Osteoporosis does not hurt. That is the problem. Bones thin and lose their internal architecture quietly over years, an estimated 2.3 million Canadians live with it, and for many people the first announcement is a fracture from something minor: a fall from standing height, a twist, occasionally just a cough or a lift. Wrist, hip, and spine (vertebral) fractures are the classic results. So the goals of management are really two goals: keep the bones as strong as possible, and make the fall much less likely.
The Canadian guideline’s take on exercise
The 2023 Osteoporosis Canada clinical practice guideline, published in CMAJ, is clear about exercise’s role, and it is more specific than “stay active.” It recommends balance training and resistance (strength) training at least twice a week for people with osteoporosis, alongside adequate protein, calcium, and vitamin D. It also recommends assessment after any fracture from a minor fall, a “fragility fracture” should always trigger a bone-health workup, because the first fracture is the strongest predictor of the next one, and medication can cut that risk substantially.
What works, specifically
- Progressive resistance training: muscles pulling on bone is the signal bone responds to. Weighted exercises, progressed over time, are the closest thing to a bone-building stimulus we can prescribe. Light, unchanging exercise maintains fitness but does little for bone density.
- Balance training: this is the fracture-prevention arm. Challenging balance, safely, with support nearby, reduces falls, and falls are the event that turns thin bones into broken ones. Tai chi has good evidence here; so do structured physio balance programs.
- Posture and back-extensor work for people with vertebral fractures or a rounding spine: strengthening the back extensors, and learning hip-hinge lifting mechanics so loads travel through the legs rather than a flexed spine.
What to be careful with
Loaded spinal flexion, think heavy sit-ups, toe-touches with weights, and twisting under load, is generally discouraged for people with low spinal bone density or vertebral fractures, because it concentrates force on the front of the vertebrae, exactly where compression fractures happen. That does not mean a fragile, fearful approach to movement. It means smart mechanics. People with osteoporosis should be lifting, carrying, and living, with technique that respects the spine.
The home matters as much as the gym
Most fractures from osteoporosis happen in falls at home. Night lighting, secured rugs and cords, bathroom grab bars, proper footwear, a review of medications that cause dizziness (with your physician), and vision checks are boring interventions with an outsized effect. In our home visits, that walk-through of the actual house is part of the clinical work, not small talk.
References
- Morin SN, Feldman S, Funnell L, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023;195(39):E1333–E1348. doi:10.1503/cmaj.221647. Full text (PMC)
- Handoll HHG, Cameron ID, Mak JCS, Panagoda CE, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database of Systematic Reviews. 2021;(11):CD007125. PMID 34766330
General information only, not medical advice. Medication decisions for osteoporosis belong with your physician; physiotherapy addresses the exercise, balance, and falls side.