VITRUVIAN EXERCISE PHYSIOLOGY
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OSTEOPOROSIS
What is Osteoporosis?
Osteoporosis is a bone condition characterised by low bone mass and changes to the internal structure of the bone. These changes lead to increased bone fragility and therefore, increased susceptibility to fracture. Osteopenia refers to a level of bone density that is lower than the average adult, but not low enough to be diagnosed as osteoporosis.
Our bones are constantly being remodelled. Bone is formed by cells called osteoblasts, and bone is lost (known as resorption), by cells called osteoclasts. In normal circumstances, the amount of bone formation equals the amount of bone resorption. In osteoporosis, this ratio is altered, and the amount of bone loss is greater than bone formation.
Osteoporosis is asymptomatic until a fracture occurs (we don’t experience symptoms such as pain and stiffness). Often, the first an individual becomes aware they have osteoporosis is following an osteoporotic fracture, most commonly after a fall. There are risk factors (which we will look at shortly) that can increase our suspicions that an individual might be predisposed to osteoporosis.
Healthy vs osteoporotic bone
Osteoporosis Prevalence
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Over 3.5 million individuals in the UK have osteoporosis
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In Australia, more than two thirds of people over the age of 60 have osteoporosis or osteopenia
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It is estimated that 200 million individuals have osteoporosis worldwide
Fracture is the most serious clinical consequence of osteoporosis:
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The number of yearly fragility fractures in the UK is projected to increase from 527 000 in 2019 to 665 000 in 2034, largely due to an ageing population
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Osteoporotic fracture predominantly affects post-menopausal women
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Hip fracture is the most serious consequence of osteoporosis in terms of morbidity, mortality and health care expenditure.
Diagnosis
The most widely used diagnostic scan for osteoporosis is DXA (dual-energy x-ray absorptiometry). A DXA scan gives us information on our bone mineral density (BMD), usually at the spine, hip, and forearm. These sites are chosen as they are the most commonly fractured.
The World Health Organisation (WHO) has devised thresholds for categorising individuals based on bone mineral density T-scores. The T-score compares your BMD results to those of the young adult mean (the peak bone mineral density of healthy young adults).
Bone mineral density T-score
Osteoporosis risk factors:
Personal History
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Family history of osteoporosis
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Sedentary lifestyle / lack of physical activity
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Previous fragility fracture
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Female sex – particularly post-menopausal women
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Low BMI / low body weight
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Smoking and/or excessive alcohol intake
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Inadequate calcium, vitamin D
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Age ≥ 70 years
Medical Conditions
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Malabsorptive disease (e.g., coeliac, Crohn’s)
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Overactive thyroid
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Rheumatoid arthritis
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Early menopause/Low testosterone
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Chronic kidney disease or liver disease
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Diabetes
Medications
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Certain treatments for breast and prostate cancer (e.g. androgen deprivation therapy, immunotherapies)
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Corticosteroids
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Anti-epilepsy treatment
Treatment / Management
If, following a risk assessment and scan, the decision is made to offer treatment, first steps involve addressing modifiable lifestyle factors including:
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Appropriate exercise and physical activity (we will look at specifics in the next section)
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Nutrition - calcium, vitamin D, and general nutritional intake
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Smoking cessation and alcohol moderation
If required, pharmacological treatment commonly involves the use of medications including Bisphosphonates (Fosamax, Actonel) and Denosumab (Prolia). It may also include hormone treatment (Oestrogen).
The overall management plan will depend on various factors including age, current bone mineral density scores, general health, fracture risk (including falls risk), medical history, and possible side effects of medications.
Role of Appropriately Prescribed Exercise
Bone is a dynamic tissue, and therefore, if an appropriate amount of strain is placed on it, our skeleton adapts by becoming stronger and reinforcing itself. Activities that promote the formation of bone are known as ‘osteogenic’ exercises.
Current best evidence indicates that the most osteogenic (bone forming) exercise protocols include progressive resistance training and jumping/impact activities. These protocols involve low numbers (repetitions) of high intensity loads.
Non-weightbearing and low-impact exercises such as walking, swimming, pilates, yoga, and cycling have little to no ability to improve bone mass in older age. They can, of course, offer benefits relating to cardiovascular and metabolic health, however, cannot be recommended for the purpose of increasing bone mass or preventing bone loss.
A program combining progressive resistance exercise and impact training at moderate to high intensities provide greater osteogenic effect than a program including only one of these types of training.
Progressive Resistance Training
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2-3 days per week
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2-3 sets of 5-8 repetitions per exercise
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Multi-joint exercises that focus on major muscle groups, particularly those attaching to the hip and spine
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Loads to be progressively increased over time
Impact / Jumping Exercises
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Performed on 3+ days per week
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Gradually increasing to jumping/landing impacts at 2-4 x bodyweight, as tolerated
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Approximately 50 impacts per session
Balance Training
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Appropriately prescribed exercise is the most effective method of preventing falls
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Although balance training does not have a positive impact on bone formation, it is key for those with low bone mass who have an increased risk of falling
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Minimum 3 days per week
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Progressive and challenging balance activities
The above protocols represent a best case scenario but will not be applicable or achievable for everyone. The starting point, progression, and end point of any exercise program will be specific to the individual.
Exercise capacity and prescription will be influenced by exercise history, medical history, current bone mineral density, and risk of falls. Additionally, because osteoporosis is more common in older populations, exercise capacity may be further influenced by conditions including osteoarthritis, cardiopulmonary disease, musculoskeletal pain, previous fracture, neurological conditions, and cognitive limitations.
For some individuals, a period of lower intensity training/activity may be required initially, and where certain recommended activities (such as squats or jumps) are not appropriate, alternative exercises can be prescribed.
Among the evidence and studies demonstrating the effectiveness and safety of these protocols are a series of trials known as LIFTMOR (Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation). These trials, from Australia, involved postmenopausal women with diagnosed osteopenia and osteoporosis. Protocols included:
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2 x weekly sessions
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High intensity resistance training (squats, deadlifts, overhead press)
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Jumping and landing exercises
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Intensity was progressed over 8 months
Results showed improvements in bone density at clinically relevant sites (hip and spine) as well as improvements in physical function and muscle strength. Importantly, no fractures or injuries occurred due to the training program. Keys to the safety of this program were:
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The first 1-2 months were focused on teaching correct technique before progressing
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A graduated progression of loading
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Close ongoing supervision
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Focus on correct technique
It is recommended that exercise is prescribed and supervised by a Clinical Exercise Physiologist (as we are here at Vitruvian) or a Physiotherapist, in order to assess exercise capacity and comorbidities. This is key to making appropriate modifications to ensure safety and meet individual needs.
No matter the starting point, each and every one of us has the capacity for progress.
The Vitruvian Team.
Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis
Brook-Wavell et al. British Journal of Sports Medicine. 2022
High-intensity resistance and impact training improves bone mineral density and physical function in post-menopausal women with osteopenia and osteoporosis: the LIFTMOR randomised controlled trial
Watson et al. Journal of Bone and Mineral Research. 2018
A comparison of bone-targeted exercise strategies to reduce fracture risk in middle-age and older men with osteopenia and osteoporosis: LIFTMOR-M semi-randomised controlled trial
Harding et al. Journal of Bone and Mineral Research. 2020
Exercise prescription to support the management of osteoporosis: For Physiotherapists and Exercise Physiologists
Klug et al. Healthy Bones Australia. 2024
Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis
Beck et al. Journal of Science and Medicine in Sport. 2016
International Osteoporosis Foundation. 2022
A comprehensive overview on osteoporosis and its risk factors
Pouresmaeii et al. Therapeutics and Clinical Risk Management. 2018
A comparison of the bone response to impact loading and resistance training in young adult women: The OPTIMA-Ex trial
Lambert et al. BMJ Open. 2017
The effect of exercise intensity on bone in postmenopausal women: A meta-analysis
Kistler-Fischbacher et al. Bone. 2021
Exercise to prevent falls in older adults: an updated systematic review and meta-analysis
Sherrington et al. British Journal of Sports Medicine. 2017