Bone Loading Exercise
Recommendations for Prevention and
Treatment of Osteoporosis
Written on Behalf of the IOF Committee of Scientific Advisors by
Michael Pfeifer and Helmut W. Minne,
Gustav Pommer Institute of Clinical Osteology and
German Academy of the Osteological and Rheumatological Sciences
Contents:
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Foreword
Introduction and definitions
Recommendations for children and adolescents
Recommendations for young adults and pre-menopausal
women
Recommendations for postmenopausal women
Recommendations for men
Recommended exercise for fall prevention
Recommended exercise for patients with osteoporosis
Foreword
This report, provided on the health professionals section of the IOF
website, outlines specific exercise programs which 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.
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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]:
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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 premenopausal 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 min.
High-impact jumps*
20 min.
Stretching and non-impact activities
15 min.
Cool-down
10 min.
*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 premenopausal 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.
Fig.1 shows a 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).
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).
Fig.3: Hamstring curl during strength training sequence
Figs.4 + 5: Hip abduction (left) and hip adduction (right) during strength
training
Fig.6: Leg extension during strength training sequence
Fig.7: Leg press during strength training sequence
Fig.8: Arm curl using dumbbells during strength-training
sequence
Fig.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
Fig.11: Triceps extension (using pulley) or latissimus pulldown during strength-training sequence
Fig.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 hipfracture 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
Repetitions and
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].
Fig.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].
Fig.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].
Fig.15: Balance and coordination training during warm-up
sequence
Fig.16: Supervised posture training, walking and balance on
different surfaces
Fig.17: Isometric strengthening of back extensors and
shoulder girdle muscles
Fig.18: Trunk-muscle training while sitting on a “pezzy-ball”
Fig.19: Muscle strengthening isometric exercise for the
shoulder girdle in water (32°C)
Figs.20a+b: A newly developed spinal orthosis, which is worn
like a backpad, has been shown to improve posture, trunkmuscle strength and several parameters of quality of life in
postmenopausal women with vertebral fractures due to
osteoporosis [23].
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 MayoMedical 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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