We are BoneFit™ Certified! (Exercise for Osteoporosis)

What is BoneFit™ you might ask?

“BoneFit™ is an evidence-informed exercise training workshop, designed for healthcare professionals and exercise specialists. It provides instruction on the most appropriate, safe and effective methods to prescribe and progress exercise for individuals with low bone density and minimize their risk of falls and fractures.”

The Bone Health and Osteoporosis Foundation (BHOF) held their annual Interdisciplinary Symposium on Osteoporosis last week in downtown D.C. Caroline was lucky enough to attend AND to become certified as a BoneFit professional. This means that in addition to being a scoliosis and kyphosis-specific therapist, she is now also an osteoporosis-specific physical therapist.

About time!

Why? The overlap of osteoporosis and scoliosis is profound: most of our older adult scoliosis and kyphosis patients have either osteoporosis, or its precursor, osteopenia.

We’ve written a whole other blog devoted to the link between bone health and scoliosis that you can check out here

Today is about diving into the latest research and recommendations for bone health that were presented at the conference.

I think we often think of osteopenia and osteoporosis as something that happens to the very old or to the very frail. In the mind of a young adult, or even an adult in their 50’s and 60’s, there’s not much thought or worry about bone health. Why is this a problem?

For women, menopause, which happens most typically between ages 45-55, causes a hormonal plummet, gravely effecting bone density. This process is silent. And when I think about an average 45-55 year old woman, I don’t envision someone who is frail or falling over. Worse, most physicians won’t recommend or order a DEXA Scan, the test used to measure bone density, until age 65. SIXTY-FIVE?!

It's not uncommon for a woman to be silently losing bone density starting as early as age 45, and have no idea she has osteopenia or osteoporosis until she falls and breaks her hip later in life. 

Men also experience a hormonal decline with age, but it occurs more gradually. By age 65 men will have experienced enough hormonal drop to cause bone loss. Physicians begin ordering DEXA Scans for their male patients at age 70, FYI.

Let’s look at a real life example: one of our lovely clients, a 54-year-old post-menopausal woman with scoliosis, asked her primary care physician for a referral for a DEXA Scan based on the fact that the client’s mother has osteoporosis. The physician told her she was way too young for a DEXA Scan and dismissed her request. The client was persistent and asked her endocrinologist to refer her, who thankfully obliged. In 2022, the client’s T-score was -1, just borderline osteopenic. In 2024, her T-Score was -2.2, very close to the cutoff for osteoporosis (-2.5 and below qualifies as osteoporotic). This is a rapid decline in bone mass, and remember she’s only 54. Although jarring news to receive in your 50’s, there’s a giant silver lining to this story. She doesn’t have to wait until she falls and fractures her hip to do something about her low bone mass. She’s super fit and healthy at this stage in her life. She can do so much exercise-wise that an older frail adult would not be able to do. 

In order to understand the best exercise regimen for osteoporosis, we need to consider the #1 goal of physical therapy for this condition, which is to PREVENT FRACTURES in the first place. We do this via physical therapy intervention aimed to: 

  • Prevent Falls via Balance Training/Exercise

  • Improve Posture via Postural Exercises to strengthen the spinal extensors and stretch muscles restricting optimal postural alignment

  • Teach patients how to use proper body mechanics when doing activities of daily living (vacuuming, raking leaves, shoveling snow, unloading the dishwasher, etc.)

  • Prevent further bone loss via strength training exercises, and high intensity and high impact exercises when appropriate*

  • Aerobic Physical Activity

*Preventing further bone loss in adults via exercise is hotly debated. There is some research stating this can be done (see LIFTMOR Trial), but not much.

Let’s explore each recommended exercise above and elaborate. 

Balance training

The BHOF recommends doing balance exercises daily for those with low bone mass. These can be as simple as pretending to stand on a balance beam with one foot in front of the other, standing on one foot while you’re brushing your teeth, walking on your toes or heels, or more formal like participating in a Tai Chi or dance class. Those with low bone mass are at risk of fracturing a bone from a fall from standing height, so having good balance to prevent a fall is imperative.

Improving Posture

Here’s the shameless plug for Schroth Physical Therapy: Schroth is 100% postural correction exercises. Of course there are many other ways to strengthen the spinal extensors and stretch the pectorals, hip flexors, etc: yoga, Pilates, Feldenkrais. We encourage any and all means of postural improvement methodologies that align with BHOF’s principles. BHOF recommends daily postural exercises in order to ward off the dreaded hunching posture. Other than it unsightliness, hunching increases pressure on the anterior surface of the vertebra, a leading location of osteoporotic fractures. Hunching our backs also impacts our balance in a negative way, as it changes our center of mass and pulls us more forward toward the ground.

Body Mechanics

Bring to mind 5 activities that you do on a daily basis. My 5 are: picking up my 20 pound baby from the ground multiple times, doing (a ton) of dishes, brushing my teeth, reaching down to pick up yoga blocks from the floor when working with patients, and documenting a visit note for each patient I work with on my laptop. Talk about fertile ground for hunching (or rounding) my back. Because I’m a physical therapist, I’ve known how to use proper body mechanics since PT school. But I would argue that the average person does not know how to keep their spine straight and bend at the hips while doing activities of daily living. Each time I pick up baby boy from the ground, I’m essentially going into a deep squat with my back straight and using my legs to lift him and me back upright. When brushing my teeth, I’m sticking my butt out behind me, keeping my back straight, and hinging at my hip joint. This takes practice but can totally be implemented into your daily life. Your spine will be so much happier, and you’ll get some toned legs and glutes as a bonus.

Why do body mechanics matter?

Because so much of our lives encourage a flexed/rounded position of the spine, we’re all at risk of becoming hunched over. Osteoporotic vertebral compression fractures cause increased kyphosis, or hunching, and hunching can cause osteoporotic vertebral compression fractures. Chicken or egg? BUT think of our 54 year old described above: at 54, her spine is still beautifully erect, so she has the ability to continue to train her muscles to keep her that way, likely avoiding a future vertebral compression fracture. 

Strength Training, High Intensity, and High Impact Exercises

The BHOF recommends strength training exercises 2 times per week, 8-12 repetitions per exercise for legs, arms, chest, shoulders and back using body weight, bands or weights. Again, we don’t have a boatload of evidence that we can reverse bone loss in adults. Strength training aims to maintain the bone mass we have in adulthood (before the age of 30 we can actually add or build more bone mass via strength training, so if you’re reading this and you’re under 30, get strengthening and put some bone mass in your bank!)

Every person diagnosed with low bone mass can and should do strength training appropriate for them, but not every one of those people can and should do high intensity or high impact exercise. This becomes a judgement call for your physical therapist. If you are already at risk of falls, which can easily be assessed by any PT, you will likely not receive high intensity or high impact exercise, at least to begin with. Historically, the medical field discourage these types of vigorous exercises because of the risk of falling while performing them and being at risk of fracture. But because younger, fit folks are getting diagnosed with low bone mass, many are capable of doing them and should be doing them, always under the supervision of a PT, at least to begin with. 

Examples of high impact exercise include jogging, hopping, skipping, jumping rope, jumping down from a box – again, always under the supervision of a medical professional and only if you’re a candidate for these.

Aerobic Activity

The BHOF recommends at least 150 minutes per week (this works out to about 21 and a half minutes per day) of moderate to vigorous intensity physical aerobic activity. Some examples are brisk walking, aerobics classes (including water), and sports such as soccer, basketball, ultimate frisbee, and ice hockey. The BHOF says “your heart should be beating faster, you should be breathing harder, and that you may be able to talk while doing it but not sing”. 

Recap: cardio everyday, balance exercises everyday, postural exercises everyday, use good body mechanics in your everyday life, and strength train 2x/week.

As a woman, as an almost 39 year old, and as a therapist, this recent bone health training hit close to home for me. I’m a walker and a yogi; I joke that I don’t have any fast-twitch muscle fibers, only slow ones. I don’t enjoy jogging – the panting, the sweating, the bouncing body parts – just not my jam. I’ve always argued with Eric about the superiority of body weight strength training (yoga) versus weight training (dumbbells, barbells) – looks like I’ve officially lost that argument in the realm of bone health.

How is this information changing my life?

This week, I’ve added short spurts of jogging and sprinting into my daily walks. I will likely never be “a runner”, but I’m marveling at how easy it is to add 50-100 steps of jogging into my walks. I told myself I only need to do 1 round of 50 jogging steps (50 impacts per day is the recommendation for impact), and I willing did 4 rounds today. And although I haven’t executed this yet, I’m envisioning myself out in our driveway with Eric, barbell on shoulders, joining him for back squats(!!). And jumping down off of his 2 foot high box, repetitively. And jumping rope. I’m telling myself what I’d tell patients: it’s good for all of us to get outside our comfort zones. Varied physical activity is highly recommended by the BHOF.

In the words of Teddy Roosevelt, do what you can, with what you have, where you are. Time to dust off the old jump rope. Time to take your posture seriously. Time to ask your primary care doc for a referral for a DEXA Scan. Time to schedule that physical therapy assessment. Your bones and your future self with thank you.

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