Exercise Recommendations

Exercise plays an important role in building and maintaining bone strength. Just like muscles, bones respond when they are stressed, in other words, when they are forced to bear more weight than they are used to. This can be achieved by weight bearing or impact exercises.

For information about the role of exercise in bone health download the IOF report Move it or Lose it: How Exercise helps to build and maintain strong bones, prevent falls and fractures, and speed rehabilitation. The well-illustrated report summarizes the key benefits of exercise in different age groups.

Below is information on specific exercise programs that have been shown in scientific studies to improve or maintain bone health in men, women and children and at various life stages.

Please note that many of the regimens and images shown in this article derive from professionally supervised exercise programs, are not appropriate for everyone, and should not be carried out without professional supervision.

Bone loading exercise recommendations for prevention and treatment of osteoporosis

Written by Michael Pfeifer and Helmut W. Minne, Gustav Pommer Institute of Clinical Osteology and the German Academy of the Osteological and Rheumatological Sciences.

Contents

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Introduction and definitions

Physical activity is an umbrella term defined as any bodily movement produced by skeletal muscles that results in energy expenditure above the basal level [1]. The dimensions of physical activity – frequency, intensity, time, and type (FITT) – each have an effect on the health outcome. Studies suggest that the type of physical activity carried out is by far the most important dimension that affects bone [2].

Exercise represents a sub-category of physical activity that is planned, structured, repetitive and purposeful with the aim of improving or maintaining one or more aspects of physical fitness [3]. Exercise may be carried out for pleasure or to maintain health.

Targeted Bone Loading describes force-generating activities that stimulate a specific bone or bone region beyond the level provided by daily activities. An activity may provide bone loading at one site, but not at another. For instance jumping involves lower limb bone loading, but not upper limb. Although all exercise commonly involves some form of loading through muscles and joints, some forms of exercise do not involve targeted bone loading.

While virtually all physical activity reduces the risk of cardiovascular disease, swimming and cycling, for example, will rarely augment bone mineral density (BMD) [4]. With increasing age, however, the emphasis of exercise should switch gradually from bone loading to muscle loading in order to improve parameters of muscle function such as strength and coordination. This also holds true for patients with advanced osteoporosis (characterized by multiple fractures and severely reduced bone mineral density) to help them avoid further fractures, prevent falls and to facilitate daily activities [5].

The following recommendations for exercise programs to improve or maintain bone health in various age groups are evidence-based.

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Recommendations for children and adolescents

This section focuses on children from eight years old through to adolescence and young adulthood. Data drawn from different studies with children in these age groups have been used to develop the following recommendations [6]:

  • Make a lifelong commitment to physical activity and exercise.
  • In terms of bone health, weight-bearing activities such as basketball, volleyball and gymnastics are more effective than weight-supported activities such as swimming and cycling.
  • Intense daily activity is more effective than prolonged activity carried out infrequently.
  • Perform activities that will increase muscle strength, such as running, hopping, or skipping games.
  • Select activities that work all muscle groups like gymnastics.
  • Avoid immobilization and perform short weight-bearing movements if confined to bed.
  • Eat a well-balanced diet that is rich in calcium (milk instead of soft drinks) and protein to promote normal growth and puberty as well as regular menses for girls.

The following exercise program from Melbourne, Australia, demonstrated significant increases in BMD in 9- to 10-year old children at both the lumbar spine and the proximal femur. In addition to regular physical education at school, this program incorporated extra classes for the children which resulted in an additional increase in BMD of 4% at the spine and 2% at the proximal femur [7,8].

Frequency: Three times per week

Intensity:

High impact
Time: 30 minutes of physical activity after school

Type:

1. Aerobic workouts:
Aerobics, soccer, step aerobics, skipping, ball games, modern dance and weight training
2. Circuit training:
20-minute weight-bearing, strength-building circuit consisting of 10 exercises designed to load the biceps, triceps, pectoralis major, latissimus dorsi, trunk, deltoids, rectus abdominis, quadriceps femoris, hamstrings, gastrocnemius, and soleus

Approximately 1 minute per station

One set of 10 repetitions progressing to 3 sets of 10 over time

These recommendations are based on strong scientific evidence suggesting that weight-bearing physical activity plays a key role during the normal growth and development of a healthy skeleton. High-intensity exercise of short duration appears to elicit the greatest bone density increase in the growing skeleton. This information is especially important to parents, teachers and health authorities that are responsible for school curricula. A sedentary lifestyle, rather than an excessively active one, is more likely to be the risk faced by most children today [9].

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Recommendations for young adults and pre-menopausal women

After puberty, bone mineral density (BMD) is not easily augmented. The main role of exercise in young adults and pre-menopausal women, therefore, is to maintain BMD rather than to increase it. Nevertheless, high-intensity exercise can lead to modest bone accrual in targeted areas. Even small increases in bone mineral may significantly reduce the risk of fracture in later life.

The following exercise plan designed by Heinonen and colleagues in Tampere, Finland, has been shown to increase lumbar spine and femoral neck BMD in 35- to 45-year old Finnish women by approximately 2% [10]:

Activity Duration
Warm-up

15 minutes

High-impact jumps* 20 minutes
Stretching and non-impact activities 15 minutes
Cool-down 10 minutes

*High-impact jump training consisted of an aerobic jump program alternated weekly with a step program. Sessions were performed three times per week over an 18-month period and the height of the jumps increased progressively from 10 to 25 cm, while the number of jumps per session decreased from 200 to 100.

Friedlander and colleagues described a resistance-training protocol that used three different classes per week over two years to augment BMD at the lumbar spine (approximately 5%) and femoral neck (approximately 3%) [11]:
 

Class 1:

Participants alternate (every 12 min.) between exercise stations and high-impact aerobic activities. Exercise stations consisted of push-ups, sit-ups, arm-curls with dumbbells, and presses with barbells.

Class 2:

Moderate weights (dumbbells between 3 and 6 kg and barbells between 8 and 18 kg) were used to exercise the gluteus maximus, erector spinae, and shoulder girdle muscles. Lifts were started from ground level to shoulder height.

Class 3:

A vigorous, high-impact aerobic workout was performed during which the heart rate was maintained at between 70 to 85% of maximum performance, calculated as 220 minus age.

In 2002, Mehrsheed Sinaki and colleagues published the first randomized prospective study demonstrating that exercise in pre-menopausal women may not only increase BMD at the lumbar spine but also decrease the risk of vertebral fractures [12]. They found that progressive, resistive back strengthening exercise performed 5 days per week over two years reduced the risk for vertebral fractures 10 years later.

Back-strengthening exercise to increase back extensor strength to maintain BMD at the lumbar spine and to decrease the risk of vertebral fractures

Fig.1: Back-strengthening exercise to increase back extensor strength to maintain BMD at the lumbar spine and to decrease the risk of vertebral fractures.

 

 

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Recommendations for postmenopausal women

Besides maintaining bone strength, the main goal of exercise therapy in postmenopausal women is to increase muscle mass in order to improve parameters of muscle function such as balance and strength, which are both important risk factors for falls and - independent of bone density – risk factors for bone fractures.

Kemmler and colleagues from Erlangen, Germany, described an exercise program which is effective in maintaining bone density and skeletal health in postmenopausal women between 48 and 60 years of age with low bone mass [13]. The program consists of four sessions per week with two group sessions lasting 60 to 70 minutes each and two home training sessions of 25 minutes each.

Warm up/Endurance sequence

For the first three months or so, gradually increase walking and running to 20 minutes to get patients accustomed to higher impact rates. Running games can be added to promote unusual strain distributions under weight-bearing conditions. After three months, 10 minutes of low to high impact aerobic exercise with an increasing amount of high-impact aerobic exercise can conclude the sequence (Fig.2).

Aerobic exercise during warm-up and endurance sequence

Fig.2: Aerobic exercise during warm-up and endurance sequence

 

 

 

 

 

Jumping sequence

The jumping sequence is integrated after six months of training, by which time a certain level of training adaptation had been achieved. For patients who have suffered vertebral fractures, “jumping” should be substituted by “walking” in order to reduce the impact on the spine. After an introductory rope-skipping phase, more complicated jumps (e.g. closed leg jumps) can be attempted.

Strength-training sequence

This consists of two sessions, one using resistance machines and the other isometric exercises, elastic belts, dumbbells, and weighted vests. On the hydraulic resistance machines specifically designed for seated rows, back extension, abdominal flexion or bench press, 13 exercises are performed that use all the main muscle groups (Figs.3-12).

Exercise intensity should be increased slowly. In the first three months, two sets of 20 repetitions at 50% of the “one-repetition maximum” (1RM) are performed. The 1RM is the maximum mass of a free weight or other resistance that can be moved by a muscle group through the full range of motion with good form one time only. The 1RM should be determined very cautiously in order to avoid vertebral fractures, especially in patients with low bone mass. After three months, two sets of 15 repetitions at 60% of 1RM and after five months two sets of 15 repetitions at 65% of 1RM are performed. After seven months of training, the intensity should be increased to 70%-80% of 1RM.

The second strength-training session consists of 12 to 15 different isometric exercises* predominantly dedicated to the trunk and legs. In addition, three different belt exercises of 15 to 20 repetitions are applied to the upper trunk. After the first seven months, belt training is replaced by exercises using dumbbells (Fig.8) and a weighted vest (Fig.9).

Hamstring curl during strength training sequenceFig.3: Hamstring curl during strength training sequence

 

 

 

 

 

Hip abduction (left) and hip adduction (right) during strength trainingFigs.4 + 5: Hip abduction (left) and hip adduction (right) during strength training

 

 

 

 

 

Leg extension during strength training sequenceFig.6: Leg extension during strength training sequence

 

 

 

 


Leg press during strength training sequenceFig.7: Leg press during strength training sequence

 

 

 

 

Arm curl using dumbbells during strength-training sequenceFig.8: Arm curl using dumbbells during strength-training sequence

 

 

 

 

 

 

 

 


 

 

 

 

 


 

Arm curl using dumbbell or 'one-arm rowing' during strength trainingFig.9: Arm curl using dumbbell or 'one-arm rowing' during strength training

 

 

 

 

 

 

 


 

Fig.10: Bent knee dead lifts with weighted vest during strength training sequence

 


 

 

 

 

 

 

 

Triceps extension (using pulley) or latissimus pull-down during strength-training sequenceFig.11: Triceps extension (using pulley) or latissimus pull-down during strength-training sequence

 

 

 

 

 

 

 


 

Hyper-extension of the back to improve back extensor strength during strength-training sequenceFig.12: Hyper-extension of the back to improve back extensor strength during strength-training sequence

 

 

 

 

 

 

 

 

 

Flexibility-training sequence

This sequence is performed before and after the strength-training sessions and during the rest periods. The stretching program consists of 10 exercises for all main muscle groups. Two sets of passive stretching exercises lasting over 30 seconds are performed.

Additional home-training sessions

Isometric, belt, and stretching exercises should also be performed at home twice weekly for 25 minutes. An additional rope-skipping program can be introduced 20 weeks after the start of the training program.

* Isometric exercise involves tensing a muscle and holding the position while maintaining tension (especially helpful to people recovering from injuries that limit range of motion).

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Recommendations for men

Fewer studies of the effect of exercise have been conducted in men than women, but it appears that the skeleton responds similarly in both sexes. In men, high-impact training and strength-training produce increases in BMD. In addition, a prospective study showed a 60% reduction in hip-fracture rates in men who were physically very active compared with those who were not [14].

A study in 23- to 31-year-old Japanese men found that the following protocol (Table 1) led to changes in bone markers that suggested bone formation was occurring without an increase in bone resorption. In the four-month study, total body and regional BMD did not change [15].

Table 1: Exercise prescription in young men that led to increase in biomarkers of bone formation without evidence of increased bone resorption.

Type of Exercise Intensity of exercise   Time  
Frequency in times/week 1RM

% of 1RM

Repetition Sets
Leg extension (2) 30 kg 60-80% 10 3
Leg curl (2) 15 kg 60-80% 10 3
Bench press (3) 70 kg 60-80% 10 3
Sit-up (3) 22 kg 60-80% 10 3
Back extension (3) 15 kg 60-80% 10 3
Latissimus pull-down (1) 45 kg 60-80% 10 3
Arm curl (1) 20 kg 60-80% 10 3
Half squat (1) 70 kg 60-80% 10 3

Free weights were used except for leg extensions, leg curls, bench presses, and latissimus pull-downs, which were all done on a machine (see Figs.3-7, 11+12)

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Recommended exercise for fall prevention

Falls and related fractures are a major health problem for older individuals and for society [16]. Changes in sensory and musculoskeletal structure and function among older adults puts them at increased risk of falls and injuries. Many intrinsic and external risk factors for falls have been identified. Exercise can modify the intrinsic fall risk factors and thus prevent falls in older adults [16]. Some of the external risk factors for falls may be modified by home safety inspections [17].

In a randomized prospective study in women with a mean age of 80 years, Campbell and colleagues demonstrated the efficacy of lower limb strength and balance training in reducing falls. Subjects in the intervention group received four home visits from a physiotherapist and performed individually tailored exercises three times per week, each session lasting more than 30 minutes, and were encouraged to take frequent walks.

After one year, the mean number of falls in the intervention group was 0.87 compared to 1.34 in the control group, which corresponds to a reduction in the number of falls of 35% [18]. After the first year, these women were followed up for another 2 years and the relative risk for falls for the exercise group at two years was 0.69 (95% confidence interval 0.49-0.97) compared with controls [19].

The Posturomed has been shown to be an excellent training device for balance and coordinationFig.13: The Posturomed has been shown to be an excellent training device for balance and coordination

 

 

 

 

 

 

 

 

 

 

 

 

 

Another form of exercise which has been shown to reduce the risk of falls is Tai Chi. Wolf and colleagues compared Tai Chi performed for 15 minutes twice daily at home over 4 months in a group of 200 women with a mean age of 80 years against a control group participating in education sessions once a week. At the end of the study, subjects who performed Tai Chi had a 47% lower risk for falls compared to the control group [20].

Daily performance of Tai Chi Chun may reduce the risk for falls by half and may retard loss of BMD in postmenopausal womenFig.14: Daily performance of Tai Chi Chun may reduce the risk for falls by half and may retard loss of BMD in postmenopausal women [21].

 

 

 

 

 

 

 

 

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Recommended exercises for patients with osteoporosis

An exercise program for people with osteoporosis should specifically target posture, balance, gait, coordination, and hip and trunk stabilization rather than general aerobic fitness. A typical class for relatively pain-free patients should consist of a warm-up, a workout, and a relaxation component.

Warm-up: The general 10- to 15-minute warm-up may be done to music and starts with gentle range of motion exercises for the major joints, which are performed either seated or standing. The warm-up may end with walking and simple dance steps in order to achieve a heart rate of between 110 and 125 beats per minute.

Workout: The workout may consist of strengthening and stretching exercises to improve posture by combating medially rotated shoulders, chin protrusion, thoracic kyphosis, and loss of lumbar lordosis. Exercises to improve balance and coordination may progress from heel raises and toe pulls to more challenging tandem walks and obstacle courses.

Relaxation: The last 5 to 10 minutes of the class may be devoted to relaxation techniques such as deep breathing, progressive muscle tensing and relaxing, and perhaps visualizations to a background of soft music and/or nature sounds.

In a study that investigated the efficacy of such a program carried out by a Canadian group from Vancouver in women with osteoporosis aged 65 to 75 years, the program resulted in an increased ability to undertake daily activities, decreased back pain, increased general health, and decreased risk of falling, and no patient suffered any exercise-related injuries [22].

Balance and coordination training during warm-up sequenceFig.15: Balance and coordination training during warm-up sequence

 

 

 

 

 

Supervised posture training, walking and balance on different surfacesFig.16: Supervised posture training, walking and balance on different surfaces

 

 

 

 

 

 

Isometric strengthening of back extensors and shoulder girdle musclesFig.17: Isometric strengthening of back extensors and shoulder girdle muscles

 

 

 

 

 

 

Trunk-muscle training while sitting on a 'pezzy-ball'Fig.18: Trunk-muscle training while sitting on a 'pezzy-ball'

 

 

 

 

 

 

 

 

Muscle strengthening isometric exercise for the shoulder girdle in water (32°C)Fig.19: Muscle strengthening isometric exercise for the shoulder girdle in water (32°C)

 

 

 

 

 

A spinal orthosis, which is worn like a backpad, has been shown to improve posture, trunk-muscle strength and several parameters of quality of life in postmenopausal women with vertebral fractures due to osteoporosisFigs.20a+b: A spinal orthosis, which is worn like a backpad, has been shown to improve posture, trunk-muscle strength and several parameters of quality of life in postmenopausal women with vertebral fractures due to osteoporosis [23].

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exercises not suitable for people with osteoporosis

Several exercises are not suitable for people with osteoporosis as they can exert strong force on relatively weak bone. Dynamic abdominal exercises like sit-ups and excessive trunk flexion can cause vertebral crush fractures. Twisting movements such as a golf swing can also cause fractures [24]. Exercises that involve abrupt or explosive loading, or high-impact loading, are also contraindicated. Daily activities such as bending to pick up objects can cause vertebral fracture and should be avoided [25].

Figures:

Fig.1: Courtesy of Mehrsheed Sinaki, M.D., Mayo-Clinic and Mayo-Medical School Rochester, MN, U.S.A.
Figs.2-12: Courtesy of Wolfgang Kemmler, M.D. and Klaus Engelke, Ph.D., University of Erlangen, Erlangen, Germany.
Figs.13,15,19: Courtesy of Christian Hinz, M.D., Clinic „DER FÜRSTENHOF“, Bad Pyrmont, Germany
Fig.14: Courtesy of Ling Qin, Ph.D., Dept. of Orthopaedics, Chinese University of Hong Kong, China
Figs.16-18, 20: Courtesy of Michael Pfeifer, M.D. and Helmut W. Minne, M.D., Clinic “DER FÜRSTENHOF” and Institute of Clinical Osteology, Bad Pyrmont, Germany

Project Advisors:

Gulseren Akyuz, Turkey
Steven Boonen, Belgium
Moira O'Brien, Ireland
Outi Pohjolainen, Finland
Mehrsheed Sinaki, USA
Ethel Siris, USA
Rene Rizzoli, Switzerland
José Zanchetta, Argentina
 

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