Review
Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis

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Abstract

Objectives

Osteoporotic fractures are associated with substantial morbidity and mortality. Although exercise has long been recommended for the prevention and management of osteoporosis, existing guidelines are often non-specific and do not account for individual differences in bone health, fracture risk and functional capacity. The aim of the current position statement is to provide health practitioners with specific, evidence-based guidelines for safe and effective exercise prescription for the prevention or management of osteoporosis, accommodating a range of potential comorbidities.

Design

Position statement.

Methods

Interpretation and application of research reports describing the effects of exercise interventions for the prevention and management of low bone mass, osteoporosis and osteoporotic fracture.

Results

Evidence from animal and human trials indicates that bone responds positively to impact activities and high intensity progressive resistance training. Furthermore, the optimisation of muscle strength, balance and mobility minimises the risk of falls (and thereby fracture), which is particularly relevant for individuals with limited functional capacity and/or a very high risk of osteoporotic fracture. It is important that all exercise programs be accompanied by sufficient calcium and vitamin D, and address issues of comorbidity and safety. For example, loaded spine flexion is not recommended, and impact activities may require modification in the presence of osteoarthritis or frailty.

Conclusions

Specific guidelines for safe and effective exercise for bone health are presented. Individual exercise prescription must take into account existing bone health status, co-morbidities, and functional or clinical risk factors for falls and fracture.

Section snippets

Background

What is osteoporosis? The widely accepted definition of osteoporosis, developed by a US National Institutes of Health Consensus Panel in 2000, is “a skeletal disorder characterised by compromised bone strength predisposing a person to an increased risk of fracture”.1 The operational definition of osteoporosis of the World Health Organization (WHO),2 and one that continues to be widely applied due to its diagnostic utility, is based on an estimation of bone mineral density (BMD, g/cm2) measured

Role of exercise in the prevention and treatment of low bone mass

Regular physical activity provides a multitude of health benefits, but not all exercise modalities are equally osteogenic. The dogma that prolonged aerobic training, such as swimming, cycling, and walking, is ubiquitously beneficial to all body systems is inconsistent with empirical evidence suggesting none of those activities provide a notable stimulus to bone.7, 8, 9 Evidence from cohort studies that higher levels of self-reported physical activity are related to higher bone mass is often

Exercise prescription – boundaries of the evidence

The application of osteogenic exercise principles from the results of animal studies to the human condition has not been a trivial matter. Human data are confounded by an inability to control many variables that exert profound influence on bone; including genes, certain diseases, medications, diet and exercise history. To the best of our knowledge, none of the many human trials have managed to fully control those constraints. As a result, precise recommendations for the optimal modality, dose,

Exercise prescription – recommendations (summarised in Table 1)

An exercise program of moderate to high-impact weight-bearing activities, high intensity PRT and balance training forms the basis of the current recommendations. While frail individuals would theoretically benefit from a similar program of osteogenic exercise, limitations in clinical or functional capacity may necessitate a more conservative approach, with a particular focus on optimising muscle function and enhancing balance to reduce the risk of falling.13, 53

Thus, an exercise prescription

Special considerations

Individuals with the lowest bone mass and/or the lowest levels of previous exercise exposure are likely to exhibit the greatest response to increased exercise loading.71 Those with average or above average bone health are unlikely to experience notable increases in bone mass in response to exercise, unless the nature of the loading differs substantially from and/or imposes considerably higher levels of bone strain than habitual patterns. However, increasing muscle strength and balance will

Contraindications to exercise

As with any exercise recommendation, certain caveats apply. Individuals with known vertebral osteoporosis/kyphosis should avoid deep forward flexion activities, particularly when lifting a load or carrying an object (e.g. rowing, lifting weights with a flexed spine, yoga, Pilates, bowling, sit-ups, house and yard work), in order to avoid vertebral wedge fractures. Similarly, high-impact activities and exercises that require rapid and/or loaded twisting, and explosive or abrupt actions (e.g.,

Gaps in the literature

There are two main gaps in the literature. The first is that there has never been a study conducted with sufficient statistical power and duration to adequately examine dose responses to exercise at all stages of life and levels of risk of low trauma fracture. Consequently, it is not possible to provide definitive guidelines for the precise amount, intensity and duration of every exercise that will stimulate optimal gains in bone for every individual. The second is that although it is clear

Summary

Exercise is a vital strategy in the prevention and management of osteoporosis, if appropriately prescribed. For the healthy individual whose goal is to prevent osteoporosis, lifelong exercise including regular, brief, weight-bearing, high-impact exercise and high intensity PRT is recommended. Although the optimal dose of exercise for bone health and fracture prevention is yet to be fully determined from human trials, a minimum of two sessions of PRT, four to seven sessions of impact activities,

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