1. Exercise to Improve Bone
Mineral Density
Joaquin Calatayud, MSc, NSCA-CPT,1
Sebastien Borreani, MSc,1
Diego Moya, MSc,1
Juan C. Colado, PhD,1
and N. Travis Triplett, PhD, CSCS*D2
1
Laboratory of Physical Activity and Health, Department of Physical Education and Sports, University of Valencia,
Valencia, Spain; and 2
Department of Health, Leisure, and Exercise Science, Appalachian State University, Boone,
North Carolina
A B S T R A C T
EXERCISE IS AN IMPORTANT ELE-
MENT OF THE PREVENTION AND
TREATMENT OF OSTEOPOROSIS
(OP). DIFFERENT TYPES OF EXER-
CISE HAVE POSITIVE EFFECTS IN
PATIENTS WITH OP. CERTAINLY,
WEIGHT-BEARING EXERCISE AND
RESISTANCE TRAINING ARE THE
BEST WAY TO IMPROVE BONE
MINERAL DENSITY. THIS REVIEW
PROVIDES PRACTICAL GUIDE-
LINES FOR EXERCISE AND CON-
DITIONING SPECIALISTS.
INTRODUCTION
O
steoporosis (OP) is a disease
characterized by a reduction
of the bone mineral density
(BMD) and a structural deterioration
of the bone tissue that results in fragile
bones, leading to a high fracture risk
(26). After the age of 40, BMD declines
progressively, 0.5% per year or more
(23), especially in women (13). By 50
years of age, women from developed
countries have a probability of more
than 40% suffering OP fractures and
20% suffering a hip fracture (5). The
mortality rate after hip fractures in this
population is approximately 20% (9). In
addition to the hip, the other 2 sites
with more fracture incidence are the
spine and the wrist (18,26). OP frac-
tures are related to excessive mortality,
morbidity, chronic pain, reduction in
the quality of life, long-term attention,
social and health care costs (28). The
costs associated with OP during 2005
were estimated to be 19 trillion dollars
in the United States, and these costs are
expected to increase to 25.3 trillion dol-
lars by 2025 (26). Most of the eco-
nomic costs associated with OP are
because of the treatment of hip frac-
tures and the hospitalization needed
after all types of fractures (9).
Bone quality is determined by several
factors such as the bone geometry,
cortical thickness and porosity, tra-
becular bone morphology, and the
intrinsic properties of the bone tissue
(18). A low bone mass detected by
densitometry is one of the most
important risk factors (18), although
most fractures are because of falls
influenced by deterioration of the
visual function, muscle strength, and
balance (12). Nevertheless, measure-
ments of the BMD contribute to the
prediction of the risk of fractures (24)
and may be an indicator of other prob-
lems such as low back pain, which is
associated with reduced lumbar BMD
levels in males (16).
There are several methods to deter-
mine BMD; however, dual x-ray
absorptiometry (DXA) is the most
common method of assessing
the mineral content of the whole skel-
eton, as well as of specific sites, includ-
ing those most vulnerable to fracture
(41). DXA is regarded as the “gold
standard” because it is the most highly
developed technique and the most
thoroughly validated biologically.
The term “bone mineral content”
describes the amount of mineral in
the specific bone site scanned, whereas
BMD can be derived by dividing the
bone mineral content by the area or
volume measured (41). Peripheral
quantitative computed tomography
is another technology that shows
improvements when evaluating bone
geometric properties and verifying
bony mass changes in a precise
way (13).
Although significant effects can be
seen after 4–6 months (13), changes
in BMD occur very slowly (1). Nev-
ertheless, bone adaptation process
begins in early phases of training
(29), and rapid changes in bone resorp-
tion and bone formation markers may
be tested (41). For this reason, popu-
larity of specific bone biomarkers is
growing (30) because of the fact that
their use is less expensive than the
conventional densitometric methods
(39), and they are an easy, effective,
and a noninvasive way to verify the
short-term effects of exercise in bones
(40). The principal markers of bone
formation are the procollagen pro-
peptides of type I collagen (41),
the bone isoenzyme of alkaline phos-
phatase (41), osteocalcin (41), and
total alkaline phosphatase (19,41),
whereas the most widely used markers
of bone resorption are hydroxyproline,
pyridinium cross-links, and their pep-
tides (41).
K E Y W O R D S :
osteoporosis; bone mineral density;
weight bearing; resistance training
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2. In general, physical inactivity and
decreasing the load on the skeleton
result in a reduction of the BMD
(29,45). Postmenopausal ages are
related to a low level of physical activity
(7), and the consequences are a low
stimulation of the bones, a decrease of
the muscle mass, as well as a decrease in
strength, coordination, and balance
(30). Thus, the quality of life is nega-
tively impacted by lack of physical
activity (3,6,7,38). Participation in high-
impact sports, especially before puberty,
is important to maximize the accumula-
tion of bone mass and to obtain a greater
bone mass peak independently of sex
(15). Strong scientific evidence exists
to support that performing exercise dur-
ing childhood is associated with a better
maintenance of bone mass in advanced
age (20,23). In addition, regular exercise
is associated with a lower risk of suffer-
ing bone fragility fractures in older peo-
ple of both sexes (15).
In recent years, different types of exer-
cise have been evaluated to improve
BMD despite the fact that not all of
them have shown the same effects
(13). It is necessary to take into
account the different factors that influ-
ence and lead to bone formation. The
cellular mechanisms responsible for
the adaptation of bone are modeling
and remodeling. These mechanisms
modify the external size, contours of
bone, and its internal architecture
because of bone deposition or removal
from the surface of bone by osteo-
blasts and osteoclasts, respectively
(34) through osteocytes, which detect
mechanical strain and transduce the
applied strain to the aforementioned
cells (34,44). However, as osteogene-
sis is influenced by the stress imposed
on bone (10), a minimum effective
strain to induce bone formation must
be reached (29). Therefore, if mechan-
ical load exceeds this threshold, then
osteoblastic activity is induced and
thus bone becomes strong to provide
an adequate support structure (29) in
the specific area that experienced the
mechanical strain (15,22,29). Other
determinant factors of the results are
the initial BMD of each subject (lower
BMD baseline is related to greater im-
provements after the training pro-
gram) (13), external factors such as
diet (6,36), systemic factors such as
hormones (6,36), as well as age and
genetics (11,36).
Not all exercises are effective for
increasing BMD. The National Osteo-
porosis Foundation (NOF) distin-
guishes between 2 subgroups of
exercises that do not have an effect on
the bones (27). There are exercises with-
out impact, like balance or flexibility
exercises, and there are exercises where
the body weight is not entirely sup-
ported (non–weight-bearing exercises,
also nonimpact exercises), such as
cycling or swimming (15,27). Other
more effective types of exercise include
weight-bearing exercises and resistance
training (RT).
WEIGHT-BEARING EXERCISES
Weight bearing is one of the effective
forms of exercise that lead to mainte-
nance or improvements in BMD
(13,15,18,23,27,29,31). Based on the
NOF definition, weight-bearing exer-
cises include activities that make one
move against gravity while staying
upright (27). These exercises can be
high impact (i.e., jumping) or low
impact (i.e., walking).
Aerobic exercise, especially walking, is
the most common type of exercise
because of its ease of accomplishment
and safety (13,31). Evidence suggests
that walking and running have a few
positive effects on BMD (15). How-
ever, different results are found de-
pending on the training variables
used in the protocols. For example,
more BMD benefits from walking have
been shown when more intensity or
distance was performed (31). Also, bet-
ter results are achieved when high-
impact activities are included (13)
because high impact seems to be
a highly efficient exercise to promote
BMD except in postmenopausal
women (15). For example, running
and jumping had a significant effect
on the BMD in 2 sites: the total hip
and femur trochanter (18).
RESISTANCE TRAINING
RT is the other effective type of exercise
that is able to maintain or to improve
BMD (13,15,18,23,27,29,31,43). The
NOF considers RT as those activities
where one moves the body, a weight,
or some other resistance against grav-
ity (27). However, in some RT exer-
cises, bones and muscles work against
gravity, whereas feet and legs bear the
body’s weight, and thus, these exer-
cises may be considered also as
weight-bearing exercises (e.g., squat
jumps). On the other hand, those
exercises with different body positions
that are not performed while staying
upright (e.g., bench press) may be
considered RT non–weight-bearing
exercises.
RT has been proven to be a potent
stimulus for the formation and mainte-
nance of bone mass (13,43). Positive
effects have been found especially in
the femur neck, the lumbar spine
(13,18), and the distal radius (13).
Moreover, RT improves muscular
strength that may decrease risk of falls
in older adults (14,31).
It seems that the most effective combi-
nation of exercises would be to perform
high-impact activities, such as jumps, in
addition to RT (15). Howe et al. (18)
found that combination exercises pro-
grams, where different types of exercises
(i.e., resistance or endurance training)
were included, had a significant effect
on BMD in 3 sites: the femur neck,
the spine, and the femur trochanter.
WATER-BASED EXERCISE
Water-based exercise has shown to
provide many of the same benefits in
terms of physical fitness as land-based
training programs and thus has gained
considerable popularity in recent years
(8,25). Among the benefits reported in
some studies involving water-based ex-
ercises are improvements in strength,
the ability to perform daily living activ-
ities, flexibility, body composition, and
cardiorespiratory fitness (8,33,37).
Notwithstanding, few studies on the
effectiveness of water-based exercise
on parameters linked to OP and fall
risk, such as balance and functional
Exercise to Improve BMD
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3. status, are available. Load on the bones
in water can be achieved through RT
and running or jumping in shallow
water. It is necessary to take into con-
sideration that greater immersion
depth results in less impact and vice
versa. It has been demonstrated that
water aerobic exercise is able to
improve calcaneus BMD (4). Addition-
ally, Rotstein et al. (32) showed that the
experimental group maintained or
improved bone status in spinal verte-
brae L2–L4, whereas control group
bone status declined. The training pro-
tocol was composed of a combination
of 20 minutes of aerobic training and
20 minutes of RT with different exer-
cises and devices.
Water-based exercise may be a useful
option or first step for people with OP
who have difficulty exercising on land
because of fear of falls, poor balance,
and pain, because it is a safe exercise,
and postmenopausal women can take
advantage of the general benefits of
this type of exercise, although it might
not be the best way to improve BMD.
WHOLE BODY VIBRATION
TRAINING
Whole body vibration (WBV) training
is a new type of intervention that seems
to be more effective than walking and
to be similar to RT to improve BMD of
different body sites in postmenopausal
women (13). More studies are required
to support similar effects in men (13).
WBV has been shown to have a signif-
icant effect on BMD in 2 sites: the total
hip and the femur trochanter (18). Nev-
ertheless, additional evaluation of the
correct exercise positions and the suit-
able doses of vibration (time, intensity,
frequency, and type) is required (13). In
the same vein, a recent review (42)
emphasizes the lack of scientific evi-
dence about the optimal exercise proto-
cols of WBV for patients with OP.
In summary, reviews and original
interventions provide clear evidence
that physical activity is able to increase
BMD (13,15,18,21–23,30), strength
(21–23) increase muscle mass (22,23),
improve balance, and decrease fall risk
(2,14,17,22,23,35); each of these factors
lead to reduced bone fractures by
itself (22).
PRACTICAL APPLICATIONS
High-impact activities must be per-
formed during childhood with the pur-
pose of maximizing the accumulation
of bone mass and to obtain a greater
bone mass peak that will be main-
tained in advanced age.
Exercise for patients with OP must
prioritize weight-bearing exercise
(especially performing high-impact
exercises as early as possible) and
RT, because they are the most power-
ful exercises to improve BMD. In
addition, WBV may provide bone
mass improvements in the lower
extremities and thus may be added
to the training program. Moreover,
patients with high risk of fracture or
beginners can use low-impact and
water-based exercises as a first step.
All types of effective exercises may be
used in the training program in order
to comply with the training variation
principle and may be used as a specific
part of the training session (e.g., WBV
such as a warm-up).
Exercise load must focus on the spe-
cific sites with lower BMD and exer-
cise. However, because the sites with
more fracture incidences are multiple
around the body (e.g., hip, spine, and
the wrist), practitioners may be bene-
ficiated in a greater extent by those
exercises involving multiple joints (e.
g., back squat) that may also be per-
formed adding a high-impact variation
(e.g., jump squat).
A suitable progression with a correct
exercise technique is needed. All exer-
cises must be supervised in the first
training sessions to improve exercise
technique, program adherence, and
safety. Furthermore, exercise periodi-
zation is necessary to prevent injuries
and maintain motivation.
To ensure BMD improvements or min-
imize bone loss, lifestyle changes such as
smoking cessation, moderation in alco-
hol consumption, and an adequate diet
with appropriate caloric and calcium
intake must be taken into account.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Joaquin
Calatayud is
a member of the
research group in
Sport and Health
in the Depart-
ment of Physical
Education and
Sport at the
University of
Valencia.
Sebastien
Borreani is
a member of the
research group in
Sport and Health
in the Department
of Physical Edu-
cation and Sport
at the University
of Valencia.
Diego Moya is
a member of the
research group in
Sport and Health
in the Depart-
ment of Physical
Education and
Sport at the
University of
Valencia.
Juan C. Colado
is a faculty mem-
ber and the direc-
tor of the research
group in Sport
and Health in the
Department of
Physical Educa-
tion and Sport at
the University of
Valencia.
Strength and Conditioning Journal | www.nsca-scj.com 3
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4. N. Travis
Triplett is an
associate professor
and the graduate
program director
in the Depart-
ment of Health,
Leisure, and
Exercise Science
at Appalachian
State University.
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