Introduction by Joan to her 10-part series of articles, “The Best Exercises for Osteoporosis Prevention.

Index to the Osteoporosis Prevention Series

Current research is focused on how resistance training can help prevent osteoporosis. So what are the best exercises for osteoporosis prevention?

What is osteoporosis?

Osteoporosis – which literally means "porous bones" – is a bone-thinning disease caused by a loss of mineral, (primarily calcium) that weakens the bone structure. The thinner the bones the more vulnerable to fractures.

Bone is living dynamic tissue that is constantly undergoing change, including responding to the stress of exercise by becoming stronger. Resistance is the key factor in both types of exercise that build bone: weight-bearing, high impact aerobic exercise and weight training for osteoporosis.

In case you're new to weight training aka resistance training, here's a brief explanation.

What is resistance training?

Resistance training is a method of applying resistance to the muscles and bones to stimulate growth.

Resistance training includes:

Weight bearing, high impact cardio exercise
Weight training with free weights, machines, and body weight exercises

In weight training for osteoporosis, you apply resistance to the muscle to stimulate growth (hypertrophy) of the muscle fibers. As the muscle contracts and pulls on the bone it simultaneously strengthens it. The resistance may be bodyweight or weight lifting tools (like free weights, stretch bands and tubes, weighted balls) and weight machines.

"The greater the resistance or impact of the exercise, the greater the stimulus to the bones."
Joan Pagano, JoanPaganoFitness.com

Guidelines for weight training for osteoporosis prevention

2-3 times a week on non-consecutive days
8-12 exercises for the major muscle groups
1-2 sets using a weight that you can lift 8-10 times
If you can’t do eight in a row, the weight is too heavy. If you can do more than 10 in a row, increase the weight.

Major muscle groups, in descending size:

Legs
Back
Chest
Shoulders
Arms
Core body: abdomen and spine

What about osteopenia exercises?

There are many safe exercises for osteopenia, including modifications of the best exercises for osteoporosis prevention. The key is to moderate the amount of stress to protect vulnerable joints.

What is osteopenia?

Sometimes called “pre-osteoporosis,” osteopenia is low bone density, lower than normal yet not low enough to be osteoporosis. Osteopenia is a risk factor for osteoporosis but does not always progress to it.

If you’ve been diagnosed with osteopenia as measured in a bone density test, you can do exercises that will help maintain bone density and may even build enough bone to reverse the diagnosis. If you haven’t been tested, it’s a good idea for women over age 45 to get a screening for osteoporosis.

Exercises for osteopenia

Weight-bearing exercises for osteopenia are those you perform in a standing position, for both cardio and for weight training exercises. The emphasis shifts from high impact exercise for osteoporosis prevention to low impact exercise to protect vulnerable joints.

Weight bearing, low impact cardio exercise
Weight training with caution to protect the joints

Weight bearing, low impact cardio exercise

Weight training with lighter weights to protect the joints

What activities should you avoid if you have osteopenia?

reaching down
bending forward
rapid twisting motions
heavy lifting, especially overhead
jarring impact
anything that increases your chances of a fall

What are the osteoporosis exercises to avoid?

While there are certain osteoporosis exercises to avoid if you’ve been diagnosed with osteoporosis, exercise is extremely beneficial. Your program should follow these safety guidelines that pertain to specific positions and movements, as well as to impact-loading or jarring of the spine or hips, which we'll get into.

The cardinal rule is to talk with your doctor about any exercise program before beginning a routine or intensifying your exercise program.

If you have osteoporosis you should avoid any of these activities or exercises:

1. Jumping, jogging, and running

2. Overhead lifting

3. Reaching and lifting

4. Sit-ups and crunches

5. Twisting from the waist

6. Resistance exercise machine

The bottom line with osteoporosis exercises is to avoid falls and fractures. Most fractures occur in the spine, followed by those at the hip and the wrist. Work to improve your balance and stability, strengthen your muscles, improve vision and medical conditions, and remove hazards from your home that may increase your risk of falling.

#5 Osteoporosis exercises to avoid: twisting from the waist

Exercises for fall prevention

What are the best exercises to prevent falls?

If you’ve been diagnosed with osteoporosis, the most important fall prevention strategy is to stay in your safety zone, avoiding high risk activities and using safe body mechanics. Falls are the leading cause of injury in people over age 65. Each year about a third of all persons over 65 will fall. Many of these falls result in a broken bone, often at the hip or wrist (the result of an outstretched hand to break a fall).

Risk factors for falling include:

· Poor balance

· Weak muscles

· Vision problems

· Certain diseases

· Alcohol use

· Some medications

· Hazards in the home

Many of these factors can be corrected with appropriate exercise, medical consultation, and fall-proofing the home. A combination of non-impact, balance, and functional exercises provide a good strategy for fall prevention. Safety first!

Exercise strategy for fall prevention

Non-impact
Balance
Functional
Non-impact, non-weight bearing

Exercise for fall prevention, functional exercise example: Chair squat

Balance exercises for seniors

While certain declines are unavoidable with age, studies show that much of the sense of balance can be preserved and even restored with balance exercises for seniors that require no special equipment or training.

Balance is controlled by the brain’s cerebellum, which is responsible for movement and coordination. It’s a complicated equation involving vision, muscle strength, proprioception (knowing where your body is in space), and attention. With age, these elements deteriorate.

Specific balance exercises for seniors, combined with strength, posture, and core stability as a background, create a well-rounded exercise program to improve balance, prevent falls and maintain quality of life.

What role does strength training play?

Strength training increases muscle mass and strength in people who are weak and helps improve balance and gait. As the muscles get stronger, especially in the lower body, we become more stable and are more able to prevent a fall or an injury.

Why is posture important?

Posture is the way the body aligns itself over the earth. This alignment affects your balance whether you’re standing still or moving. Changes in spinal alignment, such as a bent-over posture or forward slump, can affect your center of gravity and increase your risk of falling.

How does core stability affect balance?

Core stability braces and sustains posture to steady the body against disturbances, like being jostled or mis-stepping. It protects the spine and facilitates the transfer of forces between the upper and lower body. A strong, stable core helps prevent injuries and makes everyday activities easier.

What are good balance exercises for seniors?

Specific balance training exercises include static (stationary), dynamic (moving), and advanced balance exercises combining static and dynamic elements.

Stork stance for static balance
Tandem gait for dynamic balance
Balance walk for static and dynamic balance

Balance exercise example #3: Balance walk. This is my 74-year old client Martha who walks the talk!

For detailed step-by-steps on how to perform these exercises, see Balance Exercises for Seniors

The fundamental steps to better balance are to improve posture and alignment and increase core strength. Let’s look at posture and alignment next.

Exercises to Improve Posture

What is Good Posture?

Protect your bones by practicing good posture and body mechanics. Train your body in all positions - standing, walking, sitting and lying - so that the joints are properly aligned, with the least strain placed on the muscles and bones. Moving with ease allows you to stay active and independent over time.

What are Safe Body Mechanics for Osteoporosis?

Safe body mechanics for osteoporosis are good posture in motion. They refer to the way you hold your body when you move. Proper body mechanics help you avoid muscle fatigue and injuries as you walk, bend over, lift objects, or perform other activities of daily living. Safe body mechanics for osteoporosis include:

Align your body - head, nose, knees, and toes should point in the same direction.
Bend your knees and hip joints, not your back.
Rotate your whole body, don’t turn from the shoulders or twist your back.
Move objects closer to you, instead of leaning into them.

Exercises for Spinal Alignment

In neutral alignment, the four natural curves of the spine create a functional balance and maintain proper posture.

the two slight inward curves of the neck (cervical) and low back (lumbar)
two slight outward curves of the mid-back (thoracic) and the sacrum

Standing in alignment puts less stress on your spine and improves balance by centering your body weight over your legs. Practice standing with your:

head over your shoulders
shoulders over your rib cage
rib cage over your hips
hips over your knees and ankles

Slow and steady overloading caused by poor posture can cause the bones to break. For example, if you have a forward curve in the upper back, as the weight of the head moves forward of the shoulders putting increased force on the spine, it may cause fragile vertebrae to fracture.

Do You Sit Like a Cashew?

Most of us do not sit well! Prolonged sitting in poor posture can increase the pressure between the disks of the spine, contributing to back pain and spinal fractures. Are you sitting like a cashew, shoulders rounding forward, pelvis tucked under, your spine in a C curve?

To realign your spine in a sitting position

Sit tall with your feet flat on the floor.
Focus on the position of your pelvis, which provides the base for stacking your torso properly, ribs over hips.
Untuck the pelvis, allowing the natural curve in the lower back.
Engage your abdominals to keep the pelvis in neutral spine alignment. (You may need to place a lumbar roll or rolled towel in the small of your lower back for support).

Your success in achieving good posture and body mechanics depend significantly on your core stability. A strong core enhances your quality of movement in every way.

Core Exercises for Osteoporosis

Core stability, strength, posture, and balance provide the elements of a well-rounded fitness program for osteoporosis. Core stability is the ability to maintain the alignment of your spine and pelvis as you move. A strong, stabile core protects us from injuries and enhances quality of movement in all exercises and activities.

When it come to your core strength, the best exercises for osteoporosis work the abdominal and spinal muscles without rounding the upper back (as in a crunch or sit-up) and without twisting or flexing the spine (as in a side crunch or lateral bend). These movements can overload the fragile vertebrae of the spine and cause spinal fractures.

The TVA Muscle is Key

The key is to target the transverse abdominis (TVA) muscle, the deepest abdominal muscle that plays a significant role in core strength. The compressive nature of this muscle makes it a natural corset, keeping the lower back stable and supporting the abdomen. The exercises that target the TVA are performed with the trunk in neutral spine alignment.

To get in touch with your TVA, do this simple exercise: Without moving your pelvis, draw your belly button toward your spine as if you were zipping up a tight pair of jeans or "making your pants loose". Whenever you hold your stomach in, you are working the TVA. You often work this muscle without realizing it, for example to keep your back straight when doing a push-up.

Work the TVA in Three Easy Steps

Belly breathing
Neutral spine alignment
Leg slide exercise

1) Belly breathing is key here, because the TVA functions (along with the obliques) to compress the abdomen when you exhale. Practice a belly breath: Inhale, fill the belly with air, then exhale forcefully by pulling the abdominals tight (think "belly button to spine") and push the air out. Place your hands on your belly to feel the action of the abdominals as they expand and contract.

2) Neutral spine alignment (NSA), the place where your spine rests while preserving all its natural curves. You should have a slight curve in the lower back, with just enough space to slip your hand in if you are standing straight with your back against a wall. The correct alignment of the lower back, neither flattened nor arched, will allow you to recruit your core muscles most effectively.

3) Leg slide: Lie on your back with your knees bent, feet on the floor. Using abdominal compression to maintain NSA, slide one leg out straight and then return to the original position. Work your TVA to keep your lower back from arching and your hips from tilting side to side.

See related Dead Bug Exercise

The Best Core Stability Exercises for Osteoporosis

1) Forearm plank

2) Ball transfer

3) Opposite arm & leg lift

Core Stability exercise, example #2: Ball Transfer

For step-by-step instructions with videos on how to perform these exercises, see Core Stability Exercises for Osteoporosis

Osteoporosis risk factors

What are the risk factors of getting osteoporosis?

Knowing your risk factors can help prevent fractures! Osteoporosis risk factors include anything that may increase your chance of developing this condition - your gender, age, family history, medical history, or lifestyle choices. They can serve as early warning signs that you may be at risk of developing this potentially debilitating condition.

Gender
Age
Family history
Medical history
Lifestyle choices
Read more on osteoporosis risk factors

While osteoporosis risk factors can increase your probability of bone loss, they do not necessarily cause it. Some people with risk factors never develop the disease, while others do despite having no known risk factors.

Common Osteoporosis Fracture Risk

40% spinal fractures
25% hip fractures
15% wrist fractures

Bone fractures are the consequences of osteoporosis. The most common osteoporotic fractures occur in the vertebrae of the spine (40% of fractures), then followed by the hip (25%), and finally, the wrist (15%). Hip fractures are the most debilitating fractures, usually requiring surgery, and often affecting your ability to walk and live independently.

Hip Fracture Risk Factors

Hip fractures are breaks in the thighbone (femur) just below the hip joint. A hip fracture can be life-altering, limiting mobility and independence. Awareness of your risk factors can help prevent an event that could change your life forever.

While women are usually more concerned about developing cancer, statistics show that a woman’s risk of breaking a hip due to osteoporosis is equal to her combined risk of breast, ovarian, and uterine cancer.

Primary vs. Secondary Risk Factors

There are primary and secondary risk factors for a hip fracture. Primary risk factors are uncontrollable, meaning those you cannot change. Secondary risk factors may be modifiable. So we’ll cover both of these.

Primary risk factors for a hip fracture

Being female at advanced age
Being Caucasian, Asian, or Latino
A family history of osteoporosis
Being thin or having a small frame

Related: Osteoporosis Risk Factors

Why is it important to get a bone density test?

Getting a bone density test is important for osteoporosis prevention. Before we get into that, let’s cover a brief explanation of osteoporosis.

What is Osteoporosis?

Osteoporosis is a decrease in bone mass leading to enhanced bone fragility and risk of fracture. Loss of bone mass causes the structural deterioration of bone tissue.

What is Bone Composition?

Normal bone is living, dynamic tissue, constantly being renewed. Osteoporosis is caused by a disruption of the bone renewal or remodeling process, which replaces old bone with new. When bone breakdown outpaces formation, the bones deteriorate and lose their infrastructure.

Degrees of bone density: normal, osteopenia, osteoporosis

Bone serves as a repository of minerals, mostly calcium and phosphorous, which gives bones their hardness and strength. The bone mineral density test measures bone density, the amount of bone mineral you have in certain areas of bone. It can tell you if you have low bone density before you break a bone.

What is the Best Bone Mineral Density (BMD) Test?

The best available screening we have for bone strength measures bone mineral density (BMD) using a DEXA scan (Dual-energy X-ray absorptiometry), where two x-ray beams are aimed at the bones. When the soft tissue absorption is subtracted, the bone’s mineral density can be determined from the absorption of each beam by bone. The level of exposure to radiation is about 50 times lower than of that of a mammogram. It is a brief, noninvasive test covered by Medicare after age 65. For younger women past menopause, a scan may be appropriate depending on their risk factors for osteoporosis.

Osteoporosis screening

Most people don’t realize they need osteoporosis screening because they don’t notice the symptoms. We’ll get into that, but first let’s identify part of the problem.

What are the Signs and Symptoms of Osteoporosis?

Osteoporosis is a silent disease that sneaks up on most people because the signs of osteoporosis may not show up until you experience an injury. There are rarely any symptoms of diminished bone strength with osteoporosis, which is why the osteoporosis screening is so important.

What Are Osteoporosis Risk Factors?

Risk factors help identify people who are more likely to develop osteoporosis. Key risk factors that affect bone mass are:

Heredity
Lifestyle
Medical conditions
Medications
Gender
Age

What are uncontrollable risk factors?

Uncontrollable or primary risk factors are beyond our control. For example, being female of older age are two primary factors.

Bone density by age

Throughout your life, your skeleton loses old bone and forms new bone. During childhood and adolescence bones grow faster than they break down, creating strong, dense bones. Between the ages of 18-25, Peak Bone Mass (PBM) is achieved, the greatest amount of bone you will have in life. From this time on, the balance between bone loss and bone formation may start to change with bone breakdown outpacing bone formation

Childhood and adolescence - rapid formation
18-25, Peak Bone Mass (PBM)
26+ Bone loss begins slowly
Post-menopausal - rapid bone loss for 5-7 years
Later years - slow bone loss
50% of women in their 80s have osteoporosis

Is Osteoporosis Hereditary?

Heredity - gender, race, and genetics - can affect as much as 80% of your ability to build bone. Bone Mineral Density (BMD) is 30% higher for men than for women; 10% higher for blacks than whites; and as much as 60-80% of your BMD may be determined by genetics.

Heredity affects the ability to build bone. As much as 60-80% of BMD may be determined by genetics.

Lifestyle and Osteoporosis

Lifestyle or environmental factors can contribute up to 40%, especially for children and teenagers. Diets high in calcium and vitamin D plus regular weight-bearing physical activity are essential for developing and maintaining strong bones. Inadequate total calorie consumption, as in disordered eating, can negatively impact bone growth.

Medical Conditions That Can Cause Osteoporosis

Chronic disorders like hyperthyroidism, certain cancers, chronic liver disease and rheumatoid arthritis can cause bone loss, as can medications such as those used to treat thyroid issues and glucocorticoids to control asthma and immune disorders.