the fascial release work because they're just stiff and tight. So I don't know that there's that much of a difference in that both benefit from it, but maybe they benefit in different ways.

[44:36] Dr. Linda Bluestein: How did you discover things like nutrition and other forms of intervention? How did you find experts to help you with that? Because we know that exercise is a hugely important component, but there are other factors important for bone health as well.

[44:50] Rebekah Rotstein: Well, the answer is that I'm still in the process. I've worked with various nutritionists, and I've also had colleagues in the field that I've referred to. It can be an interesting topic because it's one that is constantly shifting and constantly changing. And the discussion about vitamin K now is the new vitamin D.

[45:27] Dr. Linda Bluestein: You and I have talked about that.

[45:28] Rebekah Rotstein: Yes, we have. And I'm fascinated with vitamin K. Yet I also don't talk about it much myself because people like my father, who was on Coumadin for much of his life — it would have been totally contraindicated for him. So A, it's out of my scope, and B, I'm not doing a full medical intake to be qualified to tell people whether they should be taking certain vitamins or not.
[45:58] But I do find it challenging because sometimes people come back to me after I've referred them to a nutritionist where they appreciate what the person said, or they don't, or they don't like the path that person took them on, or maybe they had to go into so many supplements. I find it to be a really tricky road, partly because there are differing beliefs as well. Some of those beliefs are evidence-based and some are not. And I don't always find myself thrilled with some of the things that are evidence-based because I feel they overlook other components. But then the ones that are less evidence-based — you want to be careful of what you're aligning yourself with.
[46:45] At the same time, there are things that seem to have some evidence, but not enough to warrant standard physicians backing them. In some ways it parallels what I find in the exercise world — maybe you're just ahead of the curve. Maybe as a nutritionist or movement professional, the reason there's no evidence is that it just hasn't been shown yet. But at the same time, you don't want to be out there reporting things that aren't valid. So I find it's a really tough balance.

[47:29] Dr. Linda Bluestein: Yeah, definitely. And it's funny — my husband had a stress fracture recently and nobody had advised him about vitamin D or diet or anything. They just put him on crutches, he had some complications, and that was that. No one discussed nutrition. And you're right — it's challenging. Are you an early adopter? A late adopter? Somewhere in the middle? And to me, it's all about the risk. For someone like your dad who was on Coumadin, eating a lot of dark leafy greens, which are high in vitamin K, is dangerous because it negates the effects of the Coumadin. But otherwise, a lot of nutritional-type advice is something you can be an earlier adopter on because the risks are less.
[48:31] But it can be really challenging to find somebody with the expertise to provide that additional information, because I really do feel that no matter how great the pill or supplement is, you still need a good quality diet. It's not going to make up completely for a poor diet or things like smoking — which, in terms of bone health, is definitely not beneficial. I was trying recently to look for a more recent study on smoking and dancers, and I couldn't find one. Do either of you know anything about more recent statistics on that? It used to be really common among dancers, probably because of weight, but has that shifted?

[49:29] Rebekah Rotstein: I don't see it as much now, and I work mostly with pre-professionals. But even with the professionals I work with, none of them smoke and they don't talk about that. I do encounter a few dancers who smoke. I know one male dancer who smokes and works as a freelance dancer, and I've actually heard a few of his dance partners mention it — they can kind of tell. I think it's changed. I think it's become more of a stigma than a stimulant.
[50:03] When I was dancing, there were so many dancers who said, "My lunch is a Tab and a cigarette." Both of which are not good for bone density. But that was just kind of the way it was. I think it's a lot different now, and hopefully everybody listening knows you shouldn't smoke for so many different reasons — but for the purpose of this conversation, because of bone density. So, right.

[50:27] Dr. Linda Bluestein: That's our little PSA. And I'm sorry to digress. But as you pointed out, Rebekah, very early on, so many people think of bone as being static and it's not, right? It's how fast are we building bone and how fast are we breaking it down? Just like every other tissue in our body — we're constantly growing cells and destroying cells. So it's a question of the balance of those two.

[51:02] Rebekah Rotstein: Well, the digression about stress fractures is actually really germane to the conversation because so many of my dancers get stress fractures or stress reactions in their feet and shins, and we have to talk through what's causing this — look at the exercises they're doing or not doing. But then it's also a great time to say, have you been to your doctor? Say to the parents, has your kid ever had blood work done? Have you looked at vitamin D? Let's examine the diet. And the dancers who commit to a healthier diet and to using nutrition as well will hopefully see that they don't get more stress fractures and also recover faster than if someone just said, "Here's a boot, sit in that for 6 weeks and don't do anything else."
[51:58] Just like with osteoporosis, if you sit on the couch, you will have different results than if you start moving and try to do a system like Buff Bones. If dancers sit on the couch while they're stress fractured, they will have different results than if they move with a doctor's supervision and look at their nutrition.
Well, there are two parts that are really interesting about that. First, a stress fracture could actually be a sign of osteoporosis. Even outside the dancer population, when someone premenopausal gets a fracture that seems unusual — maybe a stress fracture, but also just any kind of fracture — like someone I know who was skiing, fell, and fractured her arm. The doctor wisely said, let's do a DEXA. And sure enough, it came back as osteoporosis, and it wasn't the first fracture she had had.
[52:51] The other interesting thing, Jen — and I think this would be intriguing for Linda as a physician — is, how often do we have clients who experienced a fracture, and they're told by their physician they're not supposed to do any exercise for 6 to 8 weeks? Let's say you fracture your wrist — the third most common site for postmenopausal women due to osteoporosis. And they're told, well, no exercise for 6 to 8 weeks. But what does your wrist have to do with all the ankle work that's going to help you balance?
[53:42] The reason I say this is different for dancers is that the idea of being bedridden or inactive for 6 to 8 weeks is hell for a dancer. For the average person, they might take it as a reward. So your clients who are dancers are probably much more eager to say, "Jen, give me something I can do." I find that with my non-dancer population, it's trying to convince them that no, this is not a free ticket to inactivity — are there things we can get physician clearance to do? Because I want that clearance from the physician.

[54:29] Dr. Linda Bluestein: Right. And there's a difference between what we provide in written instructions versus verbal, and how clear we are, and what people actually recall. It's also possible that the doctor didn't say "do nothing for 6 weeks," but the patient interpreted it that way — because that's what they want to hear. Or because the physician didn't clarify that, yes, your wrist is broken and needs to be immobilized, but you can still do a whole bunch of other things, including walking. So that came to mind as you were talking.
[55:01] And speaking of seeing a doctor, Rebekah — if you're working with someone who came to you independently, not because a doctor suggested it, and you're thinking maybe they should see a physician about their bone density, at what point do you encourage them to do that?

[55:30] Rebekah Rotstein: Well, the reason they've come to me for their bones, though — let's put it this way. The reason someone would come to me for their bones is because they got a diagnosis, and the only way they would have gotten the diagnosis is because they saw a doctor.

[55:48] Dr. Linda Bluestein: Okay.

[55:48] Rebekah Rotstein: So they would have come to me because of the medical side to begin with.

[55:53] Dr. Linda Bluestein: Sure.

[55:54] Rebekah Rotstein: And even in those cases, I always tell them: all right, you got this diagnosis, but one of the first things to do — well, the first question they always ask me is, should I take medication? The first thing I always tell them is that I'm not going to give them an answer on that. But the second thing I tell them is that in order to make a decision on that — which is a decision between you, your family, and your doctor — you need to get more information. So I tell them to see an endocrinologist or a rheumatologist so that they can get the proper blood workup and identify whether there's any other underlying cause. Do you have a thyroid disorder? Are you hyperparathyroid perhaps?
[56:38] I had a client where that was the case. She went and got her parathyroid tested, and it turned out it was hyperactive, which was leading to unusual bone breakdown — because that's what regulates osteoclast activity. So by addressing that, she was able to control her osteoporosis by controlling the parathyroid. It was actually a really wonderful thing that she discovered some other underlying condition.
[57:05] And that often is the case with osteoporosis too — it's really just an indicator of something else going on. Sometimes it's just idiopathic osteoporosis where we don't know why this is happening, and that's sometimes the case for younger people as well. But even now, after all this discussion, it makes me wonder — with that whole idiopathic category, maybe there's something going on with a connective tissue disorder that we thought was just unknown in origin, but there is something there.
[57:49] I do send clients right back to another specialist to at least rule out any other conditions that might be the cause of unusual bone breakdown, and then we take it from there.

[58:06] Jennifer Milner: Okay. So let me follow up on that. If you were still doing private practice — because you're still a Pilates teacher and work with some non-osteoporosis clients — is there a client you might work with who wasn't sent from a doctor? What are some things that might lead you to tell someone, "Hey, maybe you should go get your bone density checked out?"

[58:36] Rebekah Rotstein: Definitely. A couple of things. The signs and symptoms — including if they've experienced one or more fractures, specifically what we call a fragility fracture. Meaning a fracture that is not because you were standing on a chair changing a light bulb and fell, but a fracture that has occurred from standing height or from a seated height that should not be occurring in normal healthy bone. So: one or more fragility fractures, loss of height, and a clear sign of kyphosis or excess curvature and roundedness in the spine.
[59:23] A symptom of, say, a vertebral fracture could be pain, but that can be so misinterpreted because the pain could be from anything. Likewise, loss of height could be from just degenerative disc disease. But if somebody has lost height, if they are a certain age, if they have experienced any fractures — that's a deal breaker for me to say, you should go get your DEXA checked. And I'm talking not just about a stress fracture in the foot, but also if they fell and fractured an ankle or a wrist.
I would also say the guidelines, the medical guidelines, have shifted considerably in the last decade as well — from saying women over 65 should be getting a DEXA, to varying recommendations depending on the guidelines. Some have stated that if you have had a DEXA and it's fine, you do not need to get another one for 10 years. But 10 years is a really long time. At what point, what age did you get the first DEXA? Because you lose up to 20% of your bone mass in the first 5 to 7 years after menopause. So I look at that when I'm talking to somebody. Are they in that large bone loss period immediately after menopause, or are they far out where it's probably leveled off?
[1:01:20] I do tell people to get a DEXA if they've experienced a fracture. And I am a proponent of the DEXA. Some people are not, but I do believe in at least having a baseline measurement. When people come to me showing me one single DEXA, I think, okay, well, that's fine. But I don't know if the reason your bone density is low is because it's just low to begin with. What's really helpful is if I have two — I can compare them. Now I can see: are you low, or are you low and dropping from the last time you had your DEXA?
I also have clients use the FRAX score, which is another measurement — an algorithm developed by the University of Sheffield in the UK. It looks at different factors: your age, your bone density or your last T-score from a DEXA of your hip, secondary osteoporosis, history of smoking, history of glucocorticosteroids such as prednisone — especially those like with Crohn's or colitis — and alcohol units per day.
[1:02:45] I was just going through this with a client the other day so that she could ask her doctor about it. Her doctor wants her to go on medication, and I said, that's your decision, but talk to your doctor about the FRAX because it gives you a 10-year probability fracture risk.
[1:03:01] Well, guess what's missing from this algorithm? Have you ever exercised? Do you have an exercise history? How's your balance? To me, there's again a fault in the system, because I have a lot of trouble believing that your dancer — or your patient or client who is now 60 years old, but was either a professional dancer or just an avid mover who has excellent balance — has the exact same fracture risk as Patient P, who has been sedentary most of her life and whose balance assessment would come out very poorly. According to this algorithm, yes, they have the exact same probability of fracture. There are so many different things that I think can and should be considered.
[1:04:13] It also comes into play with the work that you do, Jen — specifically with your training, whether they are a dancer or not. Even if they have osteoporosis, balance training and all the proprioceptive work will make a difference in fall reduction. Evidence totally shows that. And evidence also shows that if you fall less, you are less likely to fracture. Isn't that the goal of all this to begin with?

[1:04:47] Dr. Linda Bluestein: Preach.
And Rebekah, we know that you've presented to doctors and hospitals around the world. How has the medical community reacted in general to your approach, and how have you pulled together so much research to inform your system?

[1:05:06] Rebekah Rotstein: Several questions. I'll start with the last one — that initial literature review back in, I think, 2008 was really the genesis of everything for Buff Bones. And then I just look at it and update our instructor training manual every year with the latest research studies. I should mention that we have an instructor training program, a certification for exercise professionals. So I update that yearly with the latest research, and I look at it as well just to see what's coming out.
[1:05:50] In terms of the medical world — it's an interesting one. I think there are some in the medical world who really don't care because what they're looking at is purely the evidence. And there is evidence, especially in the last 5 years or so — a growing body of evidence on high-intensity progressive resistance training, and adding in some impact as well, that is having really promising results. So either they don't want to see it, or they do acknowledge it and encourage it, but the challenge is that so many in that same population also have arthritis. So they get concerned: how are we going to do heavy loading for people who already have pain in their joints? Isn't it going to add more compression? And part of the answer to that is, well, it depends on how you do it. And that's where Buff Bones comes in — we really prepare the bones and the joints to be smart so that you can move in an intelligent fashion, get those extra forces in, and have the body know how to absorb and transmit those loads.
[1:07:01] The other answer is that sometimes physicians will say, actually, we love this idea. It just depends. I remember presenting at an international osteoporosis conference once, presenting the latest research on exercise, and a physician who was moderating really questioned what I was saying. I was saying, "This is not my beliefs. I'm telling you what the research is showing right now." So sometimes you have physicians questioning it because it just doesn't seem possible. Sometimes you have physicians who are embracing it but still going to say, yes, but you need medication. And I think maybe there are some who might say, well, we can hold off.
[1:08:04] I know my mom's physician honored her request in the last couple of years to hold off on one of the medications so she could see what the weight training would do. And in fact, the weight training did increase her bone density — now granted, that was prior to COVID, her having COVID, and all the gyms closing down. And I actually do think this is a frightening time for the osteoporosis world with COVID, because so many people who were active and going to gyms are no longer doing that. That's why I've been trying to bring in more and created an online studio in the meantime so that people have an option of something they can do at home.
[1:08:49] It just depends on the physicians, and that's why I am so happy to know physicians such as yourself, Linda, who come from a background of movement. This has become very clear to me in the past couple of years: the greatest advocates I'm going to have for this work are physicians who personally understand the importance of movement and exercise. I can talk till I'm blue in the face to a physician who is a wonderful human being, but the idea of going to a gym or taking a movement class would make them laugh. They like their sedentary lifestyle, and that's fine, but they're not going to be my advocate. If they don't believe it for themselves, why would they advocate it for their patients?
[1:09:48] My alliance is going to be with physicians who believe in movement because they understand and embrace it themselves. Or maybe they haven't, but they've seen the effects on a spouse or a parent. And then that becomes the game changer that makes them a convert to the gospel that the three of us are trying to spread.

[1:10:18] Dr. Linda Bluestein: And that's the ironic thing. If you could take all the benefits of exercise and put them into a pill, it would be the best-selling pill ever. There is also data in osteoarthritis that muscle strengthening improves pain and improves function. It makes sense — it can be challenging to figure out what exercises a given person can do, but muscle protects the joint. So it's not an either/or choice. As Jen and I have figured out, we just keep converting the easier to convert. The people who are going to be at the very tail end, we don't worry about them quite yet.

[1:11:09] Jennifer Milner: You know, I'm always surprised, in how many of our conversations and podcasts, how many times we come back to the basics of nutrition, exercise, and sleep. I remember it was Dr. Ruhoy — I think, right? — our neurologist. We were talking about how to heal the brain holistically, and she listed out these 3 things as the 3 non-negotiables she works on: get better sleep, clean up your gut and what you eat, and get exercise. Every single expert in their field, one of those three things is talked about as "this is what you've got to do." And it feels a little silly that we keep saying this over and over again — diet, exercise, and sleep. But that's what it is.

[1:12:04] Rebekah Rotstein: I find this — I've been doing a lot of thinking this year about hurdles. And one of the things that comes to me, exactly about what you're referring to, is how can we change the mindset? How do we change this paradigm so that it's not, "Oh, I have to change my diet. I have to get more sleep. I have to exercise"? That's been part of what I've been working on with the Buff Bites program — it's just a 5-minute-a-day subscription. What is the least amount of time to let you realize that it's not something you have to do?
[1:12:50] Brushing your teeth doesn't just keep cavities away — brushing your teeth also makes your breath smell better. 5 minutes a day of exercise doesn't just mean you're following doctor's orders to keep your joints mobile. It's that, wow, I actually feel better. My attitude is more positive. I can more easily tackle every other component of my life when I've done this. So how could we possibly shift this triad of sleep, movement, and nutrition to things that feel more joyous? Like, "Oh, I don't have to cook my own meal — I get to create and produce something." Yes, preach.

[1:13:52] Dr. Linda Bluestein: It's all in the attitude, for sure. So Rebekah, we definitely know that exercise — and ideally some kind of program where you're getting really informed advice and doing the proper type of exercise to achieve your goal — is really ideal for everyone. Is there any point at which you encourage a person not to exercise?

[1:14:26] Rebekah Rotstein: No.

[1:14:27] Dr. Linda Bluestein: Well, that was quick.

[1:14:30] Rebekah Rotstein: I always say, do you notice I always have two things? I can't answer succinctly. Part of it is that I sometimes prefer the word "movement" over "exercise," because "exercise" is sometimes misconstrued even by the medical community — when they're saying, oh, you just had surgery, you're not allowed to exercise for such and such number of weeks. Well, sure, you had surgery, but maybe you can just breathe. Maybe you can just move your arm. Maybe you're doing some kind of somatic movement that is not affecting the area of concern. So even just movement — no, there's not really an instance where I would say don't.
[1:15:22] Now, certain types of exercise, certain types of movement — absolutely, there are times I say it's not appropriate. But there's always something that somebody can do. Just as we were saying before, it goes back into mindset and self-efficacy. If you are told that you're not allowed to do anything, I know from my own experience that has been some of the worst times for me emotionally — when I was told I was on a very restricted diet, or when I got the initial diagnosis of osteoporosis and was told, "You are not to bend your back anymore." That feels awesome. The idea of being given only a list of things not to do creates a very negative cyclical pattern and negative mindset. Very, very dangerous.
So there's always something that somebody can do. I can't think of any scenario where I say no — because even if you're just doing finger exercises. And here, you can see my bendy fingers.

[1:16:46] Dr. Linda Bluestein: Oh yes, look at that!

[1:16:47] Rebekah Rotstein: There's always something that you can do. How we define it as exercise or movement might be part of it, but there's always something. Do I say you should just do any exercise? No. There are specific things we shouldn't do based on what might be happening in our bodies at certain times. But that's all the more reason to do the 568,000 other things that you can do.

[1:17:19] Dr. Linda Bluestein: Right. And I love the movement-as-opposed-to-exercise concept, because if we want to be able to move, we need to move. I think we often don't think of it in those terms. We've covered so many great and interesting things, and this has been really educational. Is there anything else we didn't ask you that you wanted to be sure to cover?

[1:17:45] Rebekah Rotstein: Something that I think is interesting is the discussion of instability that comes up a lot in the movement world. This might not be relevant to everything here, but the movement and Pilates world especially has become very focused on this term "stability" — we want to help stability, we want to fight instability — when really the majority of the population doesn't need to worry about joint stability and instability.
[1:18:22] In your population, in your world, that is a huge focus. But I think we need, in the movement world, to stop leading with fear about joint instability, because all we're doing is creating more fear when most people really don't have to worry about that. They need to move more and focus more on mobility. And even in a hypermobile world, we can still talk about where you find your mobility from — it's just not in your thoracolumbar junction. It's not just hanging out on that Y ligament. We're even finding stability from a different part so that we work in this integrated fashion.
I've become really immersed in the world of biotensegrity — the idea that the body is a self-sustaining structure that is inherently stable unto itself. Absent, let's say, of Ehlers-Danlos Syndrome or a hypermobile condition. When we move and work in a way that leverages the biotensegrity of the body — taking on the natural compression and tension components that are inherently there, allowing the body to work as a systematic unit where one part affects another — that inherent stability is automatically found. And we can start moving away from worrying about stability or instability, again absent from the population you're focused on, where there are very valid concerns about joint instability. But how do we stabilize certain areas through movement? And how do we embrace all of that to move away from some of the fear-based discussion of movement, which I know was a very big part of my life for a long time?

[1:20:51] Dr. Linda Bluestein: Fantastic. And where can people best find you and learn more about what you're doing?

[1:21:02] Rebekah Rotstein: The name of the brand is Buff Bones, and the website is buff-bones.com. I also have an online studio that you can find through there — it's called Revive. You can find it when you're looking for the classes on the website. You can also find us on Instagram and Facebook — Got Buff Bones is the name on Instagram, and on Facebook it is just Buff Bones. And the Buff Bites 5-minute-a-day subscription is also findable through there.

[1:21:55] Dr. Linda Bluestein: Fabulous. And we will also have links to all of that on the website as well.

[1:22:01] Rebekah Rotstein: I should mention also, sorry, I forgot — I also have my own work that is separate from Buff Bones, focused on integrated movement and biotensegrity, on my personal Instagram, which is Rebekah Rotstein. I also do things that may be of more interest to the dancer population through there, because I teach a class every Tuesday that is for dancers and movement professionals.

[1:22:36] Dr. Linda Bluestein: Oh, very good. Great. Well, we'll point everyone in the right direction through the show notes and the website, so people can check all of that out. Well, it's been so great chatting with you today, Rebekah. You all have been listening to Bendy Bodies with the Hypermobility MD. Today we have been speaking with Rebekah Rotstein, creator of the medically endorsed Buff Bones System, industry leader in Pilates, bone health, and movement education. Thank you so much for taking the time to talk to us and share your knowledge.

[1:23:08] Rebekah Rotstein: Thank you both for inviting me to speak with you, and also just for all that you're doing for the world of dance and the world of hypermobile populations and for Bendy Bodies. I wish I had you guys 20 years ago.

[1:23:33] Jennifer Milner: So do we.

[1:23:34] Dr. Linda Bluestein: That's part of why we're doing this. We wish that we had us back 20 years ago. We're trying to do what we wish we had back then, right, Jen?

[1:23:44] Jennifer Milner: Yes, ma'am.

[1:23:49] Dr. Linda Bluestein: Well, great. It's been fun. It was great seeing you, Jen, and we'll catch you next time on Bendy Bodies.
[1:23:57] Thank you for joining us for this episode of Bendy Bodies with the Hypermobility MD, where we explore the intersection of health and hypermobility for dancers and other artistic athletes. Please leave us a review on your favorite podcast player. Remember to subscribe so you won't miss future episodes. Be sure to subscribe to the Bendy Bodies YouTube channel as well. Thank you for helping us spread the word about hypermobility and associated conditions. Visit our website at www.bendybodies.org for more information.
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[1:24:43] The thoughts and opinions expressed on this podcast are solely those of the co-hosts and their guests. They do not necessarily represent the views and opinions of any organization. The thoughts and opinions do not constitute medical advice and should not be used in any legal capacity whatsoever. This podcast is intended for general education only and does not constitute medical advice. Your own individual situation may vary. Do not make any changes without first seeking your own individual care from your physician. We'll catch you next time on the Bendy Bodies Podcast.