For those with low bone density, physical activity is an important ingredient for good bone health. The trick is to learn what types of exercise and activities are most beneficial and which ones to avoid or modify — and that's where a physical therapist can be a big help.

When it comes to building bone strength, you probably know the basic advice: Get your fill of calcium and vitamin D, exercise, and don’t smoke.

Like muscles, bones require stresses on them to get stronger. Being inactive, like on bed rest, leads to rapid bone decline. 

But what if your bones are already weak? For those with low bone density, physical activity is an important ingredient for good bone health. The trick is to learn what types of exercise and activities are most beneficial and which ones to avoid or modify — and that’s where a physical therapist can be a big help. 

Weakening bones

Just like all other tissues in the body, bones are in a constant state of turnover: building, remodeling and breaking down. In the earlier phases of life, bone building is stronger than breakdown, resulting in an overall bone density increase. But around age 40, bone breakdown tends to outpace bone building — thanks to age and the hormonal changes that come with perimenopause and menopause.

With too much bone breakdown, you may be diagnosed with osteoporosis or osteopenia, conditions of low bone mass and deterioration of bone tissue. Osteoporosis is a more advanced state of bone loss. The definition for each depends on your clinical history and the result of a DEXA scan, also called a DXA scan. This scan is a type of radiology test that shows the density of the bones, typically the low back and hips. Unfortunately, low bone density is very common and can result in significant disability through bone fractures.

After a diagnosis of osteoporosis or osteopenia, your first step is to discuss your treatment options with your health care provider. Treatments may include hormone therapy, medications to reduce bone loss and a referral to physical therapy.

Physical therapy is a crucial part of treating people with concerns about low bone mass. A physical therapist can teach you about your condition and how you can best move and exercise safely to optimize your bone health and reduce the risk of fractures.

What to expect

At your first appointment, your physical therapist takes a detailed history of your symptoms and asks about your current lifestyle, including your physical activity and exercise habits. This is followed by a detailed examination of your posture, mobility of all major joints, muscle strength and balance. The therapist may ask to see how you do some of your daily tasks like lifting, gardening or carrying groceries.

Based on the findings of the examination and your activity limitations and goals, you and your therapist create a treatment plan. The main goal is for you to learn how to safely practice your favorite activities while reducing your risk of injury.

The typical components of a physical therapy program for healthy bones include:

• Strength training. It’s important to improve muscle mass through a progressive resistance training program that uses weights, resistance bands or body weight resistance. Physical therapists are experts in teaching people how to do this safely and efficiently. For example, situps strengthen the abdominal muscles. But because of the forces they put on the spine, physical therapists often discourage someone with low bone density from doing them — instead, a plank or “dead bug” exercise is a better option. Impact cardio exercises like jogging might be recommended for someone with only mild reduction in bone mass. For those with more advanced bone loss, easy hiking with trekking poles, walking on a treadmill, or stair climbing might be better.  
• Posture education. One of the risks of more advanced osteoporosis is a rounded upper back. This can restrict breathing and digestion in addition to causing imbalance, back pain and a higher risk of fractures. To prevent this, a physical therapist can help you find your best possible back and neck posture. Additionally, the therapist will teach you exercises to strengthen the upper back muscles so you can maintain upright posture.
• Stretching. It might be surprising, but flexibility is another important aspect of being able to move comfortably and have optimal posture. For example, good upper back posture requires not only strong back muscles but also adequate flexibility of the front of the chest and abdominal muscles. A physical therapist can demonstrate and teach safe and effective stretching techniques to do in the home exercise program.
• Balance. Because most fractures happen as result of falls, balance training is an important part of a comprehensive physical therapy program for bone health.
• Body mechanics. A physical therapist can make sure you know how to safely use your body in daily activities. This includes activities like lifting, reaching and doing your hobbies.
• Sports modification. A physical therapist can teach you how to modify your favorite exercise activities like weightlifting, yoga or Pilates to make sure they’re safe to do. For example, yoga poses like the plow pose or forward bends can put too much unhealthy stress on the upper and lower spine. A therapist can offer modifications for those poses, so you will still have the benefits of the yoga practice.

Physical therapists are experts in teaching safe and personalized exercise programs. They will create an exercise routine that you can do on your own. The ultimate goal is that you feel empowered by having a good understanding of your condition and how to move in a way that is enjoyable and reduces the risk of injury.

Depending on your specific needs, you may see a physical therapist for about 4 to 8 sessions — ideally followed by additional regular checkups, possibly on an annual basis.