Osteoporosis: exercise as prevention and treatment (Part 2)

Osteoporosis: exercise as prevention and treatment (Part 2)

Resistance, aerobic and flexibility exercise

The two types of exercise most recommended for individuals with osteoporosis are strength training and weight-bearing cardiovascular exercise. To reduce the likelihood of injury, clients should use proper body mechanics and avoid ballistic or jarring movements. Individuals with advanced osteoporosis should also avoid high load work.


Strength training (or joint reaction forces being applied to the bone). In building or maintaining bone, the magnitude of force on the bone counts more than the number of times the stress is applied, says Skinner. As strength training allows for progressive mechancal loading, this activlty is considered a more effective exercise for bone health.


Numerous studies have shown that resistance exercise maintains or Improves bone mass and bone mineral density. but changes are specific to the bones bearing the weight. Strength training "also increases muscle mass and strength, dynamic balance, and overall levels of physical activity," says the ACSM pos'tion stand, adding that these outcomes may reduce the risk of osteoporotic fractures.


Dr. James H. Rimmer, director of the National Center on Physical Activity and Disability in Chicago, suggests clients do resistance training two to three days per week. For the first month, these individualsshould use hand weights of 1—5 Ibs., progressing to heavier weights if they have "no pain in the muscle groups being worked." He recommends 8—12 repetltions in one to three sets "performed to near failure for clients with mild osteoporosis and to 50 to 70 percent of one repetition maximum for those with moderate to severe osteoporosis, depending on the client's level."


When beginning a strength training program, people with significant osteoporosis should use resistance bands or light hand weights to prevent injury, says Rimmer. After a few months, they can start using heavier bands or weights. But those with severe osteoporosis must progress more slowly.


Other items capable of providing light resistance include soft putty, sponges or Nerf balls, according to recreation therapist Elizabeth Best-Martini and exercise physiologist Kim A. Botenhagen-DiGenova. In their book Exercise for Frail Elders, the women advocate seated resistance training for clients with advanced osteoporosis. "Standing exercise may not be safe because of the risk of falling," they explain, "and because body weight alone can fracture spinal vertebrae."


ACSM's Bloomfield and Smith also recommend resistance exercise for 20—40 minutes two to three days per week. The goal is to increase both upper and lower body strength. Health and wellness professionals should emphasize hip flexors/extensors. back extensors. lower abdominals and postural muscles. Suggested modes of training include dumbbells. weight machines, cuff weights and floor calisthenics.


Weight-bearing aerobic training (or ground reaction forces being applied to bone). Findings are mixed on the usefulness of weight-bearing aerobic exercise for building bone mineral density in postmenopausal women.


Participants in some studies improved bone density compared to inactive controls, with gains specific to the bones receiving the load and muscular force during the exercise. But in studies where researchers noted no improvements. participants generally maintained bone density, while those in control groups continued losing bone at an accelerated rate. So weight-bearing cardiovascular activity appears to slow bone loss In addition. aerobic exercise improves cardiovascular fitness and contributes to overall wellness.


For individuals with osteoporosis, ACSM's Bloomfield and Smith recommend 20—30 minutes of aerobic activity three to fivedays per week, exercising at 40—70% peak heart rate. The authors suggest that "all modes of exercise ... are possible as long as forward flexion and twisting is minimized." Although individuals with osteopenia can include impact-loading activities, such as jogging, heel drops and aerobics, those with severe osteoporosis should avoid these "more vigorous, impact-oriented activities." Clients who have numerous spinal fractures, back pain or severe osteopenia should choose activities such as swimming, water aerobics, water walking and chair exercises.


Rimmer recommends circuit training for older adults with osteoporosis, as these individuals may find it difficult to use the same muscle groups for longer periods of time. For deconditioned clients in advanced stages of the disease, he suggests interval training. By alternating periods of work and rest, these individuals "can delay fatigue and help sustain longer periods of activity." For those with advanced osteoporosis, Rimmer recommends seated aerobic training for at least some of the session. "The recumbent stepper is especially useful," he says. "since it allows frail clients to safely move their arms and legs simultaneously in a seated position."


The biomechanical changes that result from kyphosis (dowager's hump) can have an impact on a client's ability to exercise. These effects include impaired breathing, field of vision, balance and gait, plus an altered center of gravity. This client will fatigue more quickly, due to reduced respiratory function. Walking on a treadmill is a fall risk to this individual. as he/she may have difficulty seeing the machine's front. For individuals with extreme kyphosis, cardiovascular training should be limited to stationary equipment and walking with support, write Bloomfield and Smith.


Flexibility (or range of motion exercise).

Maintaining and increasing flexibility improves overall mobility and contributes to proper gait and alignment. Stretching should be slow and controlled, once again avoiding unsupported forward flexion of the spine, especially combined with stooping. ACSM's Bloomfield and Smith recommend flexibility exercises five to seven days per week. The goal is to improve or maintain range of motion, say Bloomfield and Smith, especially in the pectoral muscles.


Rimmer suggests including exercises that pull the shoulders back and open the chest to help with inflexible chest and neck muscles. He also recommends exercises that stretch tight hip flexors for clients who stoop. But he advises against doing stretching exercises with those "experiencing pain in areas prone to fracture."


Incorporate functional exercise

"In older people with low bone mass, exercise is critical to prevent osteoporotic fracture," says NORA's lead author, Dr. Siris, of Columbia Presbyterian Medical Center in New York. But people mlsunderstand why, she says. According to Siris. "The real reason to exercise is twofold: it guards against falls and it helps prevent injuries when someone does fall, which lowers the risk of fracture." Rather than building bone density, the post-menopausal woman who exercises "helps herself primarily through her balance, coordination and muscle." she adds.


Fall prevention. When programming for clients with osteoporosis, health and wellness professionals should weigh the benefits of all activities against the potential risks. Fall prevention must always be a high priority.


Appropriate weight-bearing exercise for individuals with balance abnormalities, compromised vision. and coordination or strength deficits includes walking, standing and strength training. Appropnate aerobic exercise includes water aerobics, water walking, swimming, recumbent stepping, stationary bicycling (preferably recumbent) and chair exercises.


Gait training. This training helps clients understand the components of a normal gait, i.e. stride length and width, ankle flexion and heel strike, speed and cadence, and upright posture. Exercises that help to normalize the gait can help reduce falls.


Balance training. In combination with strength training, balance training reduces falls, making it an essential component of an overall exercise program. To incorporate balance activities safely, health and wellness professionals must provide wall, chair or partner support when challenging and practicing balance with osteoporotic clients. Exercises in which clients stand on one leg for extended periods may place vulnerable bones in the hips at risk and should be avoided. For example, when performing 16 standing leg lifts, alternate eight right lifts with eight left lifts.


Bloomfield and Smith recommend functional training three to five days per week to help clients maintain or increase their ability to perform activities of daily living. Suggested modes include brisk walking, chair sit to stand and activity-specific exercises.


More than a physical condition

Osteoporosis can have a significant impact on the older person's quality of life. Pain, fear. anxiety and depression often accompany physical manifestations of the disease, says Dr. Walter Frontera, chairman of the Department of Physical Medlcine and Rehabilitation at Aarvard Medical School.


Khyphosis can cause gastrointestinal or abdominal problems and constipation, a common complaint among people with the disease. Individuals with osteoporosis also complain of weakness, loss of appetite, limited motion in activities of daily living and fear of falling, adds Frontera.


Exercise is an important component in preventing and treating this devastating disease. Health and wellness professionals have the opportunity to help older clients with osteoporosis improve not only their physical health and function, but also their quality of life.




  • American College of Sports Medicine. 1995. Position Stand on Osteoporosis and Exercise. Medicine & Science in Sports & Exercise 1995;27(4):i-vii
  • Best-Martini, E. and Botenhagen-DiGenova, K.A. 2003. Exercise for Frail Elders. Champaign IL: Human Kinetics
  • Bonnick, S.L. 2000. The Osteoporosis Handbook. Third Edition. Lanham MD: Taylor Trade Publishlng
  • Durstine, J.L. and Moore, G.E., eds. 2003. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. Second Edition. Champaign IL: Human Kinetics
  • Frontera, W.R. and Skinner, J.S. 1998. Osteoporosis and Exercise: Guidelines for Exercise Professionals. Chicago IL: Life Fitness Academy
  • Mazzeo, R.S., et al. 1998. "ACSM Position Stand on Exercise and Physical Activity for Older Adults." Medicine & Science in Sports & Exercise 1998;30(6)
  • Mayo Foundatim for Medical Education and Research. Osteoporosis. www.mayoclinic.com/invoke.cfm?-objectid=74832633-C5B7-4681A61498080-4652CIA&section=I, accessed August 28, 2003
  • Milner, Colin. 2002. "Making bone health a priority." Journal on Active Aging 2002;3:20—25
  • National Center for Injury Prevention and Control. A Tool Kit to Prevent Senior Falls. Atlanta GA: Centers for Disease Control and Prevention. www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm#Women, accessed August 25, 2003
  • --. Falls and Hip Fractures Among Older Adults. Atlanta GA: Centers for Disease Control and Prevention. www.cdc.gov/ncipc/factsheets/falls.htm, accessed August 26, 2003
  • National Osteoporosis Foundation. Osteoporosis: Disease Statistics. www.nof.org/osteoporosis/stats.htm, accessed August 26, 2003
  • --. Prevention: How Can I Prevent Osteoporosis? www.nof.org/prevention/index.htm, accessed August 26, 2003
  • Rimmer, J.h. 1999. "Programming for Clients With Osteoporosis." IDEA Health & Fitness Source June 1999
  • Samelson, E.J.; Zhang, Y.; Kiel, D.P.; Hannan, M.T.; Felson, D.T. 2002. "Effect of birth cohort on risk of hip fracture: age—specific incidence rates in the Framingham Study." American Journal of Public Health 2002;92:858—62
  • Scott, J.C. 1990. "Osteoporosis and hip fractures.' Rheumatic Diseases Clinics of of North America 1990;16:717—740


This article is provided courtesy of the International Council on Active Aging www.icaa.cc