Does physiotherapy really help if you already have osteoporosis?

Intensive strength training works best for the bones themselves. A study of 49 postmenopausal women with osteoporosis or low bone density showed that training intensively twice a week under supervision increased bone density in the spine by almost 3%, while the control group that did not do the same actually lost bone mass. The femoral neck (top of the thigh bone, a common fracture site) remained stable in the training group but declined in the control group. A large meta-analysis of 84 study groups confirms this pattern: virtually every type of exercise, from strength training to weight-bearing sports, measurably improves bone density at multiple sites. The gains are modest: bones do not become spectacularly stronger, but loss is slowed or reversed.

Beyond the bones themselves, supervised exercise also improves daily functioning quickly. After just 4 weeks of a combined programme of strength training, balance exercises and aerobic training, women showed measurable improvements in getting up, maintaining balance and walking. After 12 weeks they scored clearly better on all measures than peers who did nothing. Notably, fear of falling also decreased substantially. This is not a minor detail: fear of falling can make people with osteoporosis so cautious that they move less and less, which in turn increases the risk of falls and fractures.

The question of whether intensive training is safe in osteoporosis is understandable, but the answer is more nuanced than many people think. In the intensive training study mentioned above, only one minor incident occurred over eight months: a brief back spasm that caused someone to miss two sessions. Not a single fracture occurred. That is reassuring, but an important caveat applies: all participants were otherwise healthy, and the programme took place under close professional supervision. Seeking the same intensity at home without supervision is not supported by this research.

The evidence for swimming and pilates is considerably thinner. Swimming appears to improve bone density, but only at three to six hours per week, and that is based on just five small studies. Pilates scores better than doing nothing in most studies for pain and movement, but there are too few good studies to make firm statements specifically about bone density. When a vertebral fracture has already occurred, physiotherapy is part of standard treatment, but that is a guideline recommendation, not a figure from a study.

None of the studies was able to establish unequivocally which type of exercise is most optimal. What is clear: more is better than less, higher intensity is better than light, and supervision makes it both more effective and safer. If you have osteoporosis and want to start exercising, professional guidance from a physiotherapist is not a luxury but a prerequisite for both achieving the greatest benefit and exercising safely.