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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

Whether a person has been diagnosed with low bone density or full-blown osteoporosis or perhaps has already suffered a fragility fracture, staying active physically is a key part of treatment.

Regular daily activity combined with purposeful, more intense exercise can stimulate bone formation and increase muscle mass. Weight-bearing activity has osteogenic effects, and increasing muscle mass strengthens muscular support to and pressure on the skeletal system and provides bones with a thicker layer of protection in case of falls.

"In contrast, disuse -- for example, bed rest or a poor level of physical activity -- is a risk for bone loss even in younger people," said Nahid. J. Rianon, MBBS, DrPH, of the McGovern Medical School at UTHealth Houston.

She pointed to in which people in gravity-free space flight showed evidence of bone resorption but had improvement after an intervention with resistive exercise.

And in other research settings, structured exercise programs for older people have resulted in modest increases in . It is not possible, however, to tease out the effect of exercise on its own on bone density in osteoporosis patients undergoing medical treatment, noted Willy Marcos Valencia Rodrigo, MD, of the Cleveland Clinic. "No studies of exercise alone for stimulating bone growth in this population can be done, since it would obviously be unethical to withhold needed medical treatment."

Fall/Fracture Prevention

If the major goal of treatment is preventing falls and by extension fractures, a 2020 in British Journal of Sports Medicine found that exercise reduced falls in elderly individuals by 23% and by 34% if a regimen combined balance, functional, and resistance training.

In addition, exercise can help reduce musculoskeletal pain, stabilize the body's core, improve gait and posture, and enhance balance, stability, and cardiovascular endurance – all important aspects of warding off falls and fractures. The result for persons living with osteoporosis is improved confidence, physical and psychological well-being, and quality of life overall.

"I can't stress enough how much osteoporosis patients can benefit from exercise – it's life-changing, and crucial for preventing falls and fractures," said Valencia Rodrigo. He added that low-energy functional activities of daily living such as walking a dog or picking up the mail at the end of a driveway should always be supplemented with more intense and purposeful activities designed to raise heart rate.

"For instance, walking yes, but walking as if you're really late for something," Valencia Rodrigo explained. "Patients need to understand the difference between activity and exercise."

His recommendation is that patients engage in multiple complementary types of exercise, aimed variously at aerobic/cardiovascular fitness, mobility, flexibility, balance, stability, strength, and endurance.

An illustrated series of , as well as , can be found on the website of the Bone Health & Osteoporosis Foundation.

Overcoming Reluctance

Getting this population to exercise often has a psychological component, Valencia Rodrigo noted. Some individuals, especially those who have sustained a fracture and fear having another, may need to overcome barriers of confidence. "They may feel reticence, but they need to understand that the risk of falling and fracture increases the longer they remain sedentary. They can't be sitting around all day," he said.

Added Rianon: "Even after a fracture, patients should exercise other parts of the body while the broken bone is healing and can't be moved. Overall mobility is important, and exercising other areas can stimulate strength and help prevent falling."

She too emphasized that exercising may require psychological preparation and encouragement to build up the patient's confidence: "If the exercise plan is to start after a fall or breaking a bone, mental preparation may be more important because there may be fear of falling or of pain in someone who is rehabilitating after a fracture treatment."

She recommended consulting CDC's (Stopping Elderly Accidents, Deaths, and Injuries) initiative. The site also includes an for fall risk screening, assessment, and intervention.

In addition to impaired confidence, age-related comorbidities can complicate exercise in the frail elderly: these may include weakness from a previous stroke, joint pain from arthritis, nerve pain from sciatica, shortness of breath due to a heart or lung condition, and general fatigue.

Safety Concerns

To avoid injury, patients should be evaluated before they start an exercise regimen, particularly if they want to do exercises involving compressive or contractile stressors such as running on hard surfaces or heavy weightlifting. Some forms of exercise may increase fracture risk in the Bone-jolting activities such a jogging and high-impact aerobics, therefore, are ill-advised.

Additionally, patients who have had vertebral fractures should refrain from bending far forward, reaching far down, twisting the thorax, performing spine-stressing sit-ups, and lifting heavy objects.

"Forward bending of the spine more than 45 degrees, for example, increases pressure on vertebral bodies and can increase the risk of fracture in those with low bone density or osteoporosis," said Rianon. "Twisting the spine to turn suddenly may also increase the risk of vertebral fracture. Learning how to move and exercise safely while avoiding these two movements is important for older persons."

Sports for seniors that may require bending or twisting forcefully at the waist such as golf, tennis, and bowling can be problematic. Even some yoga poses can be risky. Patients who are generally fit and accustomed to exercise, however, may be able to undertake somewhat higher-impact exercise.

Before implementing a plan, some patients may benefit from consulting a fitness professional or physiotherapist experienced in skeletal fragility. All should be encouraged to start slowly, lifting light weights in a few manageable repetitions per day and progressing gradually from there. They should follow good practice for exercising and and cool down for 10 minutes at either end of a session with light aerobic actions such as arm swinging, side-stepping, and brisk walking.

Types of Exercise

It is advisable to do a range of different types of exercise for maximum return. Some forms provide more than one type of benefit -- for example, both weight-bearing bone stimulation and cardiovascular conditioning in the case of brisk walking and stair climbing, or both aerobic and resistance training with swimming.

• Weight-bearing exercise, which works bones and muscles against gravity, includes walking, running, tai chi, stair climbing, elliptical machine training, dancing, gardening, and low-impact aerobics. Tennis provides this as well, but may involve too much twisting and hard-surface impact for osteoporosis patients. These activities strengthen the bones in the legs, hips, and lower spine. "But fast stair-climbing could put unstable patients at risk for falls," Valencia Rodrigo cautioned.

• Muscle-strengthening exercises range from weight and resistance-band training and resistive exercise such as cycling and swimming to Pilates and boot-camp calisthenics. Strength training, especially for the upper back, builds dorsal muscles to support good posture and improve bone density.

• Aerobic exercise for cardiovascular and respiratory conditioning is offered by brisk walking, cycling, swimming, taking the stairs, running, or marching on the spot, elliptical machine workouts, badminton, and dancing.

• Flexibility exercises move joints through their full range of motion and help keep muscles working well. Stretches can be done in a safe seated position and range from shoulder rolls and chest-muscle expansions to Hula-Hoop-style hip rotations and toe touches done sitting on the floor. Stretches are best performed after muscles are warmed up and should be done gently and slowly, without jerky bouncing.

• Stability and balance exercises help muscles cooperate and make falling less likely. Simple exercises that improve stability and balance include standing on one leg and movement-based exercises such as yoga and tai chi. Other balance- and posture-promoting moves may use a chair or a wall for support.

A combination of the above will yield the best all-around results and lead to a better quality of physical and psychological life for osteoporosis patients. The challenge for physicians is getting their patients to start meaningful exercising and keep at it.

Read previous installments in this series:

Part 1: New Insights Into the Complex Biology of Osteoporosis

Part 2: The Latest on Osteoporosis Treatment and Diagnosis

Part 3: Osteoporotic Fragility Fractures

Part 4: Case Study: First-Time Mom's Severe Low Back Pain After Breastfeeding

Part 5: As Men Live Longer, Osteoporosis Looms Larger

Part 6: These Other Medical Conditions and Treatments Can Also Increase Osteoporosis Risk

Part 7: Talking to Patients About Osteoporosis

Part 8: Shocking Case of Osteoporosis in a Teenager

Part 9: Osteoporosis and Oral Health