Physiotherapist's recommendations, Uncategorized
Exercise for Osteoporosis: Strength, Balance and Bone Health
Dec
Osteoporosis often develops without obvious warning signs. A person may have no significant pain or movement limitations until a fall or even a relatively minor load results in a fracture. For this reason, osteoporosis management should focus not only on bone mineral density, but also on muscle strength, balance, posture and the ability to perform everyday movements safely.
Many people become afraid of physical activity after being diagnosed with osteoporosis. They may avoid lifting objects, stop strength training and choose only gentle walking. Caution is necessary in certain situations, but excessive restriction of movement can reduce muscle strength, impair balance and increase the risk of falling.
Current recommendations encourage people with osteoporosis to remain physically active rather than unnecessarily limiting movement. Appropriately selected exercise can help maintain or modestly improve bone strength, develop muscle strength, improve posture and reduce the likelihood of falls. The most complete programmes usually combine several different forms of exercise rather than relying on only one type of activity.
What is osteoporosis?
Osteoporosis is a skeletal disease in which bone strength is reduced and the risk of fracture increases. These changes involve not only bone mineral density but also the internal structure of bone and its ability to withstand mechanical loading.
Common sites of osteoporotic fractures include the vertebrae of the spine, the hip and the wrist. However, fractures can also occur in other bones. Risk increases with age, particularly after menopause, although osteoporosis can also affect men and younger people with certain risk factors.
Physical activity is only one component of osteoporosis prevention and treatment. Depending on an individual’s fracture risk, management may also include medication prescribed by a doctor, adequate calcium and vitamin D intake, appropriate nutrition and treatment of other relevant health conditions.
How does physical activity affect bone?
Bone is living, active tissue that adapts to the loads placed upon it. When muscles contract and the body bears weight, mechanical forces are transmitted to bone. When this stimulus is repeated regularly and at an appropriate level, it can help maintain bone strength and slow age-related loss of bone mass.
Not all activities affect bone in the same way. Progressive resistance training and activities in which the body bears its own weight and interacts with the ground generally provide a stronger mechanical stimulus. Examples include climbing stairs, dancing, brisk walking, running and, when appropriate, small jumps.
Combined programmes that include both resistance exercise and weight-bearing activity can help maintain bone mineral density at important sites such as the lumbar spine and femoral neck. However, exercise-related changes in bone mineral density are generally modest and develop over a relatively long period of time.
The benefits of exercise are not limited to bone density. Stronger leg and trunk muscles, better balance and faster corrective reactions can reduce the likelihood of falling. Because many osteoporotic fractures occur as a result of a fall, improving physical function may be just as important as influencing bone itself.
Can exercise cure osteoporosis?
Exercise should not be considered the only treatment for osteoporosis. It cannot guarantee that bone mineral density will return to a normal range or that a fracture will never occur.
The aim of exercise is often to maintain existing bone strength, slow further decline and at the same time improve muscle strength, balance, posture and confidence with movement. In some people, a structured and sufficiently challenging programme may also produce measurable improvements in bone mineral density.
In the LIFTMOR trial, carefully screened postmenopausal women with low bone mass completed supervised high-intensity resistance and impact training. The programme improved lumbar-spine bone mineral density and physical function compared with a low-intensity control programme. However, this type of training was performed under professional supervision and should not simply be copied as an unsupervised home programme, particularly by people with previous fractures, significant pain or poor balance.
What types of exercise are most useful for osteoporosis?
A well-rounded programme should develop several physical qualities. Resistance and weight-bearing exercise provide mechanical loading for bone. Leg strength and balance are important for reducing the risk of falls. Back and postural muscles should also be trained to support the spine and improve control during everyday tasks such as lifting.
There is no single exercise or sport that addresses all of these goals. The most complete programmes therefore combine resistance training with walking, stair climbing, appropriate impact loading, balance exercises and regular everyday movement.
Strength training for osteoporosis
Resistance training is one of the most important components of an exercise programme for osteoporosis. Muscle contraction places load on bone, while greater muscle strength also makes everyday tasks safer, such as standing up from a chair, climbing stairs, carrying shopping and recovering balance after a stumble.
Training should involve the major muscle groups of the body. Particular attention can be given to the legs, hips, back and shoulder girdle. Practical exercises may include sit-to-stand, an appropriate squat variation, step-ups, calf raises, rowing with a resistance band, wall push-ups and controlled lifting of an object from an elevated surface.
Initially, resistance may be relatively light while correct technique, breathing and movement control are learned. However, it is usually not beneficial to remain permanently at an extremely light resistance. Once an exercise can be performed confidently and without a significant adverse symptom response, resistance can gradually be increased.
General recommendations commonly include resistance exercise two or three times per week. For many exercises, progression can eventually move towards a resistance that allows approximately 8–12 well-controlled repetitions for up to three sets. The precise load should be adjusted according to fitness level, joint health, movement quality and fracture risk.
Strength training does not require complicated gym equipment. At home, exercises can be performed using body weight, dumbbells, resistance bands and a stable exercise step. The most important factors are not the specific equipment used, but an appropriate training load, good technique and regular progression.
Weight-bearing and impact activities
Weight-bearing activities are movements performed while standing, with the legs supporting the body’s weight. Examples include walking, hiking, stair climbing, dancing and many everyday activities.
Impact activities involve slightly greater forces as the body interacts with the ground. Depending on the individual, these may include purposeful heel drops, small jumps, hopping, jogging, running or more energetic dancing. These activities can provide a stronger mechanical stimulus to bone than slow, level walking.
For people with osteoporosis who have not experienced vertebral fractures or multiple low-trauma fractures, recommendations may include short bouts of moderate-impact activity when appropriate. An example might be accumulating approximately 50 controlled impacts through purposeful steps, small hops or jogging-type movements divided into several short sets.
This recommendation should not automatically be applied to everyone with osteoporosis. Before introducing jumping or running, factors such as joint health, balance, previous fractures, pain and previous experience with impact exercise need to be considered.
For people with vertebral fractures or multiple low-trauma fractures, impact loading is generally kept no higher than the level produced by brisk walking unless a suitably qualified professional has recommended otherwise.
Is walking enough to strengthen bones?
Walking is a valuable and accessible form of physical activity. It helps maintain general endurance, leg function, walking capacity and regular everyday movement.
However, gentle walking alone does not always produce a sufficiently strong mechanical stimulus to substantially improve bone mineral density. The body adapts to repetitive loading, especially when a person has been walking at the same pace on level ground for a long time.
For this reason, walking can be complemented with resistance exercise and, where appropriate, more challenging weight-bearing activity. This might include increasing walking speed, choosing gentle hills, using stairs or adding short periods of brisker walking.
For someone with poor balance, improving leg strength and stability may need to come first. Progressing too quickly to fast or fatiguing walking can increase the risk of falling.
Balance exercises and reducing the risk of falls
With osteoporosis, fracture risk depends not only on bone strength but also on the likelihood of falling. Balance and leg-strength exercises therefore have an important place in an osteoporosis exercise programme.
Initially, balance exercises can be performed close to a stable support such as a kitchen counter or the back of a sturdy chair. Practical options include tandem standing with one foot in front of the other, transferring weight from one leg to the other, controlled sideways stepping, slow backward walking and brief single-leg standing.
Balance exercises need to be sufficiently challenging to train balance, but the environment should remain safe. Unstable surfaces are not essential. For many older adults, a carefully progressed exercise on a stable floor is more appropriate than immediately standing on a highly unstable balance cushion.
Balance and strength exercises are generally recommended at least twice per week. People who already fall regularly or have begun avoiding activities because of fear of falling may need a more targeted programme, preferably under the supervision of a physiotherapist or another appropriately trained professional.
Falls-prevention programmes tend to be most effective when exercise is performed regularly, remains sufficiently challenging and is continued over a meaningful period of time.
The importance of back muscles and posture
For people with osteoporosis, strengthening the spinal extensor muscles is particularly useful. These muscles help maintain a more upright posture, support the spine and contribute to balance control.
Back muscles can be trained in different ways, for example by standing against a wall and gently lengthening through the chest, drawing the shoulder blades backwards, performing rowing exercises with resistance bands or using appropriately modified back-extension exercises in standing or lying positions.
For exercises performed lying down, on hands and knees or kneeling, a sufficiently thick and non-slip exercise mat can improve comfort against a hard floor. Different sizes, thicknesses and uses are compared in our article about AIREX fitness and exercise mats.
Movements should be calm and controlled. There is no need to force the spine into excessive extension or attempt to achieve a maximal range of motion. The aim is to develop muscle activation, endurance and the ability to maintain good posture during everyday tasks.
Back-muscle exercises are generally recommended at least twice per week. A simple activation exercise may initially be repeated three to five times while holding the position for several seconds, but the programme should always be adapted to the person’s abilities and symptoms.
Do swimming and cycling help with osteoporosis?
Swimming and cycling are valuable activities for cardiovascular fitness, endurance and general wellbeing. They can be particularly useful for people with joint pain who find walking or running uncomfortable.
However, water supports part of the body’s weight during swimming, while the bicycle saddle supports much of the body during cycling. These activities therefore generally provide less mechanical loading to bone than resistance exercise, stair climbing, walking and impact activities.
Swimming and cycling do not need to be avoided. They simply should not be considered the only exercise used to support bone health. Ideally, they are combined with resistance and weight-bearing exercise when appropriate.
How often should you exercise?
The exact programme should always be adapted to the individual’s health and physical condition, but the following can be used as a general guide:
| Training component | General frequency | Practical examples |
|---|---|---|
| Strength exercises | 2–3 times per week | Squat variations, sit-to-stand, step-ups, dumbbells and resistance bands |
| Weight-bearing activity | On most days of the week | Walking, stairs, hiking, dancing |
| Moderate-impact activity | On most days when safe and appropriate | Purposeful stepping, small hops, jogging-type movements |
| Balance exercises | At least twice per week | Tandem stance, single-leg standing, stepping in different directions |
| Back and posture exercises | At least twice per week; short exercises can be performed more often | Back-extensor and shoulder-blade muscle strengthening |
| Aerobic activity | Regularly throughout the week | Brisk walking, stationary cycling, swimming, Nordic walking |
Strength-training sessions do not necessarily need to be long. Two well-planned 30–45 minute sessions per week may provide more useful progressive loading than frequent but extremely light exercise that never becomes more challenging.
A practical example of a training week
A person without a recent fracture and with reasonably stable balance might begin the week with a resistance-training session for the legs, hips, back and upper body. The following day could include a brisk walk and a short block of balance exercises.
After a lighter activity or rest day, resistance training can be repeated later in the week. On another day, the person might choose walking over varied terrain, stair climbing, dancing or another appropriate weight-bearing activity.
Short balance exercises can be added on several days of the week. Moderate-impact exercise should be introduced only once the person can confidently tolerate resistance exercise, brisk walking and simpler balance tasks.
Training does not need to progress in every direction at the same time. Initially, the number of repetitions may be increased. Later, resistance, exercise complexity or session duration can be progressed. A gradual approach allows the body to adapt and reduces the likelihood of excessive loading.
Which movements may need to be modified with osteoporosis?
A diagnosis of osteoporosis does not mean that a person is forbidden from bending, turning or lifting objects. Excessive restrictions can create fear of movement and reduce everyday activity.
Greater caution is appropriate with repeated, sustained or end-range spinal flexion, particularly when it is performed with additional load. Examples include repeated loaded trunk-curling exercises, lifting a heavy object with a markedly rounded spine or remaining for a prolonged period in a deeply flexed posture.
A more appropriate lifting strategy is often to initiate the movement from the hips while keeping the upper spine relatively controlled. This movement pattern is commonly called a hip hinge. The object should be kept reasonably close to the body, the movement performed in a controlled manner and the load progressed gradually.
Rotational movements are not automatically prohibited. Calm, controlled rotation within a comfortable range is generally acceptable. Greater caution is appropriate with fast, forced rotation or rotation combined with deep spinal flexion and heavy resistance.
Can people with osteoporosis do yoga and Pilates?
Yoga and Pilates can help improve muscle strength, balance, body control and posture. They do not automatically need to be excluded because of osteoporosis.
However, some positions may involve very deep spinal flexion, repeated trunk curling or movement towards extreme ranges. Particular caution is appropriate for people who already have vertebral fractures.
Ideally, choose an instructor who understands osteoporosis and osteoporotic fractures and can offer alternative movement options when necessary. A class should not be based only on restrictions—the goal is to find safe ways to continue moving and exercising.
Physical activity after a vertebral fracture
A vertebral fracture does not mean that complete rest is required indefinitely. Movement and gradually progressed exercise can help maintain mobility, muscle strength and confidence with everyday activities.
However, the initial programme should take into account pain, the stage of fracture recovery, posture and everyday function. Priorities commonly include safe mobility, activation of the leg and back muscles, balance and appropriate breathing strategies.
For people with vertebral fractures or multiple low-trauma fractures, impact loading is generally limited to approximately the level of brisk walking unless an individual assessment supports more intensive loading.
It is also useful to learn safe strategies for bending, getting in and out of bed, lifting objects and performing everyday household activities.
In this situation, consultation with a physiotherapist can be particularly valuable. An excessively cautious approach may result in unnecessary inactivity, while progressing load too quickly can increase pain or reduce confidence.
When should you be assessed before starting exercise?
Consultation with a doctor or physiotherapist is recommended if a person has recently sustained an osteoporotic fracture, has known vertebral fractures, has a marked postural deformity or experiences recurrent falls.
Assessment is also appropriate when new, severe back, hip or groin pain develops without a clear explanation. Sudden back pain after a relatively minor movement, coughing or lifting an object can sometimes be associated with a vertebral fracture and should not simply be treated as routine muscular soreness.
An exercise programme should also be individualised for people with significant balance problems, cardiovascular disease, uncontrolled blood pressure, substantial joint pain or a long history of inactivity.
A physiotherapist can assess leg and back strength, balance, movement technique and the ability to perform everyday tasks. This can help determine an appropriate starting load and whether a person is ready to introduce additional resistance, impact exercise or another more demanding activity.
Does exercise replace osteoporosis medication?
Physical activity does not replace osteoporosis treatment prescribed by a doctor. For people at high or very high risk of fracture, pharmacological treatment may play an important role in reducing fracture risk.
Exercise, medication and nutrition should not be viewed as competing treatments. They complement one another. Exercise improves muscle strength, balance and physical function, while medication can act more directly on bone metabolism.
Adequate protein, calcium and vitamin D intake is also important. Calcium is preferably obtained through food where possible, while supplements should be used according to individual need and medical advice. Very large intermittent doses of vitamin D without an appropriate medical indication should not be considered a routine osteoporosis-prevention strategy.
Common exercise mistakes with osteoporosis
One common mistake is relying only on walking. Walking is a useful everyday activity, but muscles and bones also benefit from progressive resistance.
Another mistake is using the same extremely light resistance indefinitely. If an exercise no longer provides an adequate challenge, there is little stimulus for continued adaptation. Resistance should be increased gradually while maintaining good movement quality.
Some people begin avoiding almost every movement after receiving an osteoporosis diagnosis. Excessive caution can reduce strength, endurance and confidence. The goal should not be to prohibit normal movement, but to learn how to perform everyday tasks more safely.
The opposite mistake is progressing too rapidly to heavy exercises, jumping or intense running without sufficient preparation. This is particularly important for people who have been inactive for a long period or who have already experienced fragility fractures.
Consistency is also important. Bone adaptation is a slow process, so a few weeks of exercise cannot be expected to produce a lasting result. Physical activity needs to become a regular long-term part of everyday life.
Frequently Asked Questions
Frequently Asked Questions about Osteoporosis
This depends on previous fractures, balance, joint health, and running experience. For a person who already runs regularly, feels stable, and has not had vertebrae or multiple low-energy fractures, running usually does not need to be stopped automatically.
If running is starting over, the load should be increased gradually, first by developing leg strength and maintaining fast walking. For people at high risk of falls or previous osteoporotic fractures, a safer choice at first may be brisk walking, climbing, and controlled strength exercises.
Yes, a suitable squat option can be very valuable. It strengthens the thigh and hip muscles, as well as improves the ability to get up from a chair, climb stairs, and move more safely in everyday life.
At first, you can use standing up from a higher chair or a shallow squat, holding onto a stable support. You can gradually increase the depth of movement and add extra weight. It is important to maintain controlled movement and prevent your back from becoming significantly rounded, especially when lifting heavier weights.
No. Balance can also be effectively trained on a stable floor. Standing with one foot in front of the other, controlled sideways walking, turning, and standing on one leg can be challenging enough even without special equipment.
For a person with distinctly poor balance, an unstable surface can unnecessarily increase the risk of falling. A balance cushion can be added later, when the simplest tasks on a stable surface have become safe and too easy. Regular training of leg strength and balance is important for fall prevention, rather than specific equipment.
Muscle strength, balance, and confidence in movement can improve relatively quickly, but bone tissue adaptation occurs much more slowly. A few weeks of exercise is usually not enough to significantly change bone mineral density.
Bone health requires regular and prolonged exercise over several months and years. Even then, the benefit does not always manifest as a significant increase in bone density. A significant result is also the preservation of existing bone strength, improved muscle power, and a reduced risk of falls.
Mild muscle fatigue or sensitivity after new exertion can be normal. However, sharp, sudden, or gradually increasing pain should not be ignored, especially if it is felt in the back, hip, or groin.
Sudden back pain after minor movement, coughing, or lifting objects can also be related to a vertebral fracture. In such a situation, exercise should be stopped and a medical evaluation is necessary. In cases of chronic pain, the load can often be adjusted by choosing a different exercise, a lighter weight, or a more comfortable range of motion.
Usually not. A diagnosis of osteoporosis itself does not mean that sports, strength training, or active rest should be stopped. More often, it is necessary to adjust individual movements, load intensity, or the training environment.
The decision depends on the history of fractures, balance, pain, and the specific sport. Unjustified complete cessation of activity can reduce muscle strength and increase fear of movement. A safer solution is to stay active and, if necessary, find more suitable exercise options together with a physiotherapist.
Walks are very valuable for overall health, endurance, and maintaining daily activity. However, calm walking alone is usually not enough to optimally develop muscle strength and provide the bones with a sufficiently diverse range of mechanical stimuli.
It is advisable to complement walks with strength training at least twice a week, as well as balance exercises. If it is safe, you can increase your walking pace, use stairs, or choose a route with gentle inclines. The best results are usually achieved by combining several types of loads.
It is generally recommended to do strength exercises two or three times a week, allowing time for muscle recovery between more intense sessions. It is advisable to engage the muscles of the legs, hips, back, chest, and arms during the workout.
At first, you can use body weight, light dumbbells, or resistance bands. Once the chosen number of repetitions can be performed easily and with good technique, the load should be gradually increased. By focusing on very light exercises for a long time, muscles and bones may not receive enough stimulation.
Summary
Physical activity is an important part of osteoporosis prevention and treatment. It can help maintain bone strength while improving muscle strength, balance, posture and the ability to perform everyday movements safely.
A comprehensive programme combines resistance exercise, weight-bearing activity, impact loading appropriate for the individual, balance exercises and strengthening of the back muscles. Walking alone often does not provide the optimal loading stimulus for both bone and muscle.
A diagnosis of osteoporosis does not mean that a person must stop lifting objects, bending or exercising. It is more important to learn appropriate movement strategies and adapt training according to fracture history, balance and current physical ability.
If a person has already experienced a vertebral or other osteoporotic fracture, falls regularly or is unsure what level of exercise is appropriate, a physiotherapy assessment and individual exercise programme are recommended.
The information in this article is educational and does not replace consultation with a doctor or physiotherapist.
References
Brooke-Wavell K, Skelton DA, Barker KL, et al. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. Br J Sports Med. 2022;56(15):837–846. doi:10.1136/bjsports-2021-104634.
National Osteoporosis Guideline Group. Clinical Guideline for the Prevention and Treatment of Osteoporosis. NOGG; updated December 2024.
Bae S, Lee S, Park H, et al. Position Statement: Exercise Guidelines for Osteoporosis Management and Fall Prevention in Osteoporosis Patients. J Bone Metab. 2023;30(2):149–165. doi:10.11005/jbm.2023.30.2.149.
Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res. 2018;33(2):211–220. doi:10.1002/jbmr.3284.
Mohebbi R, Shojaa M, Kohl M, et al. Exercise training and bone mineral density in postmenopausal women: an updated systematic review and meta-analysis of intervention studies with emphasis on potential moderators. Osteoporos Int. 2023;34:1145–1178. doi:10.1007/s00198-023-06682-1.
Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1(1):CD012424. doi:10.1002/14651858.CD012424.pub2.
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Appropriately prescribed resistance training is generally an important part of exercise for osteoporosis and can help maintain both muscle and bone strength. At the beginning, lighter dumbbells, resistance bands or body-weight exercises can be used while correct movement technique is learned, followed by gradual progression of the training load.
If you have already experienced vertebral fractures or multiple osteoporotic fractures, have significant pain or poor balance, it is advisable to begin strength training under the guidance of a physiotherapist. The goal is not to avoid weights completely, but to identify a level of loading that is both safe and sufficiently effective.
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