I recently had the opportunity to hear Dr. Belinda Beck* speak about the Onero exercise program that she developed for the prevention of osteoporotic fracture. Onero translates to “overload” in Latin, and that is precisely what the program aims to do: progressively overload the bones of its participants, (who are largely postmenopausal women with osteoporosis), using high resistance.
The genesis of this program was the 2018 LIFTMOR trial that I describe below. I listened to Dr. Beck’s presentation with great interest, but also with concern, and that is the subject of this month’s blog.
What the LIFTMOR Trial Revealed
The LIFTMOR trial, (Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation) (1) was the first study to compare the effectiveness of high-intensity resistance and impact training (HiRIT) against low-intensity exercises in postmenopausal women with low bone mass.
The trial involved 101 women who were randomly assigned to different exercise programs over eight months. The HiRIT group did exercises such as squats, deadlifts, overhead shoulder press, and jump chin ups with drop landings. The amount of resistance was gradually progressed, and the sessions were supervised for safety and proper technique. Meanwhile, the control group received unsupervised, low-intensity home-based exercise.
The findings were that the HiRIT group showed superior bone density improvement, with no fractures or major injuries reported by the participants.** Therefore, the researchers concluded that the LIFTMOR trial is “the first to show that a brief, supervised, twice-weekly HiRIT exercise intervention was efficacious and superior to previous programs for enhancing bone at clinically relevant sites…in postmenopausal women with low to very low bone mass” (1).
This should be welcome news to anyone who assumed that because of their osteoporosis, they should never lift anything heavier than five pounds for the rest of their life, whether it’s a grocery bag or a dumbbell. Any healthcare professional who advises that is simply not keeping up with the research.
HOWEVER…
Even though the results of the LIFTMOR trial challenge the notion that those with osteoporosis should be limited to low intensity exercise, it is very clear to me that HiRIT is not for everyone. Some may be extremely reluctant and fearful, and many are just plain uninterested. In her talk, Dr. Beck commented that the Onero program (or HiRIT in general) is the only exercise approach that will help those with osteoporosis or low bone density.
This is deeply worrisome. Many (perhaps most) people I have worked with who have osteoporosis are already feeling discouraged and anxious. The implication that if they can’t do Onero, they might as well just stop bothering with any exercise at all potentially adds to that feeling of hopelessness.
I understand that Dr. Beck was in the US to promote her program which is now commercially available, and I will always promote a supervised HiRIT approach when appropriate. BUT I also promote the important work of others, such as Dr. Laura Giangregorio and her Too Fit To Fracture Program (2). Interestingly, Dr. Giangregorio is currently recruiting subjects for a new study named Fortify Bones. The aim of this study is to help inform exercise recommendations for people with osteoporosis or low bone mass, because “we don’t know what intensity of exercise is best” (3).
Many researchers have demonstrated that a combination of exercise types is best, including the recent guidelines from the American Physical Therapy Association that I adhere to (4,5).
LaMonte and colleagues followed 77,206 postmenopausal women aged 50 to 79 from the Women’s Health Initiative for over five years and found that even mild activity and walking were associated with lower hip fracture risk (6). I think it’s safe to say that most of us are more concerned with not breaking a hip than we are with the T-scores on our DXA scans.
Katzman and colleagues demonstrated that the benefit of posture-based exercises (many of which we do in Strong Bones class) significantly improved the postural alignment of the 112 subjects in the study (7). The correlation of better posture with fall prevention is well documented, and this valuable study added to that consensus. Again, I’d rather not fall, and not break a bone, than have a better T-score.
In another study, Kitagawa and colleagues aimed to compare the effects of moderate- and high-intensity resistance and impact training (MiRIT and HiRIT, respectively) on changes in bone mineral density in postmenopausal women with osteoporosis (8). They found that postmenopausal women with osteoporosis may achieve more significantly improved lumbar spine BMD with HiRIT than with MiRIT. However, the researchers concluded that: “The certainty of evidence was extremely low because of the risk of bias, inconsistency among studies, and imprecision in terms of sample size”.
The Takeaway
The pros and cons outlining the effectiveness of high-intensity/high impact versus low-intensity/low impact exercise for building bone has been (and continues to be) extensively studied. We know that exercise can improve bone metabolism and density, improve our posture and balance, and help prevent falls. This makes exercise a very effective non-pharmacologic approach to improving bone health, even if it doesn’t always translate to an improved DXA scan.
We need to move – not only for our bones but also for our overall health and fitness. I strongly believe, and the research concurs, that anything is better than nothing. BUT, when we feel ready, we must challenge ourselves! This could certainly come in the form of using heavier weights, but for some it may come by taking a longer, faster walk. Maybe it could come in the form of trying something new, like taking a dance class.
My mission with Strong Bones is to get people moving safely and effectively, and Strong Bones students have repeatedly told me that their fitness, balance, and strength have improved in ways they never thought possible.
Here’s what one Strong Bones participant recently shared:
Joanne Fagerstrom, PT stays abreast of research in her field and shares her vast knowledge – during exercise sessions, on her blog, in after-class Q&As, and in private consultations. She encourages progress beyond our current level of exercise intensity – when that is possible! – and suggests activities beyond what we do in class, e.g., “exercise snacks” and other best practices.
More intensive programs may require supervision, but the evidence-based Strong Bones program is completely safe – without supervision. Furthermore, the benefits of intensive exercise are not clear, especially for women over 50. – Lisa Widawsky
See you in Strong Bones class!
*Dr. Beck is a Professor of Exercise Science at Griffith University in Queensland, Australia and the Director of The Bone Clinic which is a research and clinical practice facility for patients with osteoporosis.
** The only adverse event during this study was a participant who experienced a mild low-back muscle strain.
- Watson SL, et al. High‐intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women with Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research 2018;33:211–220.
- Giangregorio LM, et al. Too Fit To Fracture: Outcomes of a Delphi Consensus Process on Physical Activity and Exercise Recommendations for Adults with Osteoporosis With or Without Vertebral Fractures. Osteoporosis International 2015 Mar;26(3):891-910.
- https://uwaterloo.ca/bone-health-exercise-science-lab/projects/fortify-bones
- Hartley GW, et al. Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis. Journal of Geriatric Physical Therapy 2022 Apr-Jun 01;44(2):E106-E119.
- Kast S, et al. Effects of Different Exercise Intensity on Bone Mineral Density in Adults: A Comparative Systematic Review and Meta-analysis. Osteoporosis International 2022 Mar 18.
- LaMonte MJ, et al. Association of Physical Activity and Fracture Risk Among Postmenopausal Women. JAMA Network Open 2019 Oct 2;2(10):e1914084.
- Katzman WB, et al. Long-Term Efficacy of Treatment Effects After a Kyphosis Exercise and Posture Training Intervention in Older Community-Dwelling Adults: A Cohort Study. Journal of Geriatric Physical Therapy 2021 Jul-Sep 01;44(3):127-138.
- Kitagawa T, et al. A Comparison of Different Exercise Intensities for Improving Bone Mineral Density in Postmenopausal Women with Osteoporosis. Bone Reports 2022 Oct 21;17:101631.
