Strong, steady and straight: Exercise recommendations for osteoporosis

Exercise is good for you with multiple health benefits, including improved bone health. However, too much exercise can sometimes lead to harm (fractures), even in young people with normal bone density.

Exercise is just one tool available for the prevention of fractures in patients with osteoporosis. Other strategies include nutritional advice, pharmacological methods (vitamin D, calcium and other treatments) and lifestyle factors (avoiding smoking and moderating alcohol intake).

Although there are multiple physical activity guidelines for the general population, until recently, there have been no evidence-based recommendations for the prescription of exercise in patients with osteoporosis, to improve or even maintain bone strength without causing harm.

A recent paper in the British Journal of Sports Medicine from a multidisciplinary group of experts and a large group of stakeholders, including patient representation, is a UK consensus statement for the prescription of exercise in patients with osteoporosis. Some of the recommendations are evidence based (E), following a literature review performed by the study group, and some are by consensus (C) where the literature is lacking.¹

Their definition for osteoporosis is a dual-energy x-ray absorptiometry (DXA or DEXA) T-score of less than -2.5, or a significant fracture risk (not defined), with or without fragility fractures.

They break their recommendations down into three different sections, based on the different goals for exercise in patients with osteoporosis:

Strong – to increase bone strength.

Steady – to prevent falls.

Straight – to prevent vertebral fractures by improving posture, and to reduce pain following vertebral fracture.

There is quite a lot of detail in the paper about different exercise types and options (worth a read), but the bottom line is that there is little evidence of harm from exercise for those with osteoporosis. Normal exercise recommendations do not need to be adapted based on fracture risk or bone mineral density level (defined by DXA score).

However, there are case reports of vertebral fractures associated with end-range, sustained, repeated or loaded (spinal) flexion, so these movements should be avoided, and impact activities should be modified in those with vertebral fractures (see below).

A systematic review of studies mentioned in the UK consensus paper, looking at the use of exercise in patients with osteoporosis/osteopaenia, reported that, overall, the rate of fractures in intervention (exercise) groups was lower (5.8 per cent) than in control (no exercise) groups (9.6 per cent).²

So, what are the specific recommendations for patients with osteoporosis?

Exercises to increase bone strength.

Physical activity should be daily, and patients should be encouraged to avoid prolonged sitting (C).

Muscle strengthening activity should be performed two to three times per week to maintain bone strength. Good technique should be ensured at lower resistance before progressively increasing resistance levels. For each individual session, three sets of exercises progressively increasing in resistance are recommended, building up to the maximal weight that can be lifted eight to 12 times in the third set (E).

All muscle groups, including the back muscles, should be targeted (C).

Impact activities (eg, stamping, jogging, light jumping) on most days are recommended to increase bone strength – five sets of 10 repetitions are suggested. For those with osteoporosis and vertebral fractures, a maximal level of impact equivalent to brisk walking is recommended – this is due to a theoretical risk of further fracture (C).

For frail patients with osteoporosis, it is recommended that a supervised programme to increase strength and balance is undertaken before an individually tailored physical-activity programme is given (C).

Exercises to prevent falls.

All patients with osteoporosis should undertake activities to improve balance and strength (eg, tai chi, dance, yoga or Pilates) twice a week (C). Of course, other physical activities may provide these benefits – see the paper for examples.

For those who fall regularly, it is recommended that they start with an individualised and supervised “highly challenging” balance and strengthening programme (ideally via a falls prevention programme, if available), consisting of three hours per week over four months (E).

Progression to higher-impact exercise is recommended after completing a balance and strengthening programme (C). The Otago Exercise Programme and Falls Management Exercise (FaME) programme are recommended (E).

Exercises to prevent vertebral fracture and improve posture.

It is important to focus on teaching patients how to do certain activities (eg, correct lifting technique), rather than on things they should not do (eg, don’t lift), which may affect confidence. However, activities involving repeated, sustained or loaded end-range spinal flexion should be avoided (C).

Patients with osteoporosis and vertebral fractures should be given advice on movement and lifting as soon as possible after injury, ideally with physiotherapy supervision. It is recommended that back strengthening exercises are performed daily, with a focus on endurance at low intensity (three to five sets of exercises held for three to five seconds). Activities such as yoga and Pilates may be helpful, as can hydrotherapy where available (C).

Steve Targett is a sports physician in Doha, Qatar