Osteoporosis and Exercise
What is Osteoporosis:
Osteoporosis is a chronic skeletal disorder that occurs when there is a micro-
architectural loss of bone tissue and a decrease in bone mineral density (BMD), causing
bones to be easily susceptible to fractures (Downy & Siegel 2006). Fractures can be
caused by the simplest of movements such as daily living activities and occurs most
commonly in the proximal femur (hip), vertebrae (spine), and the distal end of radius
and ulna (wrist) (Hardman & Stensel 2003). It is estimated that 30-50% of women and
15-30% of men will experience at least one osteoporotic fracture during their lifetime
(Nikander, et al. 2010). In the UK alone, approximately 1 in every 2 women over the age
of 50 will experience an osteoporotic fracture, along with 1 in every 5 men (International
Osteoporosis Foundation 2009).
There are two types of osteoporosis: primary and secondary. Primary
osteoporosis is a deterioration of BMD caused by biological factors such as age, sex,
race, genetics, and weight. On average, each person‟s BMD peaks around 18-25 years
of age and slowly decreases as they age. Therefore, a person‟s risk of developing
osteoporosis increase as they gets old. Women are also more likely to develop
osteoporosis. This is because women‟s BMD tend to peak at a younger age in
comparison to men and decreases more rapidly due to menopause which decreases
levels of estrogen in the bodies and increases bone absorption (Vondracek 2010).
Studies have also shown that Caucasians and Asians have a higher risk of developing
the disorder as well as people with pervious family history of osteoporosis. It is
estimated that 60-80% of BMD is determined by a person‟s genetic background
(Nieman 1998). Lastly, people that are below normal weight tend to have weaker bones,
making them more susceptible to developing osteoporosis because of the reduced
starting amount of BMD (Hardman & Stensel 2003).
Secondary osteoporosis occurs from chronic conditions that prevent osteoblastic
activity such as certain medications, excessive alcohol intake, smoking, and poor
nutrition. Patients that are prescribed medications that include low to moderate amounts
of glucocorticoids have been found to have a higher risk of fractures (National
Osteoporosis Society 2006). Consuming more than 2 glasses of alcohol per day also
increases the risk of osteoporosis. People that currently smoke or were pervious
smokers have a higher risk of experiencing a fracture. Also, calcium, vitamin D, and
protein are essential for bone development, especially during the period when bone
growth is most intensive, such as in infancy, puberty, and early twenty‟s. (Stránsky &
Ryšavá 2009). Thus, people with deficiencies of any of these nutrients are more at risk
of developing osteoporosis.
Osteoporosis is most commonly diagnosed using a Dual Energy X-ray
Absorptiometry (DXA) test. The DXA is the safest and most reliable method of
measuring the grams of bone mineral per unit of bone area, which is derived from the
measurements of the person‟s BMD and bone mineral content (BMC) (Otis & Goldingay
2000). Once taken, these measurements are then compared to the standard
measurements for the person‟s age. This measurement is called a T-score (Morgan &
Kitchin 2008). If the T-score is -1 standard deviation from the mean, then the BMD is
normal. If the T-score is -1.1 to -2.4 standard deviations from the mean, then the person
is diagnosed with osteopenia and is at risk of developing osteoporosis. If the T-score is -
2.5 standard deviations from the mean, then the person has osteoporosis.
Exercise Benefits and Potential:
According to Prior, et al. (1996), many patients with osteoporosis become fearful
of exercise because of their perceived risk of falling. However, many studies have
shown that participating in exercise is more beneficial to bone health in comparison with
immobility. Nieman (1998) found that healthy individuals that go on complete bed rest
for 4-36 weeks can experience a decrease in BMD of an average of 1% per week.
Also, Cumming, et al. (1995) found that women who were mobile for less than 4 hours
per day had twice the risk of experiencing a fracture compared to women who were
Exercise maintains bone strength due to the piezoelectric effect in the bones that
is triggered during exercise. When a muscle contracts from the stress loads of exercise,
it causes the bone to slightly bend. The bend creates electrical signals that move along
the crystalline material of the bone and activate the metabolism of the osteobytes.
(Downy & Siegel 2006 and Lirani-Galvão & Lazaretti-Castro 2010). This stimulates bone
formation which helps maintain or increase a person‟s BMD, making the bones less
susceptible to fracture. Therefore, it is essential that people diagnosed with
osteoporosis exercise regularly and avoid immobility. However, to prevent fearfulness of
falling, people with osteoporosis should be educated about which exercises are safe to
preform and which types they should avoid.
However, research on exercise and osteoporosis have mixed results when it
comes to which types of exercise prevent BMD loss the most. Most research has shown
that each type of exercise is area-specific, meaning that certain exercises tend to be
beneficial for BMD in only one or two areas of the body. By integrating many different
types of exercise, a person with osteoporosis has a greater chance of retaining their
BMD throughout their entire body. This includes regular practice of aerobic, strength,
and balance exercises (Nelson, et al. 2007).
Aerobic and Weight-bearing Exercises
Although many people with osteoporosis are especially fearful when it comes to
weight-bearing and aerobic exercises, research has shown that these types of
exercises are extremely important in maintaining BMD because they stimulate the
piezoelectric effect (Lirani-Galvão & Lazaretti-Castro 2010). These types of exercises
include fast-paced walking, stair-climbing, and low-impact aerobics such as tennis,
dancing, and modified gymnastics. Berström, Brinck, and Sääf (2008) conducted a 1-
year experiment that observed the BMD contents of osteoporotic women who fast-
paced walked for 30-minute intervals 3 times a week, along with an 1 hour professional
training session per week consisting of aerobic and strength exercises. Their findings
showed an average increase of 3.5% BMD in the spine and 0.9% in the femoral neck.
This experiment suggests that light weight-bearing exercises such as fast-paced
walking, combine with strength training, can prevent BMD loss.
Aerobic exercises such as slow-paced walking and swimming are encouraged for
people with osteoporosis to maintain cardiovascular health and limit immobility, but not
to strengthen bones or prevent BMD loss. Nonetheless, these exercises are safe for
people with osteoporosis to preform, but should not be considered for treatment.
Strength and Resistance Training Exercises
Strength and resistance training exercises are also highly recommended for
osteoporotic patients. Similar to aerobic training, strength training causes muscle
contractions which stimulate the piezoelectric effect and increases bone formation
(Lirani-Galvão & Lazaretti-Castro 2010). Strength and resistance training have been
found to improve spine and hip BMD in osteoporotic and osteopenic women more than
any other areas. Studies have shown that weight training exercises involving intensities
between 50-90% of 1 resistance maximum (1 RM), for 8-12 repetitions of 2 to 3 sets,
over a duration of 1 year, are needed to increase the BMD in osteoporotic women
(Zehnacker & Dougherty 2007 and Lirani-Galvão & Lazaretti-Castro 2010). However,
strength training is area-specific as well. Therefore, integrating strength and resistance
exercises that activate different areas of the body should be considered when designing
an exercise routine.
Back exercise are also important for people with osteoporosis because they tend
to have significantly lower back extensor strength than people without the disorder.
Hongo, et al. (2006) found that osteoporotic women who preformed brief low-intensity
back exercises 5 times a week over a 4-month period improved in back extensor
strength. Also, back exercises have been shown to prevent women from developing
kyphosis, a curvature of the spine, as well as help maintain proper posture (Prior, et al.
1996). Back exercises includes isometric abdominal strengthening, pelvic tilt, and gentle
back extensions, and should be incorporated in osteoporotic patient‟s exercise routines.
Balance and Flexibility Exercises
Osteoporotic fractures are the highest causes of disability and mortality in
postmenopausal women (Lirani-Galvão & Lazaretti-Castro 2010). Therefore, exercises
that promote balance, flexibility, and postural improvements are highly recommended
for people with osteoporosis.
Balance exercises, especially, have been shown to reduce the amount of falls in
osteoporotic women. Madureira, et al. (2007) conducted a study that looked at the
benefits of balance exercises on the prevalence of falls in osteoporotic women over a
12-month period. They found that women who participated in an 1 hour balance training
program guided by a trainer, along with 3 independently guided sessions of 30-minute
balance exercises per week, had significant improvements in balance, mobility, and
preventing falls compared to women who only received training for preventing falls.
Also, yoga has been shown to improve both balance and BMD. Fishman (2009)
conducted an experiment involving 18 osteoporosis patients, of which 11 were
instructed to preform 8-10 minutes of specified yoga poses each day for 2 years. The
patients that preformed the yoga had increased their spine BMD an average of 0.563
units on the T-scale and their hip BMD an average of 0.867 units. However, since
osteoporosis increases bone fragility, yoga poses should be modified to avoid putting
too large of loads on bones or causing too much strain from twisting too far ( Krucoff, et
al. 2010). Nevertheless, yoga has been found to improve balance, flexibility, and posture
in osteoporotic patients and can be used as a technique to prevent falls.
A safer approach to improving balance and posture can be by participating in tai
chi. Tai chi uses breathing and balance techniques to strengthen bones and perfect
posture. Although, research has not shown that tai chi can improve BMD, it has been
shown to improve balance and posture in osteoporotic women (Lee, et al. 2008 and
Lirani-Galvão & Lazaretti-Castro 2010). Therefore, tai chi can be an option for
osteoporotic patients in addition to strength and aerobic exercises.
Because of the high risk of fractures associated with osteoporosis, people with
the disorder must take certain precautions when exercising. First, it is important for
people with osteoporosis to avoid any type of high-impact aerobic exercises (National
Osteoporosis Society 2006). High-impact exercises, such as running, skipping, or
jumping, put high amounts of loads on the bones, causing the strain to be too
excessive. Second, patients with low body weight should be cautious of the amount of
calories they burn from exercise and should adjust their diets to compensate for the
calories lost. It is suggested that people with low body weight should focus on strength
and balance exercises rather than aerobic exercises that promote weight loss. Third,
patients should avoid exercises that involve excessive back bending, twisting at the
spine, sit-ups, and abdominal crunches (Krucoff, et al. 2010). All of these movements
increase the risk of fracture. Nonetheless, osteoporotic people should always consult
with a professional fitness advisor to verify beforehand which exercises are safe for
them to preform.
Author Exercise Sex Body Finding
Gunendi, et Sub-maximal Post- Balance 4-weeks of sub-maximal
al. (2008) aerobic menopausal throughout aerobic exercises
exercises osteoporotic the whole improved static and
women body dynamic balances.
Karinkanta, Resistance 149 women Distal tibia, 1-year training of
et al. (2007) training and aged 70-78 tibial shaft, resistance and balance-
balance- years-old and femoral jumping training prevented
jumping neck functional decline and had
training positive effects in the
structure of the tibia.
Going, et al. Aerobic, 320 post- Femoral 12-months training with
(2003) weight-bearing menopausal neck, aerobic, weight-bearing
exercises and women trochanteric exercises and weight lifting
weightlifting and lumbar exercises increased BMD
spine in all areas by 1-2%.
Sinaki, et al. Back- 50 post- Back and After 10-year long study,
(2002) strengthening menopausal spine women who preformed
exercises women, aged back strengthening
58-75 years- exercises had a decrease
old in vertebral fracture risk.
Voukelatos, Tai chi 702 men and Reduction of 16 weeks (1 session per
et al. (2007) women over 60 Falls week) of tai chi reduced
years old the frequency of falls in
Angela, a 58 year old Caucasian women, visited her general practitioner after
suffering from severe back pain while doing everyday activities such as getting in and
out of bed, bending over, and sitting down. She has no family history of osteoporosis,
though, like her mother, she has always been “thinned-boned” and nearly underweight
(height of 5‟4 and a BMI of 19). She has never smoked a cigarette, drinks a couple of
glasses of wine occasionally, tries to maintain a healthy and balanced diet, and is taking
no medication. She has worked as a receptionist for the past 15 years and does not
participate in any exercise activity other than her daily 30-minute walk with her dog.
After a DXA scan of her spine showed a T-score of -2.6, Angela‟s practitioner
diagnosed her with osteoporosis and prescriber her an estrogen replacement
medication. The practitioner told her to take calcium and vitamin D supplements along
with her medication and registered her with a professional trainer to facilitate and
organize her exercise routine.
Because Angela has a T-score of -2.6 but has not yet fractured a bone, it is
recommended that she begin a low-intensity exercise program, consisting of 2-3
sessions per week of aerobic and strength exercises and 1-2 sessions of balance
exercises. As she gets more comfortable with the exercises the intensity may slightly
increase, but they should never reach a high-intensity level because of the increase risk
For the aerobic exercises, slow-paced to fast-paced walking on the treadmill is
encouraged as well as 3-5 minutes on a stairclimber. Strength exercises that strengthen
the back muscles are highly encouraged for Angela, along with exercises for the hip and
legs. However, with the back exercises, the intensity and the amount of reps should
start low and gradually increase overtime to prevent fractures.
For balance exercises, attending a yoga or tai chi class twice a week is
recommended to improve her balance and flexibility. Also, it is encouraged that Angela
practices simple balancing exercise at home such as walking in a straight line with one
foot directly in front of the other, walking sideways, or switching between standing on
Aerobic and Strength Training Routine:
Type Intensity Duration
Treadmill walking (start will normal-speed
walking, then slowly increase to a fast-paced Low to Moderate 3 minutes
Dynamic Stretches Moderate 3 minutes
Stair-climbing Low 5 minutes
-Adductors and abductors 1 sets of 10-12 reps
-Elbow flexors and extensors each
-Abdominal muscles exercises
Treadmill walking Low 3 minutes
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