The Evolution Of Exercise Prescription In Bone Health

couple running

Dr. Sarah West

In September 2017, I had the pleasure of attending one of my favourite international conferences: The American Society for Bone and Mineral Research (ASMBR).  This annual meeting brings together the best researchers in the area of bone health, and the most cutting edge research results via a four day intensive conference.  There are many oral sessions, poster sessions, breakout sessions, and plenary sessions to attend- all of which share a common theme- bone health.  There is always a wide range of topics covered during the conference; bone cell research, animal model research, and human based research.  Both the breadth and depth of the topics covered during this meeting is what has always been appealing to me.

I had the privilege of presenting some of my most recent research during a poster session.  My pilot study examined how magnetic resonance imaging (MRI) could be used to measure bone quality in the leg.  MRI isn’t typically used to measure bone; it is a difficult imaging technique, but we presented a protocol that was reproducible.  This was step one in my “side program” of research working to further develop this technique. 

Exercise & Bone Health

mature man walking dogMy primary research focus, however, is not the development of bone imaging techniques.  Rather, with my background in exercise science and kinesiology my interest is to look at the working associations between exercise and bone health in multiple populations across the spectrum: from healthy older individuals, to those with chronic disease, to pediatric populations.   Therefore, as excited as I was to present my current research, I think I was even more-so enthusiastic to walk through the large poster hall to learn and take a look at the newest exercise and bone research.  To my surprise (and disappointment), out of one poster sessions (which includes approximately 400 posters!), there were only 4 or 5 posters that touched on exercise.  As researchers, we know that exercise is important for bone health, in children and in adults.  So I began to wonder why it was so underrepresented at the conference, and came up with a couple of thoughts. 

First of all, I believe that exercise is poorly understood; many people are nervous of it, and think that it can be dangerous and can lead to injury.  As much research demonstrates, this is not true.  As well, many researchers are interested in finding a quick fix drug that will improve bone health.  I don’t disagree that the role of bone building drugs in people with bone disease is necessary, but I would love to see research that focuses on the role of drugs AND exercise on bone health.  I generally feel that there was an underrepresentation of exercise and bone research- and ultimately, I would love to continue to highlight the importance of exercise in maintaining our bone health for the rest of this article.

Exercise Prescription For Bone Health

As I previously mentioned, I did have the opportunity to visit a few posters who presented research focused on exercise and bone.  I was fortunate to have a conversation with one researcher in particular, Dr. Giangregorio (who works out of the University of Waterloo, Waterloo, Ontario Canada).  She was presenting some preliminary results of her exercise intervention study targeted at improving bone health in older adults.  Although these results are not currently published, I thought I would talk about some of the articles Dr. Giangregorio been involved in helping to highlight exercise prescription for bone health in older individuals.

In November 2013, the article “Too fit to fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture” was published in Osteoporosis International (1).  This was a consensus statement effort among many prominent bone researchers to develop some succinct and useful exercise recommendations for those with osteoporosis (bone disease) or vertebral fractures (small breaks in the spine), using the evidence published to date. After extensively reviewing the published literature, the team created the following recommendations.  For older adults with osteoporosis, it is recommended that they engage in a multicomponent exercise program that includes resistance training and balance training, and that they do not engage in aerobic (cardiovascular exercise) to the exclusion of resistance or balance training (1). 

Related Article: New Exercise Recommendations For Osteoporosis

What does this mean?

Well, the research team suggests that those should engage in aerobic training (exercise that gets your heart rate up) such as brisk walking, swimming, cycling etc., but that this type of physical activity should be done in combination with resistance training and balance training.  Resistance training can include exercise to strengthen big muscle groups using someone’s own body weight (ex. heel lifts), theraband, or light weights, while daily balance training can simply include standing on one leg, standing on toes, standing on heels, walking on toes etc.  The conclusion of this study is that exercise is important, but that the type of exercise needs to be varied and include exercise to strengthen your heart and lungs, as well as muscles and balance.   It should also be noted that the authors suggest that for people who have had spine fractures, that they consult with a physical therapist or exercise specialist before engaging in an exercise program.  But that when they are approved, they should also engage in a multicomponent exercise program (1).

Related Article: The Top 3 Tips To Improve Your Balance

This article really was one of the first to provide comprehensive, evidence based exercise recommendations for bone health in older individuals.  That said, there still is a lack of randomized controlled trail data looking at the effect of exercise on bone.  Randomized controlled trials are the gold standard of research- they tell us if a particular intervention leads to expected results.  They are well controlled, and consider eliminating other contributing factors as much as possible. 

Can Exercise Reduce Broken Bones?

A research protocol paper was published in September 2014 (lead author Dr. Giangregorio) (2), detailing a protocol to examine whether exercise can reduce broken bones compared to no exercise, in women 65 years and older.  Their pilot study is looking at the feasibility (is the protocol doable), if people stay in the study, and if people actually participate in the exercise intervention.  They are working across 5 Canadian sites, and are looking to recruit 160 women, with the exercise group participating in a supported (by researchers and physical therapist) exercise program 3 times per week, for one year (2).  This is a much needed study, and I eagerly await the results.  Once the results are published, I will be sure to update Forever Fit Science with a summary of their findings!

The most recent article that I would like to discuss, was published just this year (2017) (3), and looked at an important piece of the puzzle- knowledge translation of exercise guidelines for bone health in older individuals.  This is a very important component; we as researchers can conduct the research, and publish our findings in research journals.  We can even attend conferences like ASBMR and present our findings.  But we are often speaking to other researchers with similar interests; what we need, is to be able to get our results out to a larger audience of the general public and health professionals working in the community.  This will then result in true knowledge dissemination, and potentially the uptake of recommendations by those who need it.

This recent study did a behavioral analysis of physician (doctor) barriers to implementing exercise guidelines (3).  Specifically, they used knowledge of the Too Fit to Fracture Guidelines (the ones we discussed earlier, reference 1) in their study.   The conducted focus groups, and interviews with doctors and nurse practitioners (a total of 59 people) in Ontario, Canada.  They identified many barriers to exercise prescription, including lack of exercise knowledge or where to refer, lack of fitting into the health practitioners’ existing workflow, a lack of incentive to prescribe exercise, out of the scope of their practice, and a lack of communication of guidelines (just to name a few) (3). Overall, there were many barriers that were identified that would stop health care practitioners from prescribing exercise to their patients who may need it, such as those who could use it to maintain bone health. So the area of exercise research with respect to bone health really needs to address how we can translate the knowledge to those who will implement it (3). 

Related Article: 15 Minutes Of Soccer Can Improve Bone Health


The good news is that we have resources and forums such as Forever Fit Science to spread awareness of research.  For example, if you read this article and take the information about bone and exercise to your doctor, they can look into it more and help you with an exercise prescription.  You can also tell your friends and family about the research presented on Forever Fit Science, and they too can talk to their doctors.  By this reading, word of mouth and education, we can all take the research into our own hands and help to implement it with our health practitioners in order to lead healthier lives.   The area of bone and exercise is an important field that I have dedicated my career to; and I will continue to pursue research in this area, because as outlined, we are still in need of good quality research studies.

The take home message from today’s article for those looking to what they can do for their bones: a multi-component exercise program is important for maintaining bone health- focus on aerobic, resistance, and balance training.  But be sure to always consult with a medical professional before beginning a new exercise program, just to be safe!

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1. Giangregorio LM, Papaioannou A, MacIntyre NJ, Ashe MC, Heinonen A, Shipp K, Wark J, McGill S, Keller H, Jain R, Laprade J, Cheung AM. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International, 2013; 25:821-835.

2. Giangregorio LM, Thabane L, Adachi JD, Ashe MC, Bleakney RR, Braun EA, Cheung AM, Fraser L, Gibbs JC, Hill KD, Hodsman AB, Kendler DL, Mittmann N, Prasad S, Scherer SC, Wark JD, Papaioannou A. Build Better Bones With Exercise: Protocol for a Feasibility Study of a Multicenter Randomized Controlled Trial of 12 Months of Home Exercise in Women With a Vertebral Fracture. Protocols, Physical Therapy, 2014; 94(9)

3.  Clark RE, McArthur C, Papaioannou A, Cheung AM, Laprade J, Lee L, Jain R, Giangregorio LM. I do not have time. Is there a handout I can use?: combining

physicians’ needs and behavior change theory to put physical activity evidence into practice. Osteoporosis International, 2017; 28(1953-63).

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