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Prevention 2019 versus 2002

























































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How to Get Maximum Bone Benefit from Exercise

Since I’ve written a book on osteoporosis prevention, I’m often asked what type of exercise is best for building bone and how often one should exercise. This webpage addresses these questions and gives examples of beneficial exercises, but it does not offer an exercise program for you to do at home. I think it’s better to get a trainer, consult a physical therapist or sign up for classes at a gym or senior center.

     To determine the best exercise regimen for bone, it pays to understand the following concepts discussed in the 2005 Report of the US Surgeon General (pp. 125 & 171):

1.  “Bone mass is improved only at the sites that receive the impact.” The increased bone density and size of the playing arm of tennis players and baseball pitchers are common examples of this concept.

2.  “Physical activity to specifically benefit bone health should involve loading (stressing) the skeleton. . . The levels of loading should be beyond those in everyday activities.”

3.  “The evidence suggests that the most beneficial physical activity regimens for bone health include strength training or resistance training.”

4.  “The effect of physical activity on bone does not persist if the activity level is stopped or reduced.”

5.  “Bone gains will be greater in a sedentary person who becomes physically active than in an active person who increases his or her level of physical activity.”

Keep those five principles in mind when reading the following hyperlinked sections.

   Why Walking is Not Sufficient Exercise for Building Bone

   Selecting Gym Activities that Can Help Build Bone

   How Often Do You Need to Exercise to Maintain Bone?

   Avoiding Injuries

   Tips on Getting Maximum Benefit from Exercise in the Least Amount of Time

Why Walking is Not Sufficient Exercise for Building Bone

     Some people believe that walking is an ideal exercise for building bone because it is weight bearing (your body weight is bearing down on your bones as you stand and walk). Walking is a good way to warm up before exercise, and it’s a safe and effective way for sedentary people and surgical patients to build strength. It’s also more enjoyable for many people than working out in a gym. However, it is not sufficient for maintaining bone throughout the body because:

1.  The arms and shoulders receive practically no impact or loading when walking, and the spine receives very little. It’s just as important to stress the muscles and bones of the upper body as those of the lower body; arm and shoulder fractures can require hospitalization and cause lifelong problems, which in turn lead to lower activity levels and increased bone loss throughout the body.

2.  The levels of bone stress during walking are not beyond those in everyday activities. If a person walks during the day, more walking probably will not be of much benefit. It’s better to do different exercise to stress one’s bones. However, if a person seldom does any walking, it will stress some bones and provide more benefit than what a regular walker receives. It may even help improve bone densities of sedentary people with osteoporosis. If you walk for enjoyment, continue doing it. Walking is an ideal form of recreation.

3.  Walking does not load the bones evenly, so cortical bone loss and bone strength in the hip are uneven (Mayhew et al, Lancet 2005). Bones are strongest in habitual loading conditions (Keyak et al, J Biomech, 1998;31:125-33). Walking only moves the legs straight forward and back. Sideways falls are the most likely type to cause a hip fracture; one of the reasons for this is that walking does not strengthen the sides of the hip much. Soccer players, who kick balls from a variety of directions, have greater bone strength throughout their hip. To strengthen the entire hip bone, one must do a variety of hip exercises that stress the bones in various directions.

          In her book Strong Women Strong Bones (2000, p. 8), Miriam E Nelson PhD, Director of the Center for Physical Fitness at Tufts University , says that “Walking is a wonderful exercise—for the heart. But no study has ever shown that a middle-aged or older woman can increase her bone density by taking up walking. The light impact of walking provides only mild stimulation to the bone.”  

             Some osteoporosis professionals recommend wearing a weighted vest while walking in order to increase the weight-bearing effect. If you have back or joint problems, though, it would be best to consult your doctor before purchasing one. Two links discussing weighted vests are:

     https://www.inspire.com/groups/national-osteoporosis-foundation/discussion/weighted-vests/   and



  Selecting Gym Activities that Can Help Maintain Bone

      Any activity involving gravitational pull or resistance beyond normal use benefits bone. Weight training, muscle-strengthening, or bodyworks classes are usually the best choices if your goal is to maintain bone. However, if you’ve never worked with weights before or are out of shape, don’t do more than fifteen minutes to start with, and then proceed gradually. Bodyworks classes include free weight exercises, lunges, squats and some of the floor exercises that are done in Pilates and yoga. Some of the exercises such as double leg-lifts are not advisable for people with back problems or osteoporosis, but can be replaced with another exercise such as single leg lifts. A full curl sit-up can be replaced by a sit-up where your back remains straight and you barely raise it above the ground.

     Some yoga exercise is helpful for maintaining bone. The warrior and chair poses are good for the hips. The side plank, crane pose, downward facing dog and plank pose are good weight-bearing exercises for the arms and wrists. The problem with many yoga classes is that they include several poses and movements such as the sun salute and back-bends that may not be safe for people with osteoporosis or back problems. Poses that hyperextend the spine extensively can cause spinal fractures. A slight, gentle extension, however, can be beneficial. A Mayo study found that a group of women who did back extensor strengthening exercise were three times less likely to have vertebral compression fractures than women who didn’t do it. For more information go to: http://www.mayoclinicproceedings.com/content/81/10/1400.1.full.  An example of a back extensor exercise is raising the upper torso and legs slightly while lying on your belly. Most spinal fractures occur in the mid spine, but bone density measurements and T-scores for this area are not available, which makes it difficult to determine the effect of exercise on the spine section most susceptible to fracture. We can only assume that when we feel an exercise working and pulling on muscles in the mid and upper back that the bones there are benefiting from it.

     Pilates classes have a lot of floor exercises that are good for the hips such as kneeling with your hands on the floor and kicking your legs backwards, sidewards, at an angle or moving them up and down like a dog at a fire hydrant. This works the hips from various angles and is a good alternative hip exercise for somebody who cannot do lunges and squats. These types of floor exercises are also done in bodyworks classes. Pilates also incorporate plank poses which are good for strengthening the arms, wrists, shoulders and abdominal muscles. These too are done in bodyworks classes. I personally don't go to Pilates classes because the ones at my gym spend too much time on several variations of sit-ups which bother my neck, and V sits and other exercises requiring both legs off to be off the ground at the same time, which is hard on the lower back. I tried different teachers but found that generally at least 25 minutes of the class consisted of exercises that were a strain on the lower back or neck. 

     Treadmills, Nordictracks, ellipticals and stair-step machines are a means of getting low-impact weight-bearing exercise. You can adjust the settings and increase the inclines on some machines so that your hips, buttocks and thighs get a stronger work-out. Some elliptical machines even show you which muscles are being worked as you change the settings.

      The various types of rowing machines and/or lat-pull downs at a gym can also provide a good workout for your back. Leg presses are especially helpful for the hips and are not as stressful on the knees as squats. However, if you try exercise machines, make sure that somebody shows you how to use them correctly and verifies that you have correct form; otherwise, you may injure yourself. Heart patients, in particular, should find out from their cardiologist if it is okay to use weight machines.

     Using water weights during water aerobics is a safe way to work the back muscles, especially for people who are out of shape or have osteoarthritis. Some osteoporosis professionals claim that water aerobics do not benefit bone, but many water aerobics instructors strongly disagree. They point out that lifting the legs in water and working with water weights involves resistance in two directions, adding load to shoulder, back, and arm muscles, which in turn helps strengthen bone. However, simply walking in water is not an effective way to build bone. Generally, land exercise that targets the hips is more effective at preventing bone loss than most water exercise. On the other hand, water resistance exercise might benefit the spine and arms as much as land resistance exercise if done vigorously with a full range of motion with the water up to the armpits, although I am not aware of any studies that prove or disprove this claim. When water weight exercise is done fast in water, it qualifies as high-velocity resistance training for the upper body. High speed power training studies on land have indicated a benefit to bone. It seems that people who discount the potential bone benefits of water exercise have either never tried it or have not attended a class that works the upper body. Water exercise has several advantages: it allows you to do strenuous aerobic exercise without damaging the joints; it can help alleviate arthritis pain by keeping the joints mobile; it’s the safest form of exercise for people with physical ailments; it’s a more social form of exercise than most classes offered at gyms and you feel refreshed after doing it.

     Bicyclists and swimmers typically have lower bone density than weight lifters and runners. This has led some osteoporosis professionals to claim that swimming and bicycling do not benefit bone. Yet, it’s difficult to believe that the shoulders and upper spine of swimmers and the thighs and knees of bicyclists get no benefit, considering the leg muscle strength in cyclists and shoulder size and strength of professional swimmers. Stronger muscles usually create stronger bones in those that they surround. However, bone density tests usually only measure the hip and lower spine, not the femur, knee, shoulder, upper spine or upper arm, so there is no good basis for claiming that swimming and bicycling offer no bone benefit whatsoever. In addition, long-distance swimmers and bicyclists need more calcium and other bone nutrients than the general populations. If they don't get enough, the deficiency can lead to osteoporosis. In sum, if you enjoy swimming do it. Not only is it an excellent aerobic exercise that is safe for your joints, it’s probably a good way to maintain bone in your shoulders and upper spine.

     You can turn stationary bicycling into a weight bearing exercise by standing with your shoes in the toe clips of the pedals, instead of sitting on the seat while pedaling, but make sure that you are in a higher gear; your hamstrings and quadriceps will get more benefit doing this than they will when walking, and your hips will feel the weight-bearing effect, which is helpful for maintaining bone in that part of the body. For many seniors, however, using an elliptical machine would be a better alternative as a weight-bearing activity that could strengthen the thighs. Even while seated, a person can get good resistance leg and thigh exercise by using higher gears.

     Jumping and high impact aerobics is sometimes recommended by osteoporosis professionals because studies have shown that it builds bone. However, high impact exercise also damages joints and vertebral discs. It’s just as important to preserve your joints as it is your bones. If painful joints prevent you from living an active life and exercising, you will in turn lose bone faster and have a lower quality of life. In other words, avoid high-impact exercise involving jumping, especially on hard surfaces.

     Resistance bands can be useful for stretching muscles and providing resistance for them, particularly when weight machines and free-weights are not available.

     When exercising, pay attention to the areas where you feel the greatest effect. If the area feels tired or like it’s “burning,” that area is probably getting bone benefit. If you have pain, however, stop the exercise. Safe exercise does not hurt. On the other hand, if you do not feel any effect from exercise, it probably isn’t sufficient for building bone. 

      You will be more motivated to exercise if you do it in a class and you'll get a better balance of exercise than if you try to do a few exercises by yourself. Fitness centers offer a wide variety of classes for low monthly prices. However, start out gradually. If you have any physical problems, get advice from a medical professional about which types of exercise are safe and which should be avoided. Also let the instructor know if you have potential physical problems.


How Often Do You Need to Exercise to Maintain Bone?

If you have surgery to repair a fracture or to replace a joint, the physical therapist typically recommends exercise at least once a day and usually two and even three times a day in order to maintain and improve muscle function. Even though walking is part of the exercise regimen, therapists also recommend a variety of exercise in order to work different muscles and get the desired results.

I asked the head therapist in an orthopedic ward why some professionals advise doing strength training only twice or three times a week. She thinks it might be because exercise sessions in gyms are usually more strenuous than the groups of exercises she recommends for patients. In addition, trainers may just work the lower body really hard one day and the upper body the next to let each part recover. The therapist I consulted has found that doing a light to moderate amount of exercise daily (and even 2 or 3 times a day) produces better results than only exercising 2 or 3 times a week. I have found this to be true for myself as well. My best results in improving bone density and heart function have occurred when I performed bone building exercise six or even seven days a week.

I believe the amount and frequency needed to maintain bone varies from one individual to another. Postmenopausal women probably need to exercise more in order to maintain bone because of decreased estrogen levels. The required amount also depends on the type and intensity of the exercise. Generally, the more intense the exercise, the lower the duration can be to obtain the same benefit.


Avoiding Injuries

1.  Check with your doctor first before starting an aerobic or weight-training program. If you have osteoporosis, consider having a physical therapist develop an exercise program for you.

2.  Progress gradually. A common mistake is for individuals to try and progress too rapidly with exercises that are either too advanced, use too many repetitions, or require too much weight. Exercises should not be painful at the time and you shouldn't hurt that evening or the next day. Some people maximize their pain with the hope that the cliché “no pain no gain” is true. Taking that approach can cause injuries and chronic problems.

3   If you’ve never lifted weights or used resistance machines before, have a certified trainer or physical therapist show you how. Proper form with the right amount of weight is important, but this is hard to learn from a book. You should also learn how to adjust the resistance machines to suit your height and have an exercise professional verify that you can do the exercises correctly.

4.  Don’t assume that trainers know your limitations. If you can do the exercises easily without straining, they may overestimate your ability. Tell them you want to start out slowly and work different parts of your body, not just one area in a lesson.

5.  Warm up with other exercise before strength training. Many trainers suggest ten minutes on the aerobic exercise machines.

6   Breathe regularly, instead of holding your breath during the exercises. Exhale with effort or exhale as you lift the weights.

7.  Stretch after exercising. Exercise classes at gyms usually include stretches at the end of the class. Physical therapists recommend that people with osteoporosis limit flexing, bending and twisting.

8.  Make sure you do the exercise with good form. Don’t slouch as you fatigue.

9.  If you pull a muscle or injure yourself in a fall, wait about 48 hours before exercising the area or walking on it in the case of an ankle, knee or leg injury; it will heal much faster. If you still have pain, either see a doctor or wait a week before exercising the area. Following this advice can make the difference between a short term setback and a problem that can last for weeks or even become chronic. Of course, if there is a risk of a broken bone or torn ligament, tendon or muscle, you should see a doctor immediately after injury.

10. When going up and down stairs, hold onto the handrail. A colleague of mine broke her hip at the age of 51 going upstairs and not holding on. A friend of hers who was carrying laundry with both hands, also had a fracture from falling down the stairs (she was wearing socks on the stairs).


Tips on Getting Maximum Benefit from Exercise in the Least Amount of Time

1.  After warming up, increase the speed and intensity of the exercise. The faster and more intense an aerobic exercise is, the greater the aerobic benefit, and the greater potential for bone benefit. For example, researchers at the University of Erlangen, Germany compared the bone density results of two groups of postmenopausal women doing the same exercise and resistance training program, but one group (the power group) did the exercise quickly and the other did it slowly. The bone density scores of the power group were better than those of the group that did the exercises slowly and the results were published in the February 2005 issue of the Journal of Applied Physiology. 

     See: http://jap.physiology.org/content/99/1/181.full

           A few other studies have confirmed that high velocity exercise can be more beneficial for maintaining bone and muscle than slow exercise. One was presented at the 2011 annual meeting of the American Society of Bone and Mineral Research (abstract 1166). It was a University of Melbourne, Australia study entitled “Effects of High Velocity Power and Functional Training on BMD [Bone Mineral Density] and Physical Function.” After both 6 and 12 months there were significant exercise-induced net gains in back and leg muscle strength and net gains of about 1% in the participants’ bone mineral density.

One of my bodyworks instructors maintains that lifting weights slowly can be more effective at strengthening bone, because you don’t have the benefit of momentum to move the weights. Furthermore, if free weight exercise is done too quickly, it can lead to pulled muscles or ligaments. Perhaps it’s best to do a combination of fast and slow resistance exercise.

2.  Select exercise that offers multiple benefits. For example, one exercise that is often recommended to seniors or patients awaiting joint replacement surgery is the sit-stand exercise. It is also used for measuring fitness levels. You simply rise from a seated position with your arms folded and then sit back down again. This strengthens both the back and front thigh muscles, provides weight-bearing activity for the bones, and increases one’s aerobic capacity when done quickly. This was one of the exercises used in the previously mentioned Australian power exercise study (Abstract 1166, ASBM 2011 Annual Meeting). It also enables seniors to stand up from a chair or bed without needing assistance. Compared to working on a seated knee-extension weight machine, which primarily benefits the front thigh muscles and offers no aerobic or weight-bearing hip benefit, sit-stands are a much more beneficial exercise. You accomplish a lot more in less time.

Pushups are another exercise that offers multiple benefits. I used to do only 3/4 pushups with the knees on the floor until a bodyworks teacher challenged us to do full pushups and teased us for limiting ourselves to girlie pushups. Full pushups not only provide intense weight bearing activity for the shoulders, arms and wrists, they are a good core exercise for your abdominal muscles and they offer an aerobic benefit. Doing push-ups while standing in front of a wall and leaning into it is helpful for strengthening your arms but is not as effective as on the floor because the load is less. Don’t attempt to do a full push up until you are able to do about twenty 3/4 pushups with ease. Then try to do three full pushups; gradually increase the number until you can do at least twenty. Doing full floor-push-ups on a regular basis will decrease your chances of breaking an arm or shoulder when you brace yourself for a fall because your body adapts to the intense load of the pushup by strengthening your bone and muscle. The medical term for this response is Wolff’s law. If you are able to effectively brace yourself from falls with your arms, you are less likely to break a hip if you fall.

        Doing free weight exercise while standing on one leg not only builds strength in your upper body, it also improves your balance. In addition, your standing leg experiences a greater weight bearing effect, than it does when you stand on two legs at once.

3.  Increase the range of motion in order to increase the benefits of the exercise. For example, during water exercise, moving your arms far back without overextending them past your shoulders provides more resistance benefit to your bone and muscle than barely moving the arms. A large range of motion in the legs while bicycling, marching, or using the elliptical machine is more beneficial than a limited range of motion. Barely bending your arm while doing a pushup is not as effective as bending it until your elbow is almost at shoulder level.

4.  Avoid holding the handrails when doing exercise on elliptical machines and treadmills. This will help improve your balance and even give you an improved aerobic benefit. If your balance is not good, place your hand slightly above the handrails so you can catch yourself if you think you might fall. Sit-stands are most effective when you don’t brace yourself on an armchair or use the momentum of your arms to stand up from a seated position. That’s why it’s recommended to do them with your arms folded.

5.  Do most of your stationary bicycling standing with your shoes in the toe clips of the pedals, instead of sitting on the seat while pedaling; your hamstring, quadriceps and hips will get more benefit doing this than if you bike while seated. It is best to have the bike in a higher gear while standing on the pedals.

6.  Focus on maintaining good posture while exercising. This will help improve your posture and the strength of your back and abdominal muscles.

7.  Add ankle weights when doing floor exercise such as single leg lifts, circles and extensions. However, before adding weights, make sure you can do them easily without weights. Otherwise, you might strain your leg muscles.

8.  Gradually increase the incline on treadmills and elliptical machines to give your thighs and buttocks a better workout that they would get by remaining level.

9.  Consider turning water aerobics into a resistance exercise by using water weights and Styrofoam “noodles.” The water should be up to about your armpits when using the water weights.

10. Avoid overdoing exercise. If your muscles become over-saturated with stress, the beneficial effect of the exercise ceases and injuries can occur.


For more information consult:

Osteoporosis Prevention: A Proactive Approach to Strong Bones & Good Health


Copyright 2006 and 2012 by Renée Newman           Click here to go to top of web page