Guidelines for the management of osteoporosis often include recommendations related to exercise or physical therapy interventions . Historically, the emphasis has primarily been on “weight-bearing” exercise because the impact was thought to be osteogenic ; osteoporosis was previously diagnosed based on low-bone mineral density (BMD), and animal and human research suggested that mechanical loading of high magnitude or strain rate was osteogenic . However, exercise recommendations that have emerged more recently move beyond targeting BMD as the primary therapeutic goal . Indeed, exercise or physical therapy interventions can address not only bone strength but also applied loads, where applied loads can come in the form of a fall, externally applied loads, body mechanics, or muscle forces . Moreover, exercise in general, and other physical therapy interventions can be used to address therapeutic goals that may be important to people with osteoporosis or osteoporotic fractures, such as posture, pain, fear of movement, body mechanics during activities of leisure and daily living, and sarcopenia and related changes in physical function and mobility. This book chapter will (1) briefly review research related to the effects of exercise on fractures, falls and fall-related injuries, sarcopenia, BMD, posture, fear and safety; (2) summarize exercise recommendations for individuals with osteoporosis; and (3) review assessment and other physical therapy interventions for people with osteoporosis (e.g., posture exercises, bracing, modalities, and manual therapy). We will also note considerations for people with hip or vertebral fractures due to osteoporosis.
69.1
Exercise for the prevention of falls, fall-related injuries, and fractures
There are an abundance of metaanalyses examining the effects of exercise on outcomes related to falls (e.g., number of falls, risk of being a faller, multiple falls, or fall-related injuries). A consistent finding is that exercise can reduce the risk of falls, of injurious falls, and that of being a faller . Moreover, when all studies of fall prevention interventions were examined in a network metaanalysis, there was one single and three multicomponent interventions that, when compared to usual care, were associated with a reduced risk of injurious falls . Not only was exercise the only effective single intervention [odds ratio (OR), 0.51 (95% CI, 0.33–0.79); absolute risk difference (ARD), −0.67 (95% CI, −1.10 to −0.24)], but of the remaining three effective multicomponent interventions, exercise was a component of two of them, as follows: exercise plus vision assessment and treatment [OR, 0.17 (95% CI, 0.07–0.38); ARD, −1.79 (95% CI, −2.63 to −0.96)]; exercise, vision assessment and treatment, and environmental assessment and modification [OR, 0.30 (95% CI, 0.13–0.70); ARD, −1.19 (95% CI, −2.04 to −0.35)]; and a combination of clinic-level quality improvement strategies, multifactorial assessment and treatment, calcium supplementation, and vitamin D supplementation [OR, 0.12 (95% CI, 0.03–0.55); ARD, −2.08 (95% CI, −3.56 to −0.60)] .
Translation of the evidence to practice requires insight on the types of exercise interventions that have been effective in randomized trials. The most recent Cochrane review examining exercise interventions for preventing falls reveals that intervention-related characteristics influence the point estimates describing the effects of exercise on falls . For example, interventions that include functional strength and balance exercises alone, or combined with resistance exercises reduce the rate of falls and the risk of being a person who falls . Tai chi may reduce the rate and risk of falls . However, the effects of walking, dance or resistance exercise alone on fall rate or fall risk are not certain . Therefore there is strong and consistent evidence that exercise programs (especially those that include challenging functional strength and balance exercises) reduce the risk of falls and fall-related injuries . Given that nonvertebral fractures most often occur as a result of a fall, we have a compelling argument for encouraging functional strength and balance training in people with osteoporosis on the basis of the fall prevention literature alone.
What do we know about the effect of exercise on the risk of osteoporotic fractures? The studies that examine the effects of exercise on falls or fall-related injuries often target individuals at risk of falls, and not individuals with osteoporosis per se . However, emerging evidence from metaanalyses examining exercise and fall outcomes also suggests that exercise may prevent fractures in older adults, although there are fewer studies that report fracture outcomes as compared to falls. A metaanalysis of 10 studies ( n =4047) reported that exercise may reduce the number of people experiencing one or more fall-related fractures [risk ratio (RR) 0.73, 95% CI 0.56–0.95] but the evidence was judged to be of low certainty . A similar finding was reported in a prior metaanalysis regarding fall prevention exercise programs . The LIFTMOR trial challenged the notion that individuals with low bone mass should avoid lifting anything heavy and tested whether high-intensity resistance and impact training were effective in women with established low bone mass (average age was 65 years). In an analysis of 51 women (representing half of those randomized in the trial, or n =101), they reported one new grade one fracture in the control group, and three fractures apparent at baseline progressed in severity, with no new fractures or progression in the control group . Data on vertebral fractures was only available for half the sample, and the sample size was small which limits our ability to make conclusive statements on safety, but the data are promising for those who have low bone mass but are otherwise healthy . Among individuals with osteoporotic vertebral fractures, there have only been nine randomized controlled trials of exercise to date—only two have reported falls and two have reported fractures as secondary outcomes, none had the statistical power to detect between group differences, and none were observed . Therefore to date there is strong evidence that exercise can prevent falls and fall-related injuries and may prevent fractures in older adults. While the antifracture efficacy of exercise is less clear in people with established osteoporosis, it is likely that the benefits, particularly for fall prevention, outweigh the risks. Refer to the section on Fear and Safety Concerns for a review of physical activity and adverse events.
69.2
Effect of exercise on bone mineral density
When targeting BMD as an outcome, exercise interventions should be informed by theory and research that supports our understanding of the skeletal response of bone to mechanical loading. Animal studies have shown that mechanical loading can increase bone mass. A study of tennis players revealed that the humerus of their dominant arm had adapted such that bone size, but not BMD was greater than in the nondominant arm . Animal research suggests that the following mechanical loading characteristics are osteogenic:
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high magnitude loads applied rapidly
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intermittent dynamic loads (as compared to static activities)
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novel or diverse loading patterns
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short loading bouts or a limited number of loading cycles with rest periods (as compared to continuous loading) .
When translated to clinical trials in older adults or postmenopausal women, the effects of exercise on bone strength outcomes are modest but consistently point to the potential for benefit. A 2011 metaanalyses of the effects of exercise on areal BMD (aBMD) in postmenopausal women reported a between-group difference in favor of the effects of exercise on BMD at the lumbar spine, but no significant differences at the total hip or femoral neck. However, there was heterogeneity in the effect when studies were separated by exercise mode . Following are the examples:
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Low impact exercise, such as walking or Tai Chi had modest effects on spine BMD, but not hip or femoral neck BMD;
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Dynamic, high force exercise (e.g., running and jumping) resulted in significant between-group differences in favor of exercise for hip and trochanter BMD, but no effects on spine BMD.
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Multicomponent exercise programs (e.g., combined aerobic physical activity and resistance exercise, or combined high impact and resistance exercise) had a significant effect on BMD at the spine, trochanter, and neck of femur.
Similarly, a systematic review and metaanalysis reported that exercise in postmenopausal women may have modest effects on tibial volumetric bone mineral density (vBMD) (distal tibia) and cortical vBMD (tibial shaft) . Far fewer studies have been conducted in men, but, in general, the findings suggest a modest effect of impact exercise on aBMD of the femoral neck but not the spine, and that progressive resistance training (PRT) alone or in combination with impact exercise may confer the most benefit . The modest nature of the effects may indicate that more targeted or intense interventions that align with osteogenic mechanical loading characteristics are needed. Mechanical loading on bone is hypothesized to come from ground reaction forces or muscle pull on bone. Accordingly, progressive impact loading may achieve the former, and PRT may achieve the latter, so combined interventions may achieve both. A metaanalysis of 24 studies (1769 postmenopausal women) reported that PRT combined with high-impact or weight-bearing exercise significantly increased BMD at the femoral neck [standardized mean difference (SMD)=0.411, 95% CI (0.176, 0.645), P =.001] and lumbar spine [SMD=0.431, 95% CI (0.159, 0.702), P =.002] . One might also consider the speed of movement during exercise. High-velocity PRT is designed to train muscular power rather than strength; a randomized controlled trial of high velocity PRT with diverse and moderate loading weight-bearing exercises and balance training reported statistically significant gains in BMD at the femoral neck and lumbar spine (1.0%–1.1%, P <.05) in older men and women without osteoporosis or fracture history .
More studies are emerging that examine the effects of exercise on BMD in people with established osteoporosis. A small trial of impact, strength, and balance exercises in women with osteopenia (not using osteoporosis medication) reported a modest between-group difference in total hip BMD in favor of exercise . The authors of the LIFTMOR trial reported that 8 months of high intensity PRT combined with progressive impact exercise resulted in significant between-group differences in change scores for lumbar spine (+2.9% ± 2.8% for exercise group vs −1.2 %± 2.8% for control, P <.001) and femoral neck BMD (+0.3% ± 2.6% vs −1.9% ± 2.6%, P =.004) . An important distinction of the LIFTMOR trial is that it included both progressive impact exercise and progressive resistance exercise, both at relatively high intensity. Only two studies in individuals with osteoporotic vertebral fractures have examined if exercise can increase BMD. Intermittently supervised home-based exercises, such as stretching, strength training with resistance bands or body weight, and aerobic physical activity, in individuals with vertebral fracture had no statistically significant effect on BMD . One study compared three treatment regimens after percutaneous kyphoplasty (i.e., control=calcium and vitamin D, treatment=calcium and vitamin D and calcitonin, or comprehensive treatment=calcium, vitamin D calcitonin and back extensor strengthening daily) and reported a significant between-group difference in favor of the comprehensive treatment for lumbar BMD (mean between-group difference in change scores vs control 0.038 g/cm 2 , P =.005) .
To relate evidence to clinical practice the effects of exercise on BMD in older adults may be site- and exercise mode-specific, and multicomponent programs that combine impact exercise with sufficiently dosed moderate or high intensity resistance exercise and are progressive in nature (e.g., progressively increase the challenge) are likely to be most effective. While home exercise may be perceived as more practical, it may be necessary to seek skilled instruction and supervision (at least initially) to maximize the benefit and ensure safe coaching and progression.
69.3
Exercise, sarcopenia, and physical function
Having sufficient muscle strength and power enables you to get out of a chair, reduces impact on joints, and can help prevent falls, fractures, functional impairment, and disability. However, up to 30% of older adults experience age-related loss of muscle mass and strength, or sarcopenia . Sarcopenia contributes to frailty and health instability; indeed, the phenotype definition of frailty includes weakness, slowed gait, unintended weight loss, and low physical activity . Exercise that includes PRT is arguably the most potent intervention to improve muscle size and strength, and the emerging research suggests that it can improve physical function and prevent functional decline in older adults. For example, there are several lines of evidence demonstrating that PRT can increase muscle strength and hypertrophy in older adults, including a Cochrane metaanalysis (73 trials, n =3059, SMD in muscle strength 0.84, 95% CI 0.67–1.00) . Another metaanalysis (25 trials) reported that PRT improved muscle strength (13%–90%) in healthy older adults, but there was heterogeneity in the estimates of effect and many studies had poor methodological quality . Resistance training interventions that are of moderate-to-high intensity (70%–90% 1 RM, or repetition maximum) may be most effective for improving muscle strength. However, the exercise prescription depends on the therapeutic goal—is it force-generating capacity, or speed of movement? Muscular power, or the rate of force development, has been shown to improve with PRT. High-velocity PRT may elicit greater gains in muscular power than traditional PRT. High-velocity PRT is performed at a lower intensity (e.g., 20%–50% of 1RM) than traditional PRT, but participants perform the concentric phase of the movement rapidly. The efficacy of PRT extends to frailty and disability prevention. A scoping review of studies of interventions to prevent frailty reported that exercise had a significant effect on frailty markers or frailty prevalence . Similarly, a large trial of a multicomponent group-based intervention that included resistance exercise demonstrated that in older adults, exercise reduced incident mobility disability after 2.6 years of follow-up . Therefore given the potential of PRT to prevent muscle loss and functional decline with aging, combined with the potential for enhanced muscle pull on bone, appropriately dosed and progressed resistance training should be recommended for all individuals with osteoporosis.
69.4
Exercise, fear of movement, and safety concerns
A diagnosis of osteoporosis, especially when there is a history of fracture, can result in fear and avoidance of exercise and physical activities of leisure and daily living. Activity avoidance can perpetuate a cycle of impairment, where fear and activity avoidance lead to changes in physical capacity, bone and muscle loss, further increasing fracture risk and potential for disability and exacerbation of fear. Fear can be exacerbated by well-meaning health-care professionals whose physical activity advice emphasizes activity avoidance, for example, do not twist, do not flex your spine, do not do any bending or lifting more than 10 lbs. Indeed, health-care professionals report that a barrier to counseling people with osteoporosis on exercise is that they are fearful of recommending an exercise program that would increase fracture risk . Is this fear warranted?
It is possible that physical activities of leisure or daily living, or exercise might increase the risk of fractures or falls, particularly in those at high risk. Even walking can increase fracture risk, especially in icy weather . A published case series documents potential vertebral fractures that may be related to participation in yoga . A comprehensive systematic review of adverse events associated with physical activity in individuals with low bone mass described other case reports of vertebral fractures during golf (three cases) and riding horseback (two cases, horse was walking not jumping) . One trial of exercise in women with osteoporotic vertebral fractures reported four fractures as adverse events during exercise or during assessments . Notably, the two fractures occurring during exercise occurred during transitions, that is, fractured metatarsal because of weight dropped on foot, and fractured costal cartilage while rolling supine to prone. Therefore in high risk individuals it is critical to coach safe movement strategies both during exercise and during transitions.
Musculoskeletal complaints are sometimes reported as adverse events in exercise trials . However, evidence from metaanalyses suggest that overall, the benefits of exercise outweigh the risks, and reports of fractures due to exercise thus far have been infrequent . A recent metaanalysis suggest that exercise does not increase the risk of hospitalization or premature death . In fact, sensitivity analyses reveal that in clinical populations (e.g., cardiac disease, cognitive impairment), exercise participation of 1 year or more reduced mortality risk. The evidence in support of the benefits of exercise outweighs the potential risks, and the fear and risk can be minimized by (1) tailoring physical activity advice to a person’s risk of fracture; (2) using language that promotes physical activity and reduce fear; and (3) engaging supportive resources or exercise professionals to support safe participation.
69.5
Tailoring physical activity
Factors that might influence tailoring physical activity recommendations include
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a person’s history of participating in the activity in question;
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current health, body mechanics, and physical ability to do the activity;
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whether the person’s risk is reduced because they are on osteoporosis medication, and how long they have been on therapy;
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history of fracture and baseline fall or fracture risk;
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whether the activity can be modified in a way that reduces risk and permits safe participation;
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the person’s desire to do the activity;
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the type of movement or activity or applied load—activities that involve rapid, repetitive, weighted, sustained or end-range twisting or flexion of the spine or axial loading may need to be modified.
For example, a person who is moderate risk or has low BMD but no history of fracture should be encouraged to do most of the activities they wish to do, to adopt spine-sparing strategies (e.g., learn hip hinge in lieu of flexing the spine, use step to turn rather than twisting the spine, holding load close to body), and to take the same precautions one would advise anyone of a similar age (e.g., adhere to safe lifting technique, wear shoes with good traction, get help if weight is too heavy or task too difficult for ability, consider fatigue level). A step-to-turn is when one lifts one foot and steps to the direction one wishes to face, such that the toes and front of the torso move to face the same direction in one movement, rather than twisting the spine. Where an activity may be deemed risky, for example, high contact sports, high fall risk (e.g., skiing, skating), heavy lifting, rather than restricting it outright, consider whether the person with osteoporosis can modify the activity to reduce the risk (e.g., slower pace, job restrictions, protective equipment or devices like wrist guards or hip protectors, get help) or make a decision that weighs the need or desire to do it with the potential risk, in consultation with a physician or physical therapist.
For an individual with a history of osteoporotic vertebral fracture, painful vertebral fractures, multiple fractures, or gait and balance difficulties, we should still be as permissive as possible and encourage spine-sparing strategies. However, we might be more apt to consider consultation with a physical therapist on body mechanics, particularly in the presence of pain, and the risk of some activities or sports may outweigh the benefits unless they can be modified to reduce the risk. A person with multiple vertebral fractures or painful vertebral fractures, may need to get help beyond light household chores or lifting and avoid sitting for long periods.
69.6
Language
Changing our language so as not to create fear is important. There is a need to emphasize good body mechanics during exercise and physical activities of leisure and daily living, but it should not be done in a way that creates fear. Fear-mongering will discourage physical activity participation, which in the long term may exacerbate muscle atrophy, bone loss and loss of function. Language should be framed positively. For example, rather than “don’t bend,” saying, “when you bend, bend like this (demonstrate and teach hip hinge).” A person with a history of participating in a sport or activity may have the skill and body awareness to continue it safely, particularly if they are taught spine-sparing techniques, or they can make modifications to reduce the risk (Example— Box 68.1 ).
A 56-year-old patient who practices, competes in, and teaches Aikido (a martial art that involves throws and joint locks), whose bone mineral density is in the osteopenic range, but she is otherwise healthy and active, no history of fractures.
Don’t: Say she must cease Aikido
Do: Ask what types of movements are involved. Ask what aspects of Aikido are most important to her. Ask if she would be willing to consult a physical therapist to discuss body mechanics.
Physical therapist’s recommendation after assessment and discussion: Continue to practice and teach. Consider ceasing competition and or sparring with novices, where risk may be higher.
Similarly, language related to lifting should not only be based on the amount of weight lifted. Both the amount of weight lifted and how the weight is lifted influence injury risk. The torque generated is not dependent only on the mass, but on the moment arm, or the distance from the pivot point to the point where the force is applied. Fractures of the spine occurring during daily activities (e.g., bending to tie shoes) with no external load are not uncommon. Further there are many factors that influence the ability of vertebrae to withstand loads, such vertebral body strength, the integrity of the vertebral disks, the presence of microdamage, body position, or spinal curvature . In individuals at moderate risk with no fracture history, avoid lifting restrictions and place emphasis on good lifting mechanics (e.g., hip hinge, bending at hips, knees and ankles, holding weight close to body, avoiding weighted spine flexion, or twisting). In individuals with spine fractures or who are high risk, discuss good lifting mechanics and discuss the current activities they participate in that involve lifting, weighing needs, preferences and risk. Lifting using maximal strength, lifting to/from floor or lifting combined with twisting are examples of activities that may prompt need for good attention to body mechanics, or in some high fracture risk cases, modification or avoidance.
69.7
Resources and exercise professionals
Focus groups with individuals with osteoporosis reveal that they want guidance from someone who “knows what they are doing” when it comes to teaching exercises for people with osteoporosis, and want an exercise program designed to be safe and effective . The health-care provider and patient should carefully consider the risks and benefits of a desired activity together, and the available resources to ensure both efficacy (e.g., sufficient type and dose of activity) and patient safety during exercise. Some patients may be willing to consult (and pay for) a physical therapist on body mechanics, activity modification or exercise, or a clinical exercise physiologist to prescribe and supervise a moderate or high intensity PRT program, aerobic physical activity, or balance exercises. A large study of group-based exercise for older adults with mobility impairment successfully increased physical activity levels and physical function in older adults, but physical activity was not sustained when the supervised program ceased . If cost is an issue, are there local classes or resources that could be used to guide the patient? Online resources include the following:
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Osteoporosis Canada’s Too Fit To Fracture patient resources: https://osteoporosis.ca/health-care-professionals/clinical-practice-guidelines/exercise-recommendations/
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The Royal Osteoporosis Society in the United Kingdom’s Strong, Steady, and Straight Consensus Statement for health and exercise professionals ( https://nos.org.uk/strong-steady-and-straight/ ) and fact sheets and video clips for patients ( https://theros.org.uk/exercise )
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Clock Yourself Balance Training App: https://clockyourself.com.au/
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US National Physical Activity Guidelines for Older Adults booklet: https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf#page=66
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National Osteoporosis Foundation resources:
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https://www.nof.org/patients/fracturesfall-prevention/
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https://www.nof.org/patients/fracturesfall-prevention/exercisesafe-movement/
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https://www.nof.org/patients/fracturesfall-prevention/safe-movement-exercise-videos/
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American Bone Health resources: https://americanbonehealth.org/what-you-should-know/
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Stand Tall posture exercise video is available from the UCSF Department of Physical Therapy and Rehabilitation Health and Wellness Center as an mp4 file: http://ptrehab.ucsf.edu/stand-tall
69.8
Summary: exercise recommendations for people with osteoporosis
Current exercise recommendations for people with osteoporosis advise a multicomponent exercise program that includes PRT, balance challenges, exercises for back extensor muscles, and aerobic physical activity, ideally where one of these includes activities that involve impact or ground reaction forces . It may not be realistic to introduce all types of exercise at once, or expect participants to achieve the minimum recommended frequencies or intensities at the start. A good starting point would be to recommend functional strength and balance training 2 or 3 times weekly. Once that is established, patients can then be encouraged to progress the intensity or challenge of strength and balance exercises, and add in exercises for back extensor muscles and aerobic physical activities they enjoy. On the other hand, telling a patient to move more, or walk, because it is easier to recommend is not an evidence-based strategy, as evidence clearly supports the need for a multicomponent exercise intervention. Motivational interviewing strategies could be used to identify actionable priorities. For example, elicit information:
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What physical activities are they currently doing, or do they enjoy doing?
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What is the therapeutic goal of highest priority from the clinician’s perspective? (e.g., preventing falls, addressing sarcopenia, function, and endurance)
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What is the patient’s goal, what are they most concerned about?
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What resources do they have available to them? (e.g., private or publicly funded physical therapy or kinesiologist, community classes)
Provide evidence-based recommendations in a neutral way:
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We lose muscle every year after age 40. To keep your bones and muscles strong it is important to do exercises to build muscle strength, and to do exercises that involve impact. Balance exercises can keep you steady on your feet.
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Here are some options you might consider to start with: (List local options, e.g., physical therapist/kinesiologist, local exercise classes, home exercise resources, learn one new exercise to practice at home)
Elicit information using open-ended questions:
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What is a realistic starting point for you?
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Are there ways to incorporate a few strength or balance exercises into your day?
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What do your friends or family do to stay active? How can they help?
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How do you feel about trying (insert relevant program/app/resource here)?
69.9
Tips about prescribing exercise components
Aerobic physical activity: Encourage whatever modes are preferred and include activities at moderate-high intensity daily. While walking is “weight-bearing,” the impact is not very high; if walking is a preferred activity it can still be encouraged for other health benefits. Whether it is part of aerobic physical activity or a separate exercise, bouts of impact exercise can be introduced, progressively increasing the magnitude of the impact. Heel drops, step-ups and jumps with soft landings are examples; impact exercise selection and progression may need to be guided by a qualified exercise professional.
PRT: It is ideal if a qualified exercise professional can perform assessment and exercise selection. A basic resistance training program should target major muscle groups with exercises such as a pull exercise (e.g., lat pull-down, seated or standing row), a push exercise (e.g., wall, counter or military pushup, bench press), functional lower extremity exercises (e.g., squat, step-ups, lunges), and a shoulder raise or press, performed at ≥70% 1 repetition maximum at least twice a week. Exercises for back extensors and abdominals are also recommended (e.g., bird-dog, supine thoracic and lumbar extension, plank, and side plank), but the intensity should be designed to promote endurance for example, repeated/prolonged holds. Most people can do a form of each of these exercises with tailoring to regress to make it easier (e.g., unweighted, seated) or, for many individuals, the exercises need to be progressed to more challenging versions once good form is learned.
Balance exercise: Choose activities that involve reducing the base of support, moving the center of mass and reducing reliance on support objects. Examples include shifting forward and backward to limits of stability with feet together or on one foot, tandem stance or tandem walk, step-ups or lunges. Incorporating them into the day to make them a daily habit may be ideal.
Range of motion considerations: Mobilize joints that restrict upper or lower extremity mobility. Limited shoulder range of motion is common, and examples of mobility exercises to improve shoulder flexion include back to wall shoulder flexion or downward dog on floor or chair. Heel and toe taps can be used for limited ankle dorsiflexion range.
Considerations for individuals with vertebral or hip fractures: Exercise recommendations are not different for people with vertebral or hip fractures, but the way the recommendations are implemented may be different. For example, they may place more emphasis on form and alignment during exercise than on progressing intensity, at least initially. PRT at an intensity that is at least moderate (e.g., 8–12 repetitions maximum) is still recommended, but it would be advisable to get instruction on selection of exercises and performing them with good form. The tailoring of exercises to participant’s risk, goals, and ability involves good clinical judgment. For example, in some individuals at high risk of fracture, one might select exercises to limit weighted spine flexion or twisting in, particularly movements that involve end-range flexion. But there may be many others with low bone mass for whom exercises that involve some flexion can be introduced progressively. It is hard to avoid flexion or holding weights in exercise, and in daily life, so broad restrictions based on weight or types of exercise create fear and are not necessary. Where it becomes more challenging is when exercise is at home, unsupervised, or the credentials of an exercise instructor leading the exercise are unclear. When consultation with a therapist is not possible, for patients at high risk of fracture, it may be advisable to limit resistance exercises to those that use body weight, the floor, resistance bands, suspension training systems, or a wall to provide resistance—a conservative approach to maximize safety, but it may reduce the stimulus and resultant effect of the training on muscle strength.
For individuals with painful vertebral fractures, sitting or standing for long periods of time may be uncomfortable. A strategy to promote extension of the spine and stretching of anterior trunk and shoulder muscles, and “unloading” of the spine for people with pain is to intersperse prolonged sitting or standing with periods lying in supine on a firm surface (up to 15–20 minutes), like the floor or wide bench. If exercises to improve back extensor endurance are warranted (e.g., to improve posture or endurance for standing upright without pain), they can be performed in supine and progressed to more challenging versions in the quadruped or standing position. Back extensor endurance exercise usually involve reaching or extending the upper and/or lower limbs to achieve thoracic and/or lumbar extension and holding these positions for 3–10 seconds for several sets.
Patients often want to know if the physical activities they enjoy are safe—yoga is an example. There are many different types of yoga (e.g., Ashtanga, Hatha, Iyengar, and Bikram), and instructor training and experience can vary substantially. Although there have been a few case reports of fractures that may be attributable to yoga , the benefits likely outweigh the risks for most people, if strategies are put in place to minimize the risk ( Box 68.2 ), and they are not doing yoga to the exclusion of other types of exercise that are recommended, such as functional and balance training, and resistance training. Indeed, there is evidence from a metaanalysis that yoga has a small effect on balance and a moderate effect on mobility outcomes in older adults . Postures such as Corpse, Bridge, Warrior, Mountain, Chair, Crocodile, Sphinx, or Locust are example postures that can be encouraged . However, as with exercise, for individuals at high risk of fracture, particularly those with gait and balance difficulties or a history of vertebral fractures, a consultation with a physical therapist may be advisable prior to initiating yoga, and it may be wise to seek out a class designed for people with osteoporosis, or an instructor who has training in how to adapt yoga for people with osteoporosis.
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