Does strength training help against osteoporosis just as well as medication?

Strength training measurably increases bone density in the spine and hip in postmenopausal women. In one study using heavy training (more than 85% of maximum weight, twice a week), bone density in the lower back rose by 2.9%, while it fell by 1.2% in the group that did not train. Many studies combined confirm this: the effects on the spine and hip are consistently positive, though the results vary quite a bit. Training heavily (at least 70% of your maximum), three times a week for at least 48 consecutive weeks, appears to work best.

Medications such as bisphosphonates (sometimes called 'bone protectors', for example alendronate) and denosumab (an injection that slows bone breakdown) have been proven in a different area: they reduce the risk of spinal fractures by more than 50 per 1,000 person-years and hip fractures by 6 per 1,000 person-years. This has been shown in large studies in people. However, they only stop bone breakdown for as long as you use them; once you stop, the loss resumes. They also do not improve your muscle strength, your balance, or your overall stability.

A direct comparison between strength training and medication on fracture risk does not exist in the available research. Medications have solid fracture-related data; for strength training, this kind of direct evidence is lacking. What strength training does offer that medication does not: it simultaneously improves muscle strength, balance, and muscle mass. These are precisely the factors that help prevent falls and, with them, bone fractures. A programme that combines several types of exercise also reduces the risk of falling and improves quality of life.

Many people are uncertain about the safety of training intensively with osteoporosis, but in the supervised study only one mild back cramp occurred over eight months. That is reassuring, though the supervision was professional and intensive, and that result does not automatically apply to training without supervision. Walking alone, by the way, is not enough: guidelines explicitly consider it insufficient for treating osteoporosis.

Guidelines treat strength training and medication as complementary to each other, not as alternatives. For a moderately elevated risk, intensive strength training with proper supervision is a serious addition to medication. For a very high fracture risk, such as after a recent spinal fracture, bone-building medications such as teriparatide are the first choice and cannot be replaced by exercise.