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.
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.
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
Keep those five principles in mind when reading the following
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
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
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:
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.
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
and/or lat-pull downs
at a gym can also
provide a good workout for your back.
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.
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.
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
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
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.
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.
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
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.
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.
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
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.
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.
regularly, instead of holding your breath during the exercises. Exhale
with effort or exhale as you lift the weights.
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).
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.
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
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
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
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.
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.
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
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.
Focus on maintaining good posture while exercising. This
will help improve your posture and the strength of your back and abdominal
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.
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.
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:
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