In recent years, there has been a rise in popularity in glucagon-like-peptide-1 medications, commonly referred to as GLP1s and more likely to be known under their brand names such as Ozempic, Wegovy or Mounjaro. These medications are commonly used to treat type 2 diabetes and certain brands are approved in Australia to be used for chronic weight management. With a number of patients coming through our doors taking these medications, it prompted us to have a look at their impact on bone health. Diabetes impact on bone health According to Healthy Bones Australia, people with type 1 diabetes are at a higher risk of having low bone mass, as the condition can impact them at at time when they are building the majority of their skeletal mass, in childhood and adolescence. While type 2 diabetes is different, and may not have a direct impact on bone density, those with type 2 diabetes have a higher lifetime risk of developing a fracture. The reasons appear to be multi-factorial, some relating to the impact higher blood sugar can have on bone density and architecture, and others relating to complications that can arise as a result of the condition that may result in increased risk of falls later in life. GLP1-s and bone health According to a review by Zhao et al. in 2017, GLP1 medications may be beneficial to bones, if we consider them in isolation to any weight loss. That is, the drugs themselves may actually have a bone preserving effect, though research is currently inconclusive. The main outcome of taking these medications is significant weight loss, and it is actually this that is most likely to have a detrimental effect on muscle and bone health. Studies looking at the impact of these drugs show that in the studies spanning 68-72 weeks, participants lost up to 10% of their muscle mass, which is the equivalent to the muscle mass lost across 20 years of ageing (Mechanick et al., 2025). Another study found that between 25-39% of all weight loss while taking these medications is from muscle mass (Prado et al., 2024). With such rapid loses of muscle, and even just considering the significant loss of size that accompanies significant loss of body mass, it is necessary to consider the bones. Our bones remain dense directly in correlation to how much force is put through them. That is, how much our muscles are contracting and pulling on the bones. With less muscle mass, and less body mass, there is less loading on the bones, and as such losses in bone density can accompany losses in body weight, particularly when occurring in such high amounts and at such high speeds (Jensen et al., 2024). How to reduce muscle and bone loss There are a couple of really important considerations from an allied health standpoint when taking these medications and that is to consult with a dietician alongside taking these medications to avoid completely depriving the body of the nutrients required to continue to function in a healthy manner. The other is to commence resistance based exercise program to maintain muscle and bone mass and to mitigate loss of these tissues as much as possible. Some early research has indicated that exercise can mitigate bone density losses associated with these medications (Jensen et al., 2024). Many GPs are sending their patients for DEXA scans prior to starting these medications as well as referring to physio/exercise physiology and dietetics to facilitate appropriate support throughout the process. This may be particularly important in the context of diabetes or other co-morbidities that might already impact bone health. Take aways: GLP1s like Ozempic and Wegovy are being prescribed for diabetes management and in some cases for chronic weight management A side effect of these medications is often significant weight loss Significant weight loss is likely to include muscle mass Loss of muscle mass results in loss of bone & can be dangerous to your health in the long term You can mitigate these effects with appropriate dietary measures as well as by doing resistance training Getting regular DEXA scans while on these medications likely to help in monitoring their effect on these aspects We offer 1:1 consultations and small group classes to help you with an exercise program to help support you when taking these medications. Click here to get started with any of our physios. References: Healthy bones Australia, https://healthybonesaustralia.org.au/resource-hub/fact-sheets/diabetes-bone-health/ . Zhao C, Liang J, Yang Y, Yu M, Qu X. The Impact of Glucagon-Like Peptide-1 on Bone Metabolism and Its Possible Mechanisms. Front Endocrinol (Lausanne). 2017 May 3;8:98. doi: 10.3389/fendo.2017.00098. PMID: 28515711; PMCID: PMC5413504. Mechanick JI, Butsch WS, Christensen SM, Hamdy O, Li Z, Prado CM, Heymsfield SB. Strategies for minimizing muscle loss during use of incretin-mimetic drugs for treatment of obesity. Obes Rev. 2025 Jan;26(1):e13841. doi: 10.1111/obr.13841. Epub 2024 Sep 19. PMID: 39295512; PMCID: PMC11611443. Prado, Carla M et al. (2024), Muscle matters: the effects of medically induced weight loss on skeletal muscle, The Lancet Diabetes & Endocrinology, Volume 12, Issue 11, 785 - 787 Jensen SBK, Sørensen V, Sandsdal RM, Lehmann EW, Lundgren JR, Juhl CR, Janus C, Ternhamar T, Stallknecht BM, Holst JJ, Jørgensen NR, Jensen JB, Madsbad S, Torekov SS. Bone Health After Exercise Alone, GLP-1 Receptor Agonist Treatment, or Combination Treatment: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2024 Jun 3;7(6):e2416775. doi: 10.1001/jamanetworkopen.2024.16775. PMID: 38916894; PMCID: PMC11200146.

Hi! I’m Jaslynn, I’m the physiotherapist who just joined FKB Physio this month. I graduated from the University of Queensland in 2023 and have since mainly worked in private practice settings. A bit about myself I’m actually from Singapore. I moved here for studies and then stayed for work! Outside of being a physiotherapist, I illustrate designs for t-shirts, occasionally do Brazilian jiujitsu and regularly go to the gym. I’m also miserably trying to work on my cardiovascular fitness. I have a rather terrible caffeine habit that I wish I could kick but alas… coffee is too good to resist. Why did I become a physiotherapist?  I was very fortunate to have had very positive experiences with allied health and alternative health practitioners when I was growing up. Their care and support left a strong impression on me, and I grew up thinking I would love to be able to pay it forward and do that for someone else. After completing high school, I originally considered studying medicine. However, after seeing the lifestyle my sister (who is now a family doctor) led, I didn’t think I would enjoy it. So I started exploring other health professions. I was also interested in fitness at the time, and would get plenty of social media content from physiotherapists on my feed and that sparked my interest! To explore this possibility more, I shadowed physiotherapists in hospitals. I very nearly got put off by it as I was mainly shadowing inpatient physiotherapy and it wasn’t really what I could see myself doing. But on one of the last few days, I got to shadow a physiotherapist on the outpatient department. Immediately I thought; this is it. This is what I want to do. I’m not even joking when I say I had tears in my eyes at that point, but it does sound rather overdramatic now, looking back! Anyway, from then on, I became fully committed to becoming a physiotherapist. Funnily enough, I actually never personally saw a physiotherapist until I was about 18, which is when I started Brazilian jiujitsu and exposed myself to a new world of injuries. Injuries? I’ve had my fair share of injuries, given that I’ve done Brazilian jiujitsu for about 7-8 years now and was pretty obsessive for some of those years. But the one that has affected me the most, and also shaped the way I treat as a physiotherapist, would be my shoulder subluxation in March 2023. To be honest, it was almost entirely my fault. I was competing on that day and had 9 matches. About halfway through my 5 th match, I felt a click or small pop in my shoulder and immediately lost almost all my strength in it. Somehow, I managed to pull through and win that match. A wise person would have stopped there. But I was young and foolish, so obviously, I didn’t. I did a couple of shoulder tests on myself with the assistance of a fellow physiotherapy student, and thought I’d give it a go and at worst I’d just stop if it got really bad. I never got the chance to stop. My left shoulder got into an end range position which I get into all the time in training – but this time I had obviously already damaged some stabilizing structures. I felt my left shoulder shift out of place. It was the most disgusting feeling I’ve ever had in my life, but luckily enough the subluxation spontaneously reduced on the spot. It was the worst injury I’ve had in my life, which really isn’t that bad compared to some of the really messed up injuries you can get. I didn’t have any fractures from it thankfully, nor did I tear any of the rotator cuff muscles, though I believe I did get some labral damage. It did, however, put me out of action from jiujitsu. I wouldn’t say it was a bad thing overall. I learnt a lot about shoulder management from that experience, and also gained a much deeper understanding of patient’s experience of injury. It’s probably not the best way to go about gaining empathy for patients, but it definitely is one of the most effective! An injury is never just physical, it also has emotional, social and psychological impacts. The injury gave me insight to these things, and I think it has made me a much better physiotherapist overall. That’s also why I have a passion for working with athletes, especially martial arts athletes, to reduce injury risk and improve function. But to be honest, this is not really limited to athletes, they apply to most of the general population as well. Anyone who is facing injury, pain or any other dysfunction would know how it can affect their life. And I have come to really realize the importance of having guidance through that process, and being really grateful I can provide that to someone going through an injury, managing pain or other dysfunction. I guess in a full circle sort of moment, I realized I have become a source of support for people going through health concerns like what I received when I was young! So that’s the story of how I got into physiotherapy and my experiences with injury. I think the body’s ability to adapt after injury is amazing, and I think we’re finally in a new era where people are more receptive to actively work on it rather than just rest. It’s really encouraging to see all the class participants at FKBPhysio lifting heavy and working hard to get stronger and improve their health and bone density, and I’m so honoured that I get to be part of the process 😊

Take home points: - Physiotherapy's role in managing pain and injury is often largely about education, finding modifications to lifestyle and activity factors, and rehabilitating strength rather than passive treatment strategies - The medical system can be quick to refer for injections but often do not explain that these are not fixes - Tendinopathy is often not treated & ignored for other pathologies (like bursitis) which can often lead to inadequate management strategies - Early bone loading can facilitate faster/better recovery than complete rest and immobilisation after a fracture

Before we get started... Osteoarthritis: Osteoarthritis refers to joint pain and stiffness with associated joint changes, such as thinned cartilage and additional bone remodelling around a joint (i.e. extra bone laid down around a joint, changing its shape). Osteoporosis: weakened bones - NOT related to osteoarthritis and is asymptomatic Rheumatoid arthritis: an autoimmune condition that requires specific management This blog post specifically discusses osteoarthritis.

From dislocating her knees putting on her jeans to approaching her first 100kg deadlift, our physiotherapist Sarah talks about why she chose to become a physio, and why she is so passionate about supporting people with pain and hypermobility to learn safe ways to move their bodies.

This month it was world osteoporosis day. It feels like as good a time as any to go through a few of the more common misconceptions we hear in our clinic around bone health.

This year, healthy bones Australia released an updated position statement regarding the use of exercise to manage osteoporosis. This position statement was developed by an expert Working Group, Advisory Committee and a National Roundtable, and was released in February (2024). The guidelines are here if you want to check them out for yourself. In this blog, I will go over the major recommendations in this statement, as well as those made in similar guidelines that are available for the UK and Canada (as they are all slightly different). At FKB Physio we use a combination of these guidelines alongside clinical expertise to design our programs for osteoporosis prevention and management. DISCLAIMER: Please do NOT undertake any of the recommendations stated in this article on your own. There is an inherent risk associated with introducing exercise when you have poor bone health. The guidelines specifically indicate that exercise MUST be done under supervision. This article is NOT designed to be taken as medical advice. What’s osteoporosis again? If you want a bit of a refresh about exactly what osteoporosis and osteopenia are, you can click here. Briefly, osteopenia and osteoporosis are words that refer to poor bone health. A diagnosis is made once your bone density declines past a certain threshold. It is often only once a diagnosis of either osteoporosis or osteopenia has been made that people start to work on their bone health. Knowing that bone health essentially peaks at 30 and then slowly declines from there , it makes sense to both aim to maximise peak bone mass early in life , and work to reduce the decline in bone density associated with ageing as much as possible. This means paying attention to things that are good for bones as early as possible and continuing to do so across the lifespan. Exercise for osteoporosis management Exercise should always be part of osteoporotic management as medications may improve bone density but do not have any impact on reducing falls risk or sarcopenia (loss of muscle mass associated with ageing), or other impacts of osteoporosis such as loss of height and increased curvature of the upper back (hyperkyphosois). The osteoporosis guidelines specifically state that resistance training and balance exercises should be prioritised. Exercise obviously also carries some pretty significant other benefits, in that it can reduce the impacts of other co-morbidities such as high blood pressure and diabetes, among others. Additionally, independent of the relevance to osteoporosis and bone health, the WHO specifically recommends all adults participate in strength training at least twice a week. Less than 25% of adults in Australia currently meet these recommendations. This is something that is beneficial across the lifespan and I really do believe that encouraging all adults to take up strength training in a way that is enjoyable and sustainable for them is really, really important. Exercise for bone health recommendations I meet a lot of people who are very active and who have done their best to lead a healthy lifestyle and they have still ended up with osteoporosis, which seems very unfair! Remember that even with your best intentions, this condition can happen due to non-modifiable risk factors that are out of your control. I believe in trying to control the elements you can control, where possible, and it is here that having a little more information about what types of exercise are likely to be the most beneficial to the bones may be useful. Low impact exercise, such as mat pilates, walking, swimming, and cycling, will not have a positive effect on bone density (Kistler-Fischbacher et al., 2021). This is important to note as people often assume that the resistance offered with reformer pilates as an example is adequate, however, this does not appear to be the case. Running is also unfortunately not helpful for bone density - i will discuss why later in this post. Osteogenic loading – what is it? Osteogenic loading refers to loading that promotes bone growth or produces bone. During movement, the skeleton undergoes force from the muscles pulling on the bone, as well as ground reaction forces. Both of these types of force cause deformation of the bone or strain on the bone, which causes microdamage that stimulates the remodelling process (Warden et al., 2021). A particular magnitude of bone strain is required to facilitate the production of new bone (Healthy Bones Australia, 2024). It is thought that bone strain that is of a high velocity and high magnitude, that is, is large and is performed quickly causes the most significant response and consequently most significant improvement in bone health. It would seem that exposure to load also needs to be low volume (i.e. not too many repetitions) as the mechanoreceptors that detect mechanical loading of the bones become saturated quickly (Warden et al. 2021). As such, it seems that low repetition, low volume, high intensity doses of loading are the most effective. This translates to high muscle forces, i.e. lifting heavy weights, and high ground reaction forces i.e. impact loading (jumping). Exercises such as running, while being relatively high magnitude, are not effective due to their highly repetitive nature that lead to decreased sensitivity in the mechanoreceptors. It is also important to note that the loads required to facilitate bony adapation need to be significantly higher than those caused by activities of daily living. Bear in mind that the studies showing these findings are primarily animal studies and as such the results need to be interpreted with caution, however when we combine these findings with other research the findings become more likely, including: Observational studies showing increased bone density in sports with multi directional fast loading such as tennis as opposed to those with repetitive same direction loading such as running; Observational studies showing runners who strength train having higher bone density than those who don’t (Wardern et al. 2014) Studies such as the LIFTMOR trial that show improved bone density with heavy low rep lifting in comparison to high rep light lifting (Watson et al., 2017) We can be relatively sure that heavy lifting and high impact loading probably have some positive impact on bone health. 2024 recommendations (Healthy Bones Australia Position Statement): 1. Exercise prescription should follow general principles of osteogenic loading: The most osteogenic protocol includes low numbers of high intensity loads, including impact and resistance training 2. Exercise can reduce falls risk if performed > 3 hours per week and includes high level balance challenge. 3. Exercise for osteoporosis needs to include resistance training, balance training, and impact loading. 4. Exercise should be patient centred, with a focus more on how people can be active rather than messaging relating mostly to things that should be avoided. 5. Exercise interventions need to be tailored taking into account other co-morbidities. The osteoporosis guidelines specifically state that resistance training needs to be progressive, which means that the weights need to progressively increase over time where possible. These guidelines are fairly recent and quite a deviation from what was recommended historically for osteoporosis. Previously, high impact (i.e. jumping) and high intensity (i.e. heavy lifting) exercises were avoided in older adults and particularly those with osteoporosis due to the assumed risk of fracture it posed, however there have been few adverse events noted in recent studies using this type of exercise in participants with osteoporosis (Daly et al., 2020; Watson et al., 2017). That said, it is very important that this is done progressively over time, and if any period of time is taken off exercise, it must be re-introduced very gradually again. It is also VERY important to note that all guidelines suggest that this exercise should be supervised, as those with poor bone health do carry a higher risk of injury and as such exercise must be supervised and tailored by health professionals to minimise any adverse responses.

Prevalence Osteoporosis Australia estimate that in 2022, 6.2million Australians over 50 have osteoporosis, osteopenia, or poor bone health, which is 66% of all Australians over 50. Of these people, 22% have osteoporosis and 78% have osteopenia. It is estimated that 29% of health system expenditure on falls can be attributed to low bone density (Australian institute of Health and Wellness, 2023), and that osteoporosis and osteopenia cost the Australian healthcare system $2.75 billion annually. Though osteoporosis is thought to be something that primarily affects women, this is not to say that men are completely unaffected: men account for approximately 30% of osteoporotic fractures recorded. What is osteoporosis/osteopenia? Both of these conditions are diagnoses that are made based on your bone density, which is determined through a DEXA scan. The official diagnosis according to the WHO is made based on your T score, which is a measure of your bone density relative to an average healthy 30 year old person of the same sex. This is calculated based on how many standard deviations you are away from that person. If you are more than 2.5 standard deviations away from the 30 year old, you are considered to have osteoporosis. Being between 1 and 2.4 standard deviations away is osteopenia. Any better than this is considered normal. For people under 50, a T score is not used, rather a Z score is used which shows how far you are away from other people of your age and gender (Beck et al., 2017). This is likely because a T score is unlikely to be as sensitive at younger ages, that is, less able to detect an issue comparing to younger person so is more accurate comparing to your peers. Sometimes, on your scan you may see both the T and Z score. For example, I have had a patient in her 80s who had a T score of -1.2 that only just saw her into osteopenic range, which actually placed her above normal for her age, as seen with her Z score, which was +0.5. All of this is to say that these numbers are relevant, but are all recorded as relative values rather than set figures to aim for.

The "no excuses!" rhetoric might be motivating for some, but it can be damaging for others