The right amount of stress is critical for strengthening your bones and increasing bone mineral density.
If you have osteopenia or osteoporosis, you may be concerned that putting stress on your bones through exercise could lead to fractures. But with the right strategy, working out is the exact solution to help prevent those very injuries.
"Exercise causes stress on the body, which is not always a bad thing," says physical therapist Ryan Yelle, the regional clinical director at Professional Physical Therapy in New York City. "Our skeletal system needs this stress in order to help remodel and grow new bone. This keeps our bones from becoming brittle and maintains their integrity."
Through the decades, and especially in the case of adults with osteopenia and osteoporosis, where the bones become increasingly weak and porous, exercise is vital. "If [the] bone is not stimulated, the body will remove it," says physical therapist Dan Curtis, outpatient rehabilitation services supervisor at Health Central Hospital in Ocoee, Florida. "Essentially, just like many other things in the human body, it is use it or lose it."
What's more, exercising can help promote muscle strength and balance, both of which reduce the risk of falls, the leading cause of injury in older Americans, according to the National Council on Aging. "Falls can be devastating, especially for an individual with osteopenia or osteoporosis," Curtis says. "These individuals are much more susceptible to breaking a bone when falling, which can have devastating effects."
In fact, a 2014 study in the journal Acta Ortopédica Mexicana found that immediately following hip fractures, older adults have a significantly higher risk of death, largely due to sepsis. "However, the stronger your bones are, the less likely you are to suffer a fracture should you fall," Curtis says.
So how do you stress your bones just enough to boost bone density and health? Below, experts share the best exercise strategies to build bone in osteopenia or osteoporosis.
Perform weight-bearing resistance exercises. "The types of exercises proven to be the best in the treatment of osteopenia and osteoporosis are resistance exercises and weight-bearing exercises," Curtis says. In a 2016 BMC Musculoskeletal Disorders study of 150 women with osteoporosis or osteopenia, those who performed regular resistance training, prioritizing large compound movements such as lunges, increased their serum concentrations of CTX, a marker of bone resorption and formation.
Resistance exercise acts on the bone indirectly. When muscles contract and work during strength training exercise, they pull on the tendons that connect to the moving bones. "Over time, the area of bone where the tendon connects will adapt and strengthen to resist the load being placed upon it," Yelle says.
Meanwhile, weight-bearing exercise – in which you stand on your feet and your bones support your body weight – promotes bone growth more directly. The downward pressure on the bones triggers formation along the line of force, Yelle says. Examples of weight-bearing exercises include walking and running. Exercises that are both weight-bearing and resistance-based, such as squats, deadlifts and standing shoulder presses, do double duty.
Choose heavy weights. Of course, "heavy" is a relative term and should be based on your current muscle and bone strength levels. "Minimal essential strain," or the amount of force you need to apply to your bones in order to stimulate new bone formation, is generally believed to be about one-tenth of the force that would be required to fracture the bone. "Stress below this threshold will not result in the types of architectural changes that the bone needs in order to maintain its integrity over time," Yelle says.
In order to best strengthen your bones through resistance exercise, you ideally want to use loads that are 70 to 80 percent of your one-rep max, or the maximal amount of weight you can lift for a single rep with good form, says Kim Lueken, a physical therapist with the Bone Health Clinic at Northwestern Medicine Central DuPage Hospital in Winfield, Illinois. "However, you should not try to perform a one-rep max to find out what it is," she says. "The most appropriate way to find this would be to assess with an exercise. If you are fatiguing between eight and 12 reps, that is a good level to work at. Please keep in mind that for one person, 2 pounds could be the weight needed for 70 to 80 percent of their one-rep max, where someone else, it may be 15 pounds. You should always begin lighter and then reassess as you go."
Remember: Putting too much stress on bones can result in a stress fracture. "You want to challenge yourself, but not to the point where you're putting yourself at risk for injuries," says Leesa Galatz, the system chair of the Department of Orthopaedics in the Mount Sinai Health System in New York City.
Focusing on compound movements such as squats, lunges and upper-body presses, rather than isolation exercises such as biceps curls and triceps extensions, will ensure that the weight is distributed over multiple bones and joints and doesn't overly stress any one bone or part of bone. What's more, these exercises mimic acts of daily living, can help improve everyday function and have the greatest impact on muscle strength, Yelle says.
Choose the right impact for your bones. High-impact activities such as running and jumping have a bad rap when it comes to bone health, but are actually incredibly effective at stimulating bone growth in people with osteopenia and mild levels of osteoporosis, Curtis says.
For example, in a 2015 study published in the scientific journal Bone, when men with osteopenia of the hip or spine performed three jumping workouts per week over the course of 12 months, they significantly improved their bone mineral density. Each workoutincluded jumping exercises of varied intensities, direction and instability, such as squat jumps, forward hops, split squat jumps, bounding, zigzag hops, single-leg lateral hops and jumps off of a box. Each workout included no more than 100 jumps.
"For those with severe osteoporosis, however, higher impact-type activities may pose too great a risk and should be avoided," Curtis says. "It is important to remember that what is good for one individual with osteopenia or osteoporosis may not be appropriate for another. A lot depends on the severity of bone loss, comorbid [other coexisting] medical conditions and many other factors."
Avoid forward bends and twists. "With a diagnosis of osteoporosis, you want to avoid trunk flexion and rotation – bending forward and twisting," Lueken says, explaining that both movements can compress the vertebrae and can lead to spinal stress fractures. "Individuals need to train with a neutral spine and ideal trunk postures," she says.
During your workouts, keep your core braced and your spine in a straight line. When bending forward such as in a squat or deadlift, focus on hinging at the hips and sending your butt back, rather than curving your spine. Your doctor may also recommend avoiding yoga postures that involve trunk flexion (like cat pose) and rotations (like spinal twists).
Pay attention to any pain. No one – especially anyone with osteopenia or osteoporosis – should exercise through pain.
"If you have localized pain with exercise, especially if it starts hurting when you're not exercising, you should definitely have it evaluated," Galatz says. See your primary care physician or sports medicine physician to rule out any stress fractures before continuing with your workout routine.
Talk to a physical therapist. "While the effects of exercise are well established, overdoing it can result in more trouble than you might expect," Yelle says. "Working with your health care professional can help you stay within the boundaries of your individualized needs and ensure the best, healthiest outcome."
Talk to your doctor about the severity of your bone loss, ask to receive a bone mineral density scan if you haven't done so already and share the results with a physical therapist. "Physical therapists are experts in movement and can design an individualized exercise plan for someone with osteopenia or osteoporosis to exercise safely," Curtis says.
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