We all know the benefits exercise has on our muscles, but what about the effects of exercise on our bones? Known as “the silent thief,” osteoporosis can occur for a number of years without any signs or symptoms, and when symptoms do occur, they often occur in the form of fractures or bone breaks.
What is Osteoporosis?
Approximately 2.4 million Canadians live with osteoporosis, with about 1.8 million of those being women.1 Why are women more affected than men? The reason lies behind the fact that women’s estrogen levels fall after menopause, and since estrogen helps minimise bone loss in women, that protective factor is reduced. Bone is regularly being resorbed and new bone is being formed, but following menopause and in the elderly, bone resorption usually exceeds bone formation, which leads to a net loss in bone mineral mass.
Osteopenia and osteoporosis both denote a loss in Bone Mineral Density (BMD), with osteoporosis being on the more progressed end of the spectrum. This results in the bone becoming more porous and “spongy” looking, making them thinner and not as strong. This leads to an increased risk of fracture and breaks.
Some Statistics1
Over 80% of all fractures in people 50+ is due to osteoporosis
Fractures from osteoporosis are more common than heart attacks, stroke, and breast cancer combined
⅓ women will have an osteoporotic fracture in their life (versus ⅕ men)
The most common areas of osteoporotic fracture are the wrist, hip, spine, and shoulder
Women are 2x more likely to fracture their hip compared to men
⅓ hip fracture patients will refracture within a year, and over ½ will refracture within 5 years
22% of women who suffer a hip fracture will die within 1 year (versus 33% of men)
The risk of refracture in the spine within 12 months following the initial vertebral fracture is 20%
14% of people with a wrist fracture will have another fracture within 5 years.
Less than 20% of people after an osteoporotic fracture receive a proper diagnoses or the appropriate treatment
How do you Test for it?
A dual energy x-ray absorptiometry (DXA) is the most commonly used test to determine bone density. It requires lying on a table for a few minutes while the x-ray scans your spine, hips, and possibly other areas. In general, a comprehensive look at both the bone density score and other clinical risk factors will give a more accurate prediction of bone health and future fracture risk.
Bone Over the Lifespan
People reach peak bone mass between the ages of 20-30.2,3 Which means that childhood and adolescence is the time to build up bone size and strength with bone-healthy behaviours as a means to optimise bone health and prevent osteoporosis later in life. Bone-healthy behaviours include all the physical activities we thought of as fun as kids. Running, jumping, playing on the monkey bars, soccer, road hockey - anything that gets the muscles and bones moving! One study even found that kids and adolescents who were active and then ceased to be active for a few years still saw an increase in bone cortical size when they were young adults compared to people who were always inactive.4,5 Although at least 60% of peak bone mass is determined by heritable factors, lifestyle factors still play a huge role in building and maintaining healthy bones throughout life. These include: smoking, alcohol consumption, calcium and vitamin D intake, weight, age at menarche, socioeconomic status, as well as any diseases or medication use.6
Both women and men start to lose bone mass in their mid 30’s. As women approach menopause, they lose bone at a rate of 2-3% a year.1
During menopause, there’s a shift in hormones. Two important ones for bones being progesterone and estrogen, which both decrease during this time. Progesterone is responsible for forming new bone, while estrogen, as mentioned earlier, is responsible for preventing bone loss or resorption.
Exercise in Older Women
We already mentioned that most of the building blocks for bone are put in place early on in life. Chances are if you’re reading this, you’re a bit past that point. So, what can you do? Exercise! The 2023 Canadian updated clinical practice guideline for management of osteoporosis and fracture prevention puts balance and training at the top of that list!7
Several studies looking at pre- and post- menopausal women found modest increases in bone mineral density after following moderate to intense exercise protocols.8,9 When increases in density weren’t found, exercise looks to be able to at least preserve and maintain the bone that’s already there.10 Let’s not ignore other benefits of exercise that go hand-in-hand with bone health: older women who stick to a consistent exercise regimen experience less falls and fractures, better coordination, strength, balance, and quality of life!11,12,13,14
Exercise Recommendations
The current recommendations are to include balance, functional training, and resistance training at least 2x a week.7 Like any exercise program, you want to gradually increase and change the difficulty, frequency, tempo, and volume over time in order to achieve progressive overload.
Balance Training
What would balance training look like? Here are some things you may want to keep in mind when trying to train it!
Reduce base of support
Balance on one foot
Shifting your body weight to challenge stability
Leaning side to side or forwards and back
Maintaining your balance while moving
Yoga, tai chi, dancing, tip-toeing
Reacting to perturbations in balance
Being pushed, catching and throwing a ball
Functional Training
Functional training is training that mimics every day motions and actions. It goes hand-in-hand with resistance training and oftentimes overlap. Some examples of functional training would include:
Stepping up and down stairs
Transfers over to climbing the stairs at home, hiking
Box Squats or Chair Sit-to-Stands
Getting up and down from a chair, a car, the floor
Farmer’s Walk, Suitcase Carry
Carrying groceries, shopping bags, purse
Resistance Training
Using free weights, machines, bands, and even your own body weight to progressively overload and work your body is considered resistance training. Again, many functional exercises fall into the resistance training sphere and vice versa! It should follow the principles of any other exercise regimen: progressive overload, specificity, individualisation, variation, and reversibility. Ideally working each body part at least once during the week, and gradually increasing the difficulty as your body adapts to the exercises. Below are some examples of resistance training exercises:
Pushups
Deadlifts
Seated Leg Press
Cable Seated Row
Banded Pull Aparts
Bird Dog
Remember, consistency is key! Stick to it, change things as needed, and give yourself time.
Other Exercise
Other activities such as walking, pickleball, yoga, pilates, etc. are recommended as long as they can be done safely or modified for safety. Of course, the same principles mentioned for resistance training apply here as well. For example, if you’re new to pilates, it might not be the best idea to crank it up to the highest intensity right at the get-go, but rather gradually expose yourself to the new movements and resistance. Exercises should be modified to your physical fitness and fracture risk level. Another good practice statement delivered by the 2023 guidelines includes perhaps modifying activities that require rapid, sustained, weighted, or end-range twisting or flexing of the spine, especially in those that are at a high risk of fracture.7
Just remember, the priority should be on balance, functional and resistance exercise. These other activities can be done in addition to those.
Nutrition
Another thing to take into consideration when looking to improve or maintain bone health would be your calcium and Vitamin D intake. Some studies recommend that adequate dietary calcium and cholecalciferol (vitamin D3) intake, combined with exercise, is more effective at promoting bone adaptation than either component on their own.15 It’s best to talk to your physician and/or nutritionist to get a professional opinion and individualised recommendations for you.
Final Remarks
It’s best to see an exercise professional who has training and experience with osteoporosis for exercise selection, intensity and progression, and activity modification, especially after a fracture or if at a high risk of fracture. We also recommend checking out ressources given out by Osteoporosis Canada.
Our goal at Delta Kinesiology is to help women reach their health and fitness goals. We are BoneFit certified and specialise in conditions such as osteoporosis. We tailor each session using evidence-based principles and methods to help you reach your goals. Whether that be going about your day pain-free, building muscle, improving stamina, or feeling better about yourself, we are here to help.
Check out some of the services we offer below!
REFERENCES
Facts and Stats: Osteoporosis Canada. Osteoporosis Canada. (2022, October 12). http://osteoporosis.ca/facts-and-stats/
Zhu, X., & Zheng, H. (2020). Factors influencing peak bone mass gain. Frontiers of Medicine, 15(1), 53–69. https://doi.org/10.1007/s11684-020-0748-y
Teegarden, D., Proulx, W. R., Martin, B. R., Zhao, J., McCabe, G. P., Lyle, R. M., Peacock, M., Slemenda, C., Johnston, C. C., & Weaver, C. M. (1995). Peak bone mass in young women. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 10(5), 711–715. https://doi.org/10.1002/jbmr.5650100507
Otsuka, H., Tabata, H., Shi, H., Sugimoto, M., Kaga, H., Someya, Y., Naito, H., Ito, N., Abudurezake, A., Umemura, F., Tajima, T., Kakehi, S., Yoshizawa, Y., Ishijima, M., Kawamori, R., Watada, H., & Tamura, Y. (2023). Playing basketball and volleyball during adolescence is associated with higher bone mineral density in old age: the Bunkyo Health Study. Frontiers in physiology, 14, 1227639. https://doi.org/10.3389/fphys.2023.1227639
Nilsson, M., Ohlsson, C., Mellström, D., & Lorentzon, M. (2009). Previous sport activity during childhood and adolescence is associated with increased cortical bone size in young adult men. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 24(1), 125–133. https://doi.org/10.1359/jbmr.080909
Rizzoli, R., Bianchi, M. L., Garabédian, M., McKay, H. A., & Moreno, L. A. (2010). Maximizing bone mineral mass gain during growth for the prevention of fractures in the adolescents and the elderly. Bone, 46(2), 294–305. https://doi.org/10.1016/j.bone.2009.10.005
Morin, S. N., Feldman, S., Funnell, L., Giangregorio, L., Kim, S., McDonald-Blumer, H., Santesso, N., Ridout, R., Ward, W., Ashe, M. C., Bardai, Z., Bartley, J., Binkley, N., Burrell, S., Butt, D., Cadarette, S. M., Cheung, A. M., Chilibeck, P., Dunn, S., … Wark, J. D. (2023). Clinical practice guideline for Management of Osteoporosis and Fracture Prevention in Canada: 2023 update. Canadian Medical Association Journal, 195(39). https://doi.org/10.1503/cmaj.221647
Lohman, T., Going, S., Pamenter, R., Hall, M., Boyden, T., Houtkooper, L., Ritenbaugh, C., Bare, L., Hill, A., & Aickin, M. (1995). Effects of resistance training on regional and total bone mineral density in premenopausal women: a randomized prospective study. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 10(7), 1015–1024. https://doi.org/10.1002/jbmr.5650100705
Martyn-St James, M., & Carroll, S. (2008). Meta-analysis of walking for preservation of bone mineral density in postmenopausal women. Bone, 43(3), 521–531. https://doi.org/10.1016/j.bone.2008.05.012
Pruitt, L. A., Jackson, R. D., Bartels, R. L., & Lehnhard, H. J. (1992). Weight-training effects on bone mineral density in early postmenopausal women. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research, 7(2), 179–185. https://doi.org/10.1002/jbmr.5650070209
Ringsberg, K. A., Gärdsell, P., Johnell, O., Josefsson, P. O., & Obrant, K. J. (2001). The impact of long-term moderate physical activity on functional performance, bone mineral density and fracture incidence in elderly women. Gerontology, 47(1), 15–20. https://doi.org/10.1159/000052765
Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. The Cochrane database of systematic reviews, 1(1), CD012424. https://doi.org/10.1002/14651858.CD012424.pub2
Ponzano, M., Rodrigues, I. B., Hosseini, Z., Ashe, M. C., Butt, D. A., Chilibeck, P. D., Stapleton, J., Thabane, L., Wark, J. D., & Giangregorio, L. M. (2020). Progressive resistance training for improving health-related outcomes in people at risk of fracture: A systematic review and meta-analysis of randomized controlled trials. Physical Therapy, 101(2). https://doi.org/10.1093/ptj/pzaa221
Rodrigues, I. B., Ponzano, M., Hosseini, Z., Thabane, L., Chilibeck, P. D., Butt, D. A., Ashe, M. C., Stapleton, J., Wark, J., & Giangregorio, L. M. (2021). The Effect of Impact Exercise (Alone or Multicomponent Intervention) on Health-Related Outcomes in Individuals at Risk of Fractures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Sports medicine (Auckland, N.Z.), 51(6), 1273–1292. https://doi.org/10.1007/s40279-021-01432-x
Borer K. T. (2005). Physical activity in the prevention and amelioration of osteoporosis in women : interaction of mechanical, hormonal and dietary factors. Sports medicine (Auckland, N.Z.), 35(9), 779–830. https://doi.org/10.2165/00007256-200535090-00004
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