Osteoporosis: Understanding the Connection Between Exercise and Bone Health

Did you know that nearly 1 million Australian’s suffer from osteoporosis? That’s about 4% of the population (AIHW 2020). Osteoporosis is a major health concern for many members of the Be Mobile Community. Since osteoporosis is most prevalent in older adults (particularly women) helping our clients improve their bone density is one of our big goals! However, many people with osteoporosis are concerned about exercise, especially resistance training for fear of damaging their bones. This blog will address some of the concerns about osteoporosis and exercise. But first, let’s clarify a few things about the condition.

What is Osteoporosis?

Osteoporosis translated from ancient Greek means “porous bone”. It is a skeletal condition where there is a decrease in bone mineral density - classically seen in post-menopausal women. Osteoporosis is diagnosed by a bone density scan. A T score of -2.5 or below indicates osteoporosis whereas a score between -1 to 2.5 indicates osteopenia - a milder form of bone mineral density loss.

_{(Cited in AIHW 2020)}

Why is it important to be aware of?

Many older adults suffer from osteopenia and osteoporosis, and the prevalence increases with age ^{(AIHW 2020)}.

People who have osteoporosis are at a much greater risk of fractures for all areas of the body. People with osteoporosis are more likely to fracture a bone from trauma that would not normally cause a bone to break. These are called minimal trauma fractures, and can affect many different body areas. These fractures can have a significant impact on someone’s quality of life, especially when they occur in areas like the hip, which can reduce a person’s mobility and independence. Aside from the obvious detrimental effects of breaking a bone, having a fracture also causes a 2-4 fold increase in risk that a person with low bone density will have a subsequent fracture in other areas of the body (RACGP 2010). Serious fractures like those of the hip, can unfortunately lead to disability and even premature death (AIHW 2020).

Osteoporosis also makes the skeleton less resilient to stress and loading which can result in things like vertebral compression fractures. These are associated with a gradual loss of height, and an increase in thoracic kyphosis (hunched posture) as a result of the vertebral bodies reducing in thickness. Vertebral compression fractures are often not attributable to a traumatic injury, and can silently develop over time without obvious symptoms.

Osteoporosis and osteopenia are often undiagnosed. This is because reductions in bone density don’t become apparent until an inert trauma causes a fracture. The best approach to minimising the loss of bone mineral density and therefore preventing osteoporosis is therefore preventative - engaging in strategies to maximise bone density, no matter your age. That said, we can have a big impact on bone mineral density, even after osteoporosis has been identified. For people who have been diagnosed with osteoporosis or osteopenia, it is paramount to undertake some of the treatment approaches discussed below.

How can we improve bone mineral density?

There are various strategies to improve bone mineral density. Many of these are lifestyle related. Ideally, each person will engage in these strategies throughout their lifespan, but they become more important for those over 50. Some of the lifestyle related strategies for maximising bone health recommended by Royal Australian College of General Practitioners (2010) are:

• Ensure adequate protein and calcium dietary intake
• Adequate but safe exposure to sunlight as a source of vitamin D
• Maintenance of healthy weight and body mass index
• Abstinence from smoking
• Avoiding excessive alcohol consumption
• Meet or exceed the National Minimum Physical Activity Guidelines for resistance training: 2-3 progressive resistance training sessions per week

It is important to note that these guidelines are recommended for all older adults with or without osteoporosis or osteopenia, including the resistance training guidelines:

There are of course other treatments, notably pharmacological interventions that can have a significant impact and we would advise discussing those with your doctor if you have been diagnosed with osteoporosis or osteopenia. At Be Mobile, our big focus is on the exercise side of treatment - which is where we can have a big impact on bone mineral density (as well as all the other incredible health benefits). So let’s talk about exercise and address some of the common concerns and misconceptions surrounding osteoporosis and physical activity.

How does Exercise improve Bone Mineral Density?

It is a common misconception that the skeleton is just a scaffold, holding up the ‘living’ parts of our body like the muscles and organs, but this is not the case - bones are in fact, a living tissue and just like muscle, they adapt to the stresses they are placed under. So in the same way that a muscle gets bigger and stronger when we stress it, bone’s become more dense and more resilient through exercise. However, just like muscles there are certain forms of exercise that are more effective than others for increasing bone density. 

What is the best exercise to improve bone mineral density?

A lot of guidelines suggest weight bearing exercises like walking for improving bone density. While walking has a range of health benefits, it simply provides insufficient loading for optimal improvement in bone density. We have strong evidence that the best form of exercise to improve bone density in people with, or without osteoporosis is high intensity resistance training. One of the landmark studies is the LIFTMOR trial (2017).

 The LIFTMOR trial stands for “Lifting Intervention For Training Muscle and Osteoporosis Rehabilitation”. In the study, they compared two groups of women over 58 years of age for eight months. The first group performed a high intensity resistance training program consisting of twice-weekly sessions for the 8 months. They performed 3 exercises (deadlifts, squats and overhead presses) with weights that were challenging for 5 repetitions. This group also performed impact training consisting of an arm assisted jumping exercise. The second group participated in a bodyweight and light resistance exercise home program involving movement such as lunges and heel raises, holding a maximum weight of 3kg. The study showed that the heavy resistance training caused a significant improvement in bone mineral density while the home exercise group actually reduced their bone density at various bony landmarks. Importantly, this is not to say that the lower intensity exercises were detrimental - just that they were insufficiently dosed to stem the age related loss of bone density that we would expect over an 8 month period.

But how safe is lifting weights when you have osteoporosis?

This is a common concern for people with reduced bone density. Like any exercise, lifting weights involves some amount of risk. However, resistance training has an incredibly low injury rate in the general population - likely because it can be very easily controlled by manipulating the variables of weight, repetitions, sets and exercise selection. This low injury risk for the general population was also apparent in the subjects in the LIFTMOR trail. Over the course of the 8 months of resistance training, only one participant missed training sessions. This was an episode of back pain that caused them to miss two sessions before returning to complete the program without any concerns. This confirms that high intensity resistance training is safe for people with osteoporosis. Remember, bones are a living tissue that adapt to the stresses placed on them! Just like a good resistance training program for a person with healthy bones, we can minimise the risk of injury in people with osteoporosis by starting training with loads that are well within the capabilities of the person and very slowly build up over time. This is a piece of advice we regularly give to our clients “Start low, go slow”.

How to get started with resistance training

Hopefully by now you are convinced of the benefits of resistance training for your bone health! So let’s discuss what a well planned resistance training program would look like for someone looking to improve their bone density.

Exercise Selection

In the LIFTMOR trial, they used the deadlift, squat and overhead press for the resistance movements. Here are some of the reasons why these are a great choice:

• They are multi-joint movements that use big muscle groups and thus load lots of the skeleton. 
• They can start with bodyweight or very light loads and be progressed slowly over time.
• They can be loaded with sufficient load to induce bone adaptations.

 There are many exercises that meet these criteria, but some others we often use are push-ups and bent-over row variations. Coincidentally, the aforementioned exercises are also some of the best choices for improving other important markers of health and fitness like functional capacity, strength and muscle mass. In other words, a good resistance training program for bone health is going to look very similar to one designed for general health and fitness - as long as it is sufficiently dosed and progressed over time!

The LIFTMOR trial also included the impact component - an arm assisted jump. This can be incorporated into the resistance training program. Impact exercises may have additional benefit to lifting weights because of the significant ground reaction force that goes through the bones when landing.

Frequency

In the LIFTMOR trial, the subjects trained twice per week. This falls in line with the minimum physical activity guidelines of most government guidelines. A good starting point is therefore 2-3 sessions per week, with 48 hours in between sessions to allow for recovery.

Intensity

In the study, the subjects lifted weights that were challenging by 5 repetitions and got good benefits. It is reasonable to expect however, that lighter weights done for more repetitions could elicit similar benefits. The caveat here is that a set of exercises should be challenging. For example you could perform the squat for 15 reps, but it should be with a weight that you could only do 17-18 repetitions with.

Here is an example resistance training week for someone looking to improve their bone density (including cardiovascular exercise)

If you’ve made it to the end of this article - well done! Hopefully you have found the information useful and now have a better understanding of osteoporosis, how exercise can help and how to get started!

If you’re interested in finding out more and getting some tips about exercise, you can watch this video!

If you’re looking for help getting started with resistance training, you can try a free strength workout when you sign up for a free account on our website.

References

• Australian Institute of Health and Welfare 2020. Osteoporosis. Cat. no. PHE 233. Canberra: AIHW. Viewed 16 March 2021, https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoporosis
• The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd edn. East Melbourne, Vic: RACGP, 2017.
• Watson, S., Weeks, B., Weis, L., Harding, A., Horan, S., & Beck, B. (2017). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal Of Bone And Mineral Research, 33(2), 211-220. doi: 10.1002/jbmr.3284