Osteoporosis

Osteoporosis reduces bone mineral density and disrupts the internal architecture of bone, making it fragile. It progresses without symptoms — there is no pain from thinning bone — so the first indication is very often a fracture of the spine, hip or wrist.

A hip fracture in an older adult is not only an orthopaedic event. It is one of the leading causes of permanent loss of independence, which is why osteoporosis is better understood as a movement and balance problem than as a purely skeletal one.

Osteoporosis reduces muscle strength, worsens posture, impairs balance and increases fear of movement. Reduced movement then accelerates bone loss. The result is a self-reinforcing loop: inactivity leads to bone loss, which raises falls risk, which produces a fracture, which produces more inactivity.

Breaking that loop is the purpose of rehabilitation, and it is why the programme works on balance and strength rather than only on the bone.

Drug treatment improves bone mineral density and is important. But most fractures happen because someone falls, and what determines whether they fall is strength, balance, vision, medication and the home environment.

Progressive resistance training and balance training are the interventions with evidence for reducing fracture risk. General advice to stay active is not the same thing and does not produce the same result.

Bone density results where available, muscle strength, balance and gait, falls risk and posture. From that we build a programme with the loading the bone needs and the balance work the person needs.

Some movements are specifically avoided in established osteoporosis — loaded spinal flexion and forceful twisting can cause vertebral fracture. Knowing what not to prescribe is as much a part of the plan as knowing what to prescribe.

Progressive resistance training loads bone where it matters — hip and spine — and balance work reduces the falls that turn low bone density into a fracture. Both are trained, and the resistance has to be meaningful rather than token; light weights repeated many times do not provide the stimulus bone responds to.

What is avoided is loaded forward bending and forceful twisting of the spine, particularly where vertebral fractures have already occurred. That rules out a number of common gym and class exercises, which is why supervision in the early weeks matters.

Bone density determines how much force a bone can take; falls determine how much force it meets. Addressing only the first leaves half the risk untouched, and most fragility fractures happen in a fall from standing height.

So the programme includes balance and reaction training, a review of medication that affects steadiness, vision and footwear, and a look at the home environment where relevant.

Pain from a new vertebral fracture usually settles over weeks, and the priority in that period is enough pain control to keep moving, because immobility costs bone and muscle quickly.

Afterwards the emphasis shifts to posture and back extensor strength. Height loss and increasing thoracic curvature are not inevitable consequences, and extensor training influences both.

Bone responds to load continuously, and the response reverses when loading stops. This is a condition where the home programme is the treatment and the supervised block is the training period for it.

You leave with the specific exercises, the load, the progression schedule, and a statement of which movements to keep avoiding.