Osteoporosis and Osteopenia

Please remember the advice we give is general and not meant to be used as a substitute for professional medical or health advice, diagnosis, or treatment. If you want specific advice then please seek help from your doctor or local physio.

What is Osteoporosis and Osteopenia?

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 bone density scanning - also known as dual-energy x-ray absorptiometry (DXA). This scan tells us a T-score, which is a comparison of your bone mass with the bone mass of an average, healthy 30 year old (the age when bone density is at its peak). 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.

Why is it important to be aware of?

Osteoporosis massively increases the risk of fractures resulting from falls. It also makes the skeleton less resilient to stress which can result in issues such as vertebral compression fractures (that present as the hunched posture commonly seen in elderly women) or insufficiency fractures that occur from normal loading of abnormal bone. Identification of osteoporosis and osteopenia means we can implement treatments to improve bone density straight away.

How do you treat it?

There are a few strategies that can be employed to treat osteoporosis:

1. Dietary and lifestyle considerations
   1. Specific advice can be sought from a registered Dietician, but in general a bone health promoting diet is one that includes sufficient protein, calcium and vitamin D and excludes alcohol and smoking.
2. Medications
   1. This should be discussed with your doctor.
3. Exercise
   1. See below

What is the best form of exercise for those with reduced bone mineral density? 

The best form of exercise for improving bone mineral density is high-intensity resistance training and impact training.

Resistance training is any form of exercise where you are moving against a resistance. This could be lifting weights, lifting your bodyweight or using resistance bands. The key here is that it has to be high-intensity, which means that for each exercise you need to be working your muscles against a very challenging level of resistance. Note that this does not necessarily mean you are really working up a sweat and breathing heavily, as typically happens with vigorous cardiorespiratory exercise. With resistance training, that's not the goal - although it may happen and is certainly not a bad thing. To be clear, the key goal for resistance training is that each set of each exercise feels very heavy and challenging. When doing this type of exercise, the muscles are pulling hard on the bones with large amounts of force, and this force is transmitted through the bones, signalling to the bones to grow denser and stronger.

Impact training means doing exercise which result in significant impact forces being applied to the bones. A simple example (and the most common exercise done is this context) is jumps. Starting in a standing position, jumping up in the air, and landing back on your feet in the starting position. When you jump up and then land your feet back on the ground with impact, a large force is transmitted from the ground, up through your leg bones. As with resistance exercise, this impact force signals to the bones to grow denser and stronger.

Various studies have examined this type of high-intensity resistance training and impact training in people with osteoporosis and osteopaenia and found that it is effective at causing a significant clinical improvement in bone mineral density. Control groups in these studies which did similar exercises but only used light weights (i.e. low intensity resistance training) did not improve their bone density. So once again, the key is that the training you do is highly challenging.

But is this type of exercise safe? 

It's hard to give a simple "yes or no" answer to the complex question of whether anything is truly "safe". All exercise carries certain risks. We believe in taking a measured "risk vs reward" attitude to this situation. The important facts to consider are:

1. Resistance training in general is a very low injury risk activity
2. The studies looking at this type of high intensity resistance and impact training in people with low bone density have had very few, if any, injuries or adverse events
3. Resistance training is extremely important for your health, especially if you have low bone density
4. The best way to reduce your risk of injury with exercise is to "start low and go slow". Meaning, start at a manageable level an gradually increase the intensity of the exercises over time, always making sure that you feel confident and comfortable with what you're doing

Lastly, you must consider - what are the risks of not doing resistance and impact training?? Progressively lower bone density, increased frailty, weaker muscles, increased falls risk, increased injury risk, worse quality of life, greater susceptibility to disease, higher chance of mortality, ... the list goes on.

What exercises should I avoid if I have osteoporosis?

Some exercises (particularly twisting and bending the spine) have been labelled as "dangerous" for people with osteoporosis. But, this is not based on any good scientific evidence. Unfortunately there is very little research in this field, and the research that does exist is poor quality, meaning it's difficult to make accurate recommendations. So we cannot say for sure that twisting and bending the spine is unsafe, but we also can't say with certainty that they are safe either. 

Recent expert recommendations suggest that people with osteoporosis should "modify extreme or loaded flexion unless used to those movements" and "modify exercises that involve end range sustained repeated forward bending ", whilst acknowledging that this is based on limited evidence. 

Our approach is generally that the spine is well adapted to bend it twist. Those are important aspects of its functionality. Without there being any good reason to avoid bending and twisting , we consider it generally ok to do for people with osteoporosis in most cases. As above, just making sure to "start low and go slow".

If you are comfortably doing exercises which involve spinal twisting and flexion, then it's ok to continue doing them. However, if you would rather avoid these types of exercises, that's ok too. 

To learn how to modify abdominal exercises to avoid extreme/repetitive flexion, check out our article how to modify abdominal exercises.