Note: nothing in this blog is intended to be taken as medical advice or in place of medical advice from a health professional. It is recommended to seek personal advice for your specific needs. 

In the last 5 years there have been a number of systematic reviews (things that collate all available research on a topic) as well as region specific management guidelines that discuss the optimal exercise for preventing & managing osteoporosis. 

A common feature is that the studies are so different that they can’t easily collate the information together or make any claims with strong certainty. Because so many factors influence the outcomes of an intervention, this is pretty common in healthcare research. Each review also makes slightly different conclusions from the studies they have included. 

Despite this, there are some consistencies that appear from these studies and practice guidelines: 

1. Exercise likely has a positive impact on bone density & therefore meeting exercise guidelines (a minimum of 150 minutes per week) is important. 
2. To improve bone density:
3. Exercise must target all major muscle groups to effectively target the whole skeleton. 
4. Strength based exercise that is hard, and made progressively harder over time is necessary. 
5. This type of exercise should be performed a minimum of 2-3x per week 
6. A combination of interventions is likely to be more beneficial than a sole intervention (i.e. strength training + impact training)
7. Balance training should be incorporated to reduce falls risk. 

Resistance training provides an effective way to load the entire skeleton, while also progressively overloading over time. Progressive overload = exercises need to be made harder once they become easy. 

This is GENERAL advice; for some people, they may maintain their bone density effectively without ever picking up a weight. However, for those people who have osteoporosis/osteopenia and are wanting to try and change their situation through exercise, it is necessary to provide realistic advice about what might be the most effective way to go about doing this.

Though exercises like yoga and pilates are a form of resistance training, it is difficult to progressively overload them in a way that is likely to build bone (Fernández-Rodríguez, 2020). 

A look at the last 5 years in bone density research (through systematic reviews)



Defining low intensity and high intensity lifting in the context of resistance training 

Before going into any more detail about these studies, I want to clear up a few terms: a lot of the studies refer to ‘high intensity resistance training’. Specifically in relation to resistance training, this term refers to weights that are very heavy for the person. I.e. high intensity refers to weights that are 80-85% of a person’s 1 repetition maximum or 1RM lift. This means a weight that someone could lift once, and only once, which is their true 1RM; a weight that is 85% of 1RM is a weight they could lift only 5 times. A weight someone could only lift 10 times is equivalent to about 75% 1RM. So in this context, high intensity = >80%1RM, so a weight someone could lift only 1-5 times; moderate intensity = 60-80% 1RM (~10-15 reps); low intensity = 40-60% 1RM (20-30 reps). 

There is a difference between lifting a light weight (40% 1RM, for example) for say, 10 reps, which would be a very low effort overall exercise, and lifting that same weight until failure, i.e. lifting it until no more reps could be completed, which might mean lifting it 30 times or more, which would be very tiring and hard. This is a really important distinction to make.  

Here are the summaries of the UK, Canadian, and Australian guidelines: 

UK guidelines - Brooke-Wavell et al., 2023

• Strength training
• For all people with osteoporosis, it is recommended to do strength based exercise 2-3x per week
• Strengthening should include progressive muscle resistance training
• Work up to a maximum weight that can be lifted 8-12 times for 3 sets 
• All muscle groups should be targeted including back muscles 
• General exercise
• Daily physical activity is recommended as a minimum 
• People should be encouraged to continue forms of exercise they enjoy
• Impact loading
• For those safe to do so, moderate impact exercise is recommended on most days: ideally about 50 moderate intensity impacts (5 sets of 10) with a low impact exercise in between 
• Low impact exercise like walking is recommended for those people who are not able to safely perform moderate to high intensity impact exercise 
• Balance training
• Falls prevention may factor in for those less steady or older individuals though balance training likely to be covered by a number of the impact/ strength exercises 
• Precautions
• Individualised exercise prescription from a trained health professional is recommended 
• Rapid, repetitive, end of range, sustained or weighted end of range twisting and flexion spine movements should be avoided for those at high risk of fracture 

Canadian guidelines (Morin et al., 2023)

• Strength training
• Balance and functional training should be performed at least twice per week 
• Progressively increase resistance training and balance training over time to achieve progressive overload
• Resistance exercise should target major muscle groups in upper and lower body as well as abdominals and back
• General exercise
• People should be encouraged to continue forms of exercise they enjoy, but be aware that these should not take the place of resistance and balance exercises
• People should aim to exceed 150 minutes of moderate to vigour physical activity per week 
• Impact exercise
• If safe to do so, impact exercise should be performed at a moderate intensity and progressed to high impact over time 
• Precautions
• Rapid, repetitive, end of range, sustained or weighted end of range twisting and flexion spine movements should be avoided for those at high risk of fracture 
• Individualised exercise prescription from a trained health professional is recommended 

Australian guidelines (Healthy Bones Australia, 2024)

• Strength training
• It is recommended to do 2-3 sets of maximal weights that can be lifted for 5-8 repetitions, 2-3 days per week,
• Exercise should be progressive heavier over time and should include the whole body, including back muscles and back extension in particular 
• Note that patients with very low BMD may require lower weights and higher repetitions to start with
• Impact loading
• 50 impacts of 2-4x body weight (moderate intensity) should be performed a minimum of 3 days per week, introduced gradually and performed according to what is safe for the patient
• General exercise
• Accumulate at least 3 hours a week of any exercise that helps balance
• Aim to encourage exercise, rather than coaching patients to avoid particular types of exercise 
• Precautions
• Excessive spine flexion and twisting should be avoided 
• Recommend submaximal lifting below 1RM for safety considerations 
• For people with an osteoporosis diagnosis, exercise should be supervised 

Systematic reviews from the last 5 years 

Souza et al. 2021

This study compared the effects of low and moderate intensity resistance training with high intensity resistance training on bone density in middle aged and older people. 

It specifically challenged the notion that high intensity training, that is, lifting weights so heavy you are only able to lift them 1-5 times (> or = to 80-85% 1 RM or 1 rep max), is superior to moderate intensity (weights you can lift 10-15 times or 60-80% 1RM) exercise for bone density. They correctly identify that the main studies that indicate it is necessary to complete high intensity weight lifting did not compare this intervention directly to to moderate intensity lifting, rather to very light exercise, and as such it is not reasonable to conclude specifically that high intensity is more effective than moderate intensity lifting. 

They argued that muscle tissue itself may be positively associated with bone health, that is, having larger muscles may facilitate having higher bone density. To increase the size of muscles, it is not necessary to lift with a high intensity (low reps close to 1RM), it is simply necessary to lift weights towards failure. This finding is backed up by recent research by Lasevicius et al. in 2022. Their review found that results on bone density improvement with resistance training was similar with high intensity vs low and moderate intensity lifting, provided effort was adequate.  

This is really important - it does not mean that lifting relatively ‘light’ weights for a given number of reps is just as effective as lifting heavy weights; it means that it is necessary to go towards failure, which might mean lifting those weights for very high repetitions. Either way, high intensity or low/moderate intensity, the exercise needs to be ‘hard’ for the person.

As stated by the authors, lifting weights in this manner is often quite unpleasant and as such this may be a deterrent to reaching the desired effect, which may lead people to choose heavier weights for lower repetitions in a practical setting. 

It is important to note that half the studies included in this review did show an increased effect of high intensity training compared to lower load resistance training, while no studies found an increased effect of low load training compared to high load. The authors also found that higher loads are likely to correlate to more significant improvements in people who have higher baseline BMD, and that higher intensity exercise may be more effective at improving BMD at the hip compared to low and moderate loads. 

The main take-aways from this are that it is not necessarily required to lift very heavy weights at low repetitions to have a positive impact on bone density, and that as long as effort is matched, low and moderate loads may work just as well, though applying this practically can have challenges. 

Kitagawa et al. 2022 

This study compared high intensity resistance training (> 80% 1RM) and high impact loading (>4x bodyweight, defined as jumps with stiff legged landing and high load aerobics) to moderate intensity resistance training (60-80% 1RM) and moderate intensity impact loading (ground reaction force between 2-4x body weight, defined as hard heel drops and light aerobics) on postmenopausal women with osteoporosis. 

It found that high intensity exercise was more effective than moderate intensity however these findings were very low certainty in nature. The study found that performing exercise more frequently likely correlated to more specific improvements, recommending performing the exercises 2-3 times per week. It also found that improvements in bone density were found at the lumbar spine but not at the femoral neck, which is fairly consistent across the research. 

Alnasser et al. 2025

This study compared lots of different types of exercise and their impact on bone density across the lifespan, ranging across young through to older adults. The aim of the study was more to look at the effects of progressive exercise loading compared to no exercise. The findings were generally that all exercise can help improve bone density, provided it is progressive.

Xiaoya et al., 2025

This study compared resistance training and aerobic training interventions for improving BMD in post-menopausal women. It found that it was possible to improve BMD at both the femoral neck and the lumbar spine, and that the most effective modalities were resistance training combined with aerobic training, or resistance training alone to a lesser extent. The authors determined that aerobic training may have a positive effect on BMD for its impact on metabolic and endocrine functioning.  

A few studies mentioned whole body vibration, however at present none of the guidelines suggest it, and some draw backs are that it does not improve strength or balance and so it may not be as all-around effective as other modalities, though we will keep our eye on the research to see if anything changes in that space. 

Limitations of the research generally:

A major limitation of all research in this space is that it tends to be quite short in duration, which is tricky because bone changes very slowly. For example, a study by Nicholson et al. 2015 found that body pump, a low intensity, high rep class that does not go near to failure with the exercises performed is effective at maintaining bone density in the lumbar spine in post-menopausal women. It would be interesting to know, however, if this result would still be the case in 5-10 years time, as people are unlikely to have been able to significantly change or progress their weights in that time.  

It is also important to recognise that there is a difference in maintaining vs building bone density, and a difference in exercise effects for people with osteoporosis or osteopenia and those without.  

As always, treatment interventions need to be tailored to the individual. A 75 year old woman with osteoporosis who has never exercised is likely to need a different intervention to a 60 year old woman who runs and does pilates 5 times week with osteoporosis.  

If you are not sure how to get started, book in with one of our physios, in person or online to start your own tailored program. 

References:

1. Alnasser, S. M., Babakair, R. A., Al Mukhlid, A. F., Al hassan, S. S. S., Nuhmani, S., & Muaidi, Q. (2025). Effectiveness of Exercise Loading on Bone Mineral Density and Quality of Life Among People Diagnosed with Osteoporosis, Osteopenia, and at Risk of Osteoporosis—A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 14(12), 4109. https://doi.org/10.3390/jcm14124109 
2. Brooke-Wavell K, Skelton DA, Barker KL, Clark EM, De Biase S, Arnold S, Paskins Z, Robinson KR, Lewis RM, Tobias JH, Ward KA, Whitney J, Leyland S. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. Br J Sports Med. 2022 May 16;56(15):837–46. doi: 10.1136/bjsports-2021-104634. Epub ahead of print. PMID: 35577538; PMCID: PMC9304091.
3. Fernández-Rodríguez R, Alvarez-Bueno C, Reina-Gutiérrez S, Torres-Costoso A, Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V. Effectiveness of Pilates and Yoga to improve bone density in adult women: A systematic review and meta-analysis. PLoS One. 2021 May 7;16(5):e0251391. doi: 10.1371/journal.pone.0251391. PMID: 33961670; PMCID: PMC8104420.
4. Kitagawa T, Hiraya K, Denda T, Yamamoto S (2022), A comparison of different exercise intensities for improving bone mineral density in postmenopausal women with osteoporosis: A systematic review and meta-analysis, Bone Reports, Volume 17, 2022, 101631, ISSN 2352-1872, https://doi.org/10.1016/j.bonr.2022.101631. (https://www.sciencedirect.com/science/article/pii/S235218722200465X)
5. Lasevicius T, Schoenfeld BJ, Silva-Batista C, Barros TS, Aihara AY, Brendon H, Longo AR, Tricoli V, Peres BA, Teixeira EL. Muscle Failure Promotes Greater Muscle Hypertrophy in Low-Load but Not in High-Load Resistance Training. J Strength Cond Res. 2022 Feb 1;36(2):346-351. doi: 10.1519/JSC.0000000000003454. PMID: 31895290. 
6. Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, Santesso N, Ridout R, Ward W, Ashe MC, Bardai Z, Bartley J, Binkley N, Burrell S, Butt D, Cadarette SM, Cheung AM, Chilibeck P, Dunn S, Falk J, Frame H, Gittings W, Hayes K, Holmes C, Ioannidis G, Jaglal SB, Josse R, Khan AA, McIntyre V, Nash L, Negm A, Papaioannou A, Ponzano M, Rodrigues IB, Thabane L, Thomas CA, Tile L, Wark JD; Osteoporosis Canada 2023 Guideline Update Group. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10;195(39):E1333-E1348. doi: 10.1503/cmaj.221647. PMID: 37816527; PMCID: PMC10610956.
7. Nicholson VP, McKean MR, Slater GJ, Kerr A, Burkett BJ. Low-Load Very High-Repetition Resistance Training Attenuates Bone Loss at the Lumbar Spine in Active Post-menopausal Women. Calcif Tissue Int. 2015 Jun;96(6):490-9. doi: 10.1007/s00223-015-9976-6. Epub 2015 Mar 14. PMID: 25772806.
8. Xiaoya L, Junpeng Z, Li X, Haoyang Z, Xueying F, Yu W. Effect of different types of exercise on bone mineral density in postmenopausal women: a systematic review and network meta-analysis. Sci Rep. 2025 Apr 5;15(1):11740. doi: 10.1038/s41598-025-94510-3. PMID: 40188285; PMCID: PMC11972399.