Strong, Steady and Straight: Physical Activity and Exercise for Osteoporosis

Quick guide: summary (for use in conjunction with full Expert Consensus Statement)
The statement is structured Strong – for bone strength Steady – to reduce falls
around important themes
for osteoporosis: ring/impact Bala
nce and mu
t-bea scl
e
Weight-bearing/impact exercise •• If unsteady, over 65 and not taking regular
h •• Most days of the week; build up to 50 moderate exercise – do some challenging balance exercises

ig
STRONG – the types and

str
2-3 days a week.
We
impacts (i.e. low level jumping, jogging, dancing,

eng
amount of exercise and
hopping). •• If repeated faller consider referral to falls

th for lls preve

physical activity needed to
promote bone strength. Strong Steady •• If frail, less mobile or has vertebral or multiple service/physiotherapist.

fa
M u s cl e

low trauma fractures – up to 20 minutes of lower •• Posture training and back exercises to improve
STEADY – the importance impact activity (e.g. walking). kyphosis may reduce falls risk.
of including exercise and
•• Avoid sitting for long periods.
re s

physical activity to reduce

nti
an Straight – a ‘spine caring’ approach
on
ist

falls and resulting fractures. ce Muscle strengthening (with increasing resistance)

•• On 2-3 days a week - activities or exercise to
Straight
STRAIGHT – a focus on ‘spine •• Correct techniques for moving and lifting
care’, keeping the back straight. feel a push or pull on the muscles (explain mild including the ‘hip hinge’.
A positive approach to bending, discomfort afterwards is normal). For maximum
Bac

benefit, depending on fitness levels, recommend •• On 2-3 days a week – exercises to strengthen

in
moving and lifting safely to reduce back muscles to help with posture with a focus

pa
km

the risk of vertebral fracture, sc increasing the intensity of exercise to work muscles
le nd a on endurance by exercising at low intensity - up
u

improve posture and relieve pain s t re
after vertebral fracture.
Key Principles
Physical activity and exercise has an important role in the management of
osteoporosis – promoting bone strength, reducing falls risk and managing
symptoms.
People with osteoporosis should be encouraged to do more rather than less.
Adopt a positive and encouraging approach – ‘how to’ rather than ‘don’t do’.
Physical activity and exercise is not associated with significant harm including
vertebral fracture – though some caution is advised, the benefits of physical
activity and exercise outweigh the risks.
Professionals should avoid restricting physical activity and exercise
unnecessarily according to bone mineral density (BMD).
u re harder using weights or resistance bands. Build up
n gth for p o st to 3 sets of exercises with 8-12 repetitions of the to 10 repetitions, held for 3-5 seconds. Daily
maximum weight that can be lifted safely. exercises to relieve back pain.
•• Consider physiotherapy referral for painful
•• Exercises to strengthen back muscles will
fractures or mobility problems.
promote bone strength in the spine.
SAFETY – Adopt a positive encouraging approach – explain that fractures are rarely caused
by exercise and the benefits outweigh the risks.
With osteoporosis
•• Recommend correct techniques when using weights or resistance bands, gym equipment – get
specialist advice if unsure.
•• Recommend modification of exercises that involve end range sustained repeated forward bending
unless you are using the ‘hip hinge’/are very experienced/have very good muscle tone and control.
•• Always increase intensity gradually and tailor according to individual fitness and ability.
With vertebral or multiple low trauma fractures
•• Recommend lower impact rather than moderate impact exercise (jogging, low level jumping) as a
general rule. May be appropriate to increase after individualised discussion.

People with painful vertebral fractures need clear and prompt guidance on how to With poor balance
adapt movements involved in day-to-day living, and exercises for posture and pain. •• Recommend improving balance and muscle strength before increasing physical activity levels. 1
Quick guide:
flow chart

All patients with osteoporosis* *Definition of osteoporosis

Low BMD, higher fracture risk, fragility fractures including
Using the vertebral
The term osteoporosis is used throughout this statement as
an umbrella term to include someone with low bone mineral
recommendations density (BMD) in the osteoporosis range (a DXA bone density
scan measurement) or a significant fracture risk (based on
fracture risk assessment) with or without fragility fractures
(including vertebral).
Frail, falling or Back pain or other vertebral
unsteady? fracture symptoms

Prioritise Prioritise
YES NO NO YES STRAIGHT
STEADY

Steady For frequent

fallers – advice
Strong Straight
from falls service/
physiotherapist may
be appropriate
MUSCLE IMPACT FOR BONE
STRENGTH AND STRENGTH
Exercise for: Advice on:
Modify extreme
BALANCE MOVING
or loaded flexion
GAIT and muscle LIFTING
unless used to
strength exercise Exercise for:
movements/ very
BACK STRENGTH
Progressive muscle good muscle tone
Vertebral fracture? POSTURE
resistance

NO YES
Progress to STRONG and STRAIGHT Progress to STRONG and STEADY
if not yet included if not yet included
Advise to consider
balance exercises STEADY,
posture and lifting advice Moderate
STRAIGHT impact
if not yet included

Lower impact For some individuals moderate impact may be appropriate

depending on number of vertebral and other fragility fractures,
level of fitness & muscle tone, previous experience of moderate
impact exercise, back pain from fractures etc.
2
Quick guide: exercise
and activity details Strong Steady Straight
Weight-bearing/impact Upper body/spine Lower body/hip Sit to stand/lunges Back muscle strengthening
+ Moderate Low jumps Wall press Squats Compensatory stepping exercises
Skipping/hopping Bicep curl/tricep press Sit-to-stand
Chest press Hip abduction, extension Heel raises/toe walking Safe moving and lifting techniques
Jogging
Stamping Back extension & flexion Toe raises/heel walking Hip hinge for safe bending
Tennis ball squeeze Lunges
– Lower Stair climbing (repeated) Overhead press Leg press
Tandem stand/walk
Exercises

Marching/brisk walking Dead lift Single leg stand

Walking Reduced base of support/
Standing Using weights (best evidence), resistance bands or body Frequency and
uneven surfaces amount
weight
Frequency and amount Frequency and amount • For all – 2-3 days per week
Frequency and amount
Increase up to moderate impact • 2-3 days per week • Focus on endurance by exercising
for optimum benefit: • For the less steady and over 65s – at low intensity - up to 10
• Build up to 3 sets of each exercise 2-3 days per week
• Most days about 50 moderate impacts repetitions, held for 3-5 seconds
• Include a variety of movements/speeds/directions • Progressive muscle resistance (using weights or
• For fallers – Most days, challenging
OR e.g. a jog/walk resistance bands for upper and lower body including
balance programme – under
• Daily if experiencing pain
from vertebral fractures
• 5 sets of 10 with reduced impacts in between spine) 8-12 repetitions (most you can lift until fatigue)
guidance
• 20 mins session if only lower impact advised

Weight-bearing/impact All sites* Lower body/ Upper body/ Many activities under impact and Swimming
+ Moderate Running/jogging Circuit training spine* spine* muscle strengthening will help
Dancing including Pilates
Aerobics Hill walking Rowing balance
Scottish/Zumba etc Aqua aerobics Yoga
Sports and activities

Rambling Sports involving

Racquet sports (excluding rowing, running, jogging
Pilates/yoga Stair-climbing upper body/ Hydrotherapy
Track events/team & swimming)
Heavy house work Sports involving power
sports/ball games Gardening/DIY lunges/squats Carrying Pilates / yoga Aqua-aerobics
– Lower Nordic walking/rambling shopping etc Tai chi

Frequency and amount Frequency and amount Frequency and amount Frequency and amount
• Most days or supplement with exercises above • 2-3 days per week • 2-3 days per week • 2-3 days per week
• Muscles need to feel warmth/tension
• Unlikely to reach ‘moderate or high intensity’ especially in hip
or spine but will help to maintain bone strength

Weight-bearing/impact Build muscle Improve balance Build back muscle

Correct technique

Strong bones Fewer falls Improved posture and pain

Fewer fragility fractures Improved wellbeing and self esteem

3
 Quick guide:
visual reference 01761 471771 For full Expert Consensus Statement visit theros.org.uk/HCPexercise

Key recommendations: physical activity and exercise for osteoporosis

Strong Steady Straight
Build bone and muscle strength Improve balance Improve pain, posture and movements

Weight-bearing/impact Build muscle Frequency Activities like tai chi or dance Manage pain from vertebral fractures
Frequency
exercise for bones Weights &
2-3 days / Daily back muscle strengthening exercises
Frequency resistance bands 2-3 days /
50 impacts week
week Frequency
per session
Most days
Daily
With osteoporosis Or a challenging balance class
Moderate impact
Build up gradually

3 sets, 8-12 reps of max weight

Progressive resistance training

Improve posture and movements
Positive approach
Lower impact
Learn safe moving and lifting
Sports
Reassurance - ‘how to’ not ‘don’t do’
and everyday activities
Benefits of exercise for osteoporosis
Hip hinge for
Keep active safe bending
– something is better than nothing
Low impact - weight bearing Frequency
Frequency
2-3 days /
Build bone and muscle strength Posture exercises
Most days week
Improve balance

Improve pain, posture and movements Use alternatives Avoid

Vertebral or multiple fractures, or less able
Extreme or loaded flexion Inactivity and prolonged
Some extra caution sitting
Exercise up to lower impact
Individualised advice
Aiming for fewer fragility fractures and
Ensure safe technique improved wellbeing
4 President: HRH The Duchess of Cornwall. Royal Osteoporosis Society is a registered charity no. 1102712 in England and Wales, no. SC039755 in Scotland, no. (pending) in Guernsey and no. (pending) in Isle of Man.
Registered as a company limited by guarantee in England and Wales no. 4995013, and no. (pending) in Isle of Man. Registered address: Camerton, Bath BA2 0PJ.. Formerly the National Osteoporosis Society. Published December 2018. V2 February 2019.