Osteoporosis.
What is osteoporosis?
Osteoporosis is a systemic skeletal disease characterised by reduced bone mass and deterioration of bone microarchitecture, producing increased bone fragility and fracture risk. It is defined by a bone mineral density (BMD) T-score of -2.5 or below on dual-energy X-ray absorptiometry (DXA) scanning, though fracture risk is elevated across a spectrum of bone density levels. Osteopenia — a T-score between -1.0 and -2.5 — represents the intermediate state between normal bone density and osteoporosis and carries meaningfully elevated fracture risk that warrants intervention.
Osteoporosis affects approximately one million Australians, with women significantly more affected than men — particularly in the postmenopausal period when the bone-protective effects of oestrogen are lost. One in two women and one in three men over 60 will sustain an osteoporotic fracture in their lifetime. The consequences of osteoporotic fractures — particularly hip and vertebral fractures — include significant morbidity, loss of independence, and in older adults, elevated mortality. Prevention through bone health management is considerably more effective and less costly than treating the fractures.
How does osteoporosis develop?
Bone is living tissue that constantly remodels — osteoclasts resorb old bone and osteoblasts form new bone. Peak bone mass is achieved in the late twenties, and from approximately age 35, bone resorption progressively outpaces formation. Oestrogen plays a critical role in regulating bone remodelling — its decline at menopause dramatically accelerates bone loss, producing the most rapid reduction in bone density in the five to seven years following the final period.
Risk factors for osteoporosis include low body mass index, a history of fractures especially fragility fractures, dieting and eating disorders which can lead to nutritional deficiencies affecting bone health, and gastrointestinal surgery which can reduce the body's ability to absorb nutrients including calcium and vitamin D. Additional significant risk factors include family history of osteoporosis, smoking, excessive alcohol consumption, prolonged corticosteroid use, vitamin D deficiency, physical inactivity, and conditions including rheumatoid arthritis, coeliac disease, inflammatory bowel disease and hypogonadism.
What are the symptoms?
Osteoporosis itself produces no symptoms — it is a silent disease until a fracture occurs. The first clinical manifestation is often a fragility fracture — a fracture from a fall from standing height or less, or in some cases from minimal or no identifiable trauma. Vertebral compression fractures can occur spontaneously without a fall and produce acute back pain, height loss and progressive thoracic kyphosis. The spine, hip, wrist and shoulder are the most common fracture sites.
Persistent back pain in a postmenopausal woman or older adult, or unexplained height loss, should prompt assessment for vertebral fractures.
How is it diagnosed?
DXA scanning measures bone mineral density at the lumbar spine and proximal femur and generates T-scores comparing the result to the young adult reference population. Fracture risk assessment using the FRAX tool — which incorporates bone density alongside clinical risk factors — provides a ten-year fracture probability that guides treatment decisions. GP referral for DXA scanning is appropriate for postmenopausal women over 50 with risk factors, and for any adult with a fragility fracture history.
Exercise and bone health — what the evidence actually says
Exercise is one of the most evidence-based interventions for osteoporosis prevention and management — but the specific type of exercise matters enormously, and not all exercise is equally effective for bone health.
Bone responds to mechanical loading through Wolff's law — bone adapts its structure and density in response to the mechanical forces placed on it. This means that to stimulate bone formation, exercise must place meaningful load on the skeleton. The exercises with the strongest evidence for improving or maintaining bone density are progressive resistance training and high-impact weight-bearing exercise. Walking, swimming and cycling — despite their cardiovascular and general health benefits — produce relatively minimal bone loading stimulus compared to resistance training and impact exercise.
Progressive resistance training — using weights or resistance bands to progressively increase the load on the skeleton — produces consistent improvements in bone density at the loaded sites. Site-specific loading is important: upper limb resistance exercises load the wrist, radius and humerus; lower limb loading and squatting load the hip and femur; spinal loading exercises stimulate lumbar vertebral density. Well-designed resistance training programs have been shown to reduce fracture risk independently of their effect on bone density, likely through the additional mechanisms of improved muscle strength, balance and fall prevention.
High-impact exercise — jumping, skipping, step aerobics — produces peak ground reaction forces that stimulate bone remodelling, but requires careful individual assessment in people with established osteoporosis or vertebral fractures where high-impact loading carries fracture risk.
Safety considerations for osteoporosis exercise
This is the most clinically important section for patients with established osteoporosis or vertebral fractures. Certain exercises must be avoided or modified to prevent fragility fractures during exercise itself.
Forward spinal flexion under load — crunches, sit-ups, bent-over rows, toe touches — places compressive and shear forces on the anterior vertebral bodies that can cause vertebral crush fractures in patients with significant spinal osteoporosis. Spinal flexion exercises are generally contraindicated in osteoporotic vertebral fracture patients. Back extension and neutral spine positions are preferred. This is one of the reasons that standard gym or group exercise programs designed for the general population are not appropriate for osteoporotic patients without modification.
High-impact activities for patients with very low bone density or existing fractures require careful individual assessment — the fracture risk from the exercise may outweigh the bone loading benefit.
How can physiotherapy and exercise physiology help?
Physiotherapy plays a vital role in the management of osteoporosis by focusing on improving balance, strength, and flexibility. A tailored physiotherapy program can design exercises to enhance bone health, muscle strength, and posture.
Physiotherapy assessment identifies the individual's current bone density, fracture history, balance status and exercise capacity, and designs a program calibrated to their specific situation — progressing safely toward the loads needed for bone health without the positions and movements that carry fracture risk.
Falls prevention is as important as bone density improvement in osteoporosis management. A strong bone in a person who falls is still a fracture, and most osteoporotic fractures are precipitated by falls. Balance training, lower limb strengthening, reaction time training and home hazard modification address the fall risk that is the proximate cause of most fractures. Our Balance and Bones exercise classes are specifically designed for this population — combining the resistance training stimulus needed for bone health with the balance and coordination work needed for falls prevention, in a monitored, small-group environment.
Exercise physiology contributes to the structured progressive resistance training and cardiovascular conditioning programs that require specific program design expertise and ongoing progression. Eligible patients can access exercise physiology through a Chronic Disease Management Plan with GP referral.
Clinical Pilates provides an excellent low-impact exercise environment for osteoporosis patients when specifically adapted — emphasising spinal extension rather than flexion, incorporating axial loading through standing and weight-bearing positions, and building core and gluteal strength in positions that are safe for the osteoporotic spine.
Our physiotherapists Bethany Kippen and Emma Cameron and Exercise Physiologist Ash O'Regan all have experience in osteoporosis management and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Osteoporosis is a systemic skeletal disease characterised by reduced bone mass and deterioration of bone microarchitecture, producing increased bone fragility and fracture risk. It is defined by a bone mineral density (BMD) T-score of -2.5 or below on dual-energy X-ray absorptiometry (DXA) scanning, though fracture risk is elevated across a spectrum of bone density levels. Osteopenia — a T-score between -1.0 and -2.5 — represents the intermediate state between normal bone density and osteoporosis and carries meaningfully elevated fracture risk that warrants intervention.
Osteoporosis affects approximately one million Australians, with women significantly more affected than men — particularly in the postmenopausal period when the bone-protective effects of oestrogen are lost. One in two women and one in three men over 60 will sustain an osteoporotic fracture in their lifetime. The consequences of osteoporotic fractures — particularly hip and vertebral fractures — include significant morbidity, loss of independence, and in older adults, elevated mortality. Prevention through bone health management is considerably more effective and less costly than treating the fractures.
How does osteoporosis develop?
Bone is living tissue that constantly remodels — osteoclasts resorb old bone and osteoblasts form new bone. Peak bone mass is achieved in the late twenties, and from approximately age 35, bone resorption progressively outpaces formation. Oestrogen plays a critical role in regulating bone remodelling — its decline at menopause dramatically accelerates bone loss, producing the most rapid reduction in bone density in the five to seven years following the final period.
Risk factors for osteoporosis include low body mass index, a history of fractures especially fragility fractures, dieting and eating disorders which can lead to nutritional deficiencies affecting bone health, and gastrointestinal surgery which can reduce the body's ability to absorb nutrients including calcium and vitamin D. Additional significant risk factors include family history of osteoporosis, smoking, excessive alcohol consumption, prolonged corticosteroid use, vitamin D deficiency, physical inactivity, and conditions including rheumatoid arthritis, coeliac disease, inflammatory bowel disease and hypogonadism.
What are the symptoms?
Osteoporosis itself produces no symptoms — it is a silent disease until a fracture occurs. The first clinical manifestation is often a fragility fracture — a fracture from a fall from standing height or less, or in some cases from minimal or no identifiable trauma. Vertebral compression fractures can occur spontaneously without a fall and produce acute back pain, height loss and progressive thoracic kyphosis. The spine, hip, wrist and shoulder are the most common fracture sites.
Persistent back pain in a postmenopausal woman or older adult, or unexplained height loss, should prompt assessment for vertebral fractures.
How is it diagnosed?
DXA scanning measures bone mineral density at the lumbar spine and proximal femur and generates T-scores comparing the result to the young adult reference population. Fracture risk assessment using the FRAX tool — which incorporates bone density alongside clinical risk factors — provides a ten-year fracture probability that guides treatment decisions. GP referral for DXA scanning is appropriate for postmenopausal women over 50 with risk factors, and for any adult with a fragility fracture history.
Exercise and bone health — what the evidence actually says
Exercise is one of the most evidence-based interventions for osteoporosis prevention and management — but the specific type of exercise matters enormously, and not all exercise is equally effective for bone health.
Bone responds to mechanical loading through Wolff's law — bone adapts its structure and density in response to the mechanical forces placed on it. This means that to stimulate bone formation, exercise must place meaningful load on the skeleton. The exercises with the strongest evidence for improving or maintaining bone density are progressive resistance training and high-impact weight-bearing exercise. Walking, swimming and cycling — despite their cardiovascular and general health benefits — produce relatively minimal bone loading stimulus compared to resistance training and impact exercise.
Progressive resistance training — using weights or resistance bands to progressively increase the load on the skeleton — produces consistent improvements in bone density at the loaded sites. Site-specific loading is important: upper limb resistance exercises load the wrist, radius and humerus; lower limb loading and squatting load the hip and femur; spinal loading exercises stimulate lumbar vertebral density. Well-designed resistance training programs have been shown to reduce fracture risk independently of their effect on bone density, likely through the additional mechanisms of improved muscle strength, balance and fall prevention.
High-impact exercise — jumping, skipping, step aerobics — produces peak ground reaction forces that stimulate bone remodelling, but requires careful individual assessment in people with established osteoporosis or vertebral fractures where high-impact loading carries fracture risk.
Safety considerations for osteoporosis exercise
This is the most clinically important section for patients with established osteoporosis or vertebral fractures. Certain exercises must be avoided or modified to prevent fragility fractures during exercise itself.
Forward spinal flexion under load — crunches, sit-ups, bent-over rows, toe touches — places compressive and shear forces on the anterior vertebral bodies that can cause vertebral crush fractures in patients with significant spinal osteoporosis. Spinal flexion exercises are generally contraindicated in osteoporotic vertebral fracture patients. Back extension and neutral spine positions are preferred. This is one of the reasons that standard gym or group exercise programs designed for the general population are not appropriate for osteoporotic patients without modification.
High-impact activities for patients with very low bone density or existing fractures require careful individual assessment — the fracture risk from the exercise may outweigh the bone loading benefit.
How can physiotherapy and exercise physiology help?
Physiotherapy plays a vital role in the management of osteoporosis by focusing on improving balance, strength, and flexibility. A tailored physiotherapy program can design exercises to enhance bone health, muscle strength, and posture.
Physiotherapy assessment identifies the individual's current bone density, fracture history, balance status and exercise capacity, and designs a program calibrated to their specific situation — progressing safely toward the loads needed for bone health without the positions and movements that carry fracture risk.
Falls prevention is as important as bone density improvement in osteoporosis management. A strong bone in a person who falls is still a fracture, and most osteoporotic fractures are precipitated by falls. Balance training, lower limb strengthening, reaction time training and home hazard modification address the fall risk that is the proximate cause of most fractures. Our Balance and Bones exercise classes are specifically designed for this population — combining the resistance training stimulus needed for bone health with the balance and coordination work needed for falls prevention, in a monitored, small-group environment.
Exercise physiology contributes to the structured progressive resistance training and cardiovascular conditioning programs that require specific program design expertise and ongoing progression. Eligible patients can access exercise physiology through a Chronic Disease Management Plan with GP referral.
Clinical Pilates provides an excellent low-impact exercise environment for osteoporosis patients when specifically adapted — emphasising spinal extension rather than flexion, incorporating axial loading through standing and weight-bearing positions, and building core and gluteal strength in positions that are safe for the osteoporotic spine.
Our physiotherapists Bethany Kippen and Emma Cameron and Exercise Physiologist Ash O'Regan all have experience in osteoporosis management and are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
