What to Know About Osteoporosis
Inside bones
Osteoporosis is a very common condition- an estimated 54 million Americans have low bone density, which puts them at an increased risk of osteoporosis. So you will likely encounter clients with osteoporosis.1

It’s important for those with osteoporosis to exercise, which means it’s even more important for trainers and fitness professionals to know how to do so effectively and safely.

To help with this, I created the acronym BONES to help you remember what to do and what to avoid when working with clients who have osteoporosis.


Be Aware

First and foremost, it’s important to know what osteoporosis is and what it isn’t.

Osteoporosis is a bone disease caused by decreased bone density or bone mineral density (BMD). The decrease in BMD leads to weakness in the bones, which increases the risk of fractures.

Osteoporotic fractures are commonly seen in the vertebrae. On an Xray, the fractured vertebrae commonly look wedge-shaped, as the front (anterior) portion of the vertebrae tends to be weaker than the back (posterior) portion. These wedge-shaped fractures cause a decrease in height and often contribute to the more “hunched” posture or kyphosis that is sometimes seen in those with osteoporosis.2

Osteopenia is sometimes confused with osteoporosis- both are a decrease in BMD, but osteoporosis is the more severe or significant loss. As mentioned above, having osteopenia increases one’s risk of being diagnosed with osteoporosis. Both are diagnosed using bone scans.

Osteoporosis and osteoarthritis are also not synonymous. Osteoarthritis is caused by inflammation and breakdown of tissue in the joint, which causes symptoms like pain and swelling.1

Osteoporosis is often asymptomatic until a fracture occurs. While fractures can be very painful and debilitating, one can’t know whether someone has osteoporosis without a bone scan and diagnosis.1

Lastly, Be Aware means knowing which of your clients has osteoporosis, so make sure you ask everyone! You won’t know just by looking at them.

Older age is a risk factor
Bone density is a marker of how much bone is being made versus how much bone is being broken down. “Broken down” or resorption isn’t the same as fracture or bones breaking. Basically, to grow and get stronger, old bone gets removed and new bone gets laid down.

From early childhood until about age 25, the rate of bone growth is greater than that of bone resorption. From age 25-50, bone density stays about the same (growth and resorption are about equal) and then from 50 on, the resorption rate becomes greater than that of growth.3

What this means is that we all lose bone density with age, however, age is just a risk factor. Osteoporosis is NOT a normal part of aging.
Women who are post-menopause are at a higher risk for developing osteoporosis as well.

No Flexion
As previously mentioned, osteoporotic fractures most commonly occur in the vertebrae, particularly in the anterior portion due to increased weakness.

When we perform flexion (forward folds, roll downs, sit ups, bending over to get groceries out of the trunk, etc.) we are putting increased pressure on the anterior portion of the vertebrae, which increases the risk of fracture.

While avoiding flexion is helpful, what’s even more beneficial is training and teaching clients proper body mechanics for strength training and functional activities.

Use flat back, rather than rounded back for any activity that normal involves flexion of the spine (roll downs, deadlifts, forward folds).

Utilize planks, bird dogs, or activities in neutral spine for strengthening abdominals, rather than traditional crunches or sit ups.

Use neutral spine, rather than imprinted spine during supine activities.

Teach clients how to pick up items from the floor or any lower surface using deadlift stance or squat stance, with emphasis on keeping the spine neutral or in more extension.

Remember that lateral flexion is also a form of flexion. Also, if rotation is being trained, ensure that you’re cueing rotation with “get taller as you rotate”, rather than rotation plus flexion.

It’s best to use neutral and extension of the spine for exercises and activities and teach clients to utilize these positions in daily life as well.

We know that our clients need to move in all kinds of directions throughout the day, so it’s not that they’ll never rotate, but think about the purpose of your exercise- is it necessary to load them in rotation or can you achieve the same goal in a safer position for this client’s body?

Educate Your Clients
I’m always surprised by the number of clients who have never been told flexion can increase risk of fracture.

Having a diagnosis doesn’t mean a healthcare provider has properly educated you about it.

Remember to know your scope of practice, but also ensure you tell your clients why you would like them to avoid flexion and replace it with a safer posture.

Also, if clients ask, it’s important to know that osteoporosis is not reversible, as in the loss of bone is not going to regenerate completely, however exercising in weightbearing positions is critical to maintaining current bone density and preventing further decline. Getting stronger and understanding safer body mechanics will help prevent fracture as well.

Strength Train
It’s crucial to do strength training with individuals with osteoporosis.

When our muscles pull on our bones, they stimulate the cells that work to build and maintain bone density, which help combat the cells that work to break down bone.

Although their bones are thinner than your clients who don’t have osteoporosis, they don’t have to be babied- they need strength training, just strength training done in a safe way!

Weightbearing activity and resistance training are crucial. Things like biking and swimming, while great cardio are not helping your clients with building/maintaining bone density, so ensure you’re focusing on exercises to stimulate bone and muscle development.

Stomping, jogging, and jumping can also be great ways to build muscle and promote bone density, particularly in those with osteopenia who we want to help avoid getting to an osteoporotic state. Be sure to check with your client’s primary care provider and/or physical therapist before starting these kinds of higher intensity programs to ensure their safety!



By Dr. Katie Landier, PT, DPT
Board Certified Specialist in Geriatric Physical Therapy