Does strength training work as well as medication for osteoporosis?

Strength training measurably increases bone density in the spine and hip in postmenopausal women. In a randomised study using high-intensity training (more than 85% of the maximum weight, twice a week), lumbar spine bone density rose by 2.9%, while it fell by 1.2% in the control group. Two meta-analyses of 17 studies each confirm this pattern: effects on the spine and femoral neck are consistently positive, although outcomes vary considerably between studies. High intensity (at least 70% of the maximum), training three times a week, and a programme of at least 48 weeks appear to work best.

Medications such as bisphosphonates and denosumab have been proven on a different front: they reduce the risk of vertebral fractures by well over 50 per 1,000 person-years and hip fractures by 6 per 1,000 person-years. This has been demonstrated in large clinical studies. However, they only halt bone loss for as long as you take them; once you stop, the loss resumes. They also do not improve muscle strength, balance, or overall stability.

A direct comparison of strength training and medication on fracture risk does not exist in the available research. Medications have hard fracture-related data; this kind of direct evidence is lacking for strength training. What strength training does offer that medications do 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 multiple forms 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 minor back cramp occurred over eight months. That is reassuring, yet the supervision was professional and intensive; such a result does not automatically apply to unsupervised training. Walking alone, incidentally, is not enough: guidelines explicitly regard it as insufficient for the treatment of osteoporosis.

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