Bone Health

You're unique, so your approach to bone health should be unique, too!

We are all different, from the shapes and sizes of our bones to our medical history. This makes all the difference in creating the right approach to your bone health. To reduce the chance of injury and to gain the most optimal results, make sure to approach your bone health in a way that respects your uniqueness.

Bone quality vs. bone density

The DXA (dual-energy x-ray absorptiometry) scan, which measure bone mineral density, indicates the presence of osteopenia or osteoporosis. The DXA scan has been the gold standard for testing bone health since 1987. However, some experts believe that bone quality may be a more important indicator of bone health than bone density. In addition, the traditional DXA scan can give inaccurate readings for some individuals, such as those with arthritis. Thus, while the DXA scan continues to be the gold standard for testing bone health, it's important to know that it's not perfect. One way to maximize accuracy of your DXA results is to use the same DXA machine each time you get a scan. By getting all of your DXA scans (typically done every 2 years) completed at the same facility, you'll also get an informative report showing changes over time.

The Trabecular Bone Score (TBS) measures the microarchitecture of the lumbar bone, specifically the density and connectivity of trabeculae (the spongy bone), and can provide clues to changes in your bone quality over time (1, 2). The TBS is software that is added to a DXA scanner and, while TBS is becoming more widely accessible, not all DXA machines are equipped with the TBS software.

A new but potentially promising technology is REMS (radiofrequency echographic multi-spectrometry), which measures bone structure and provides a bone fragility score (3). While REMS is a safe, radiation-free ultrasound technology, there are mixed reviews on its reliability.

Bone turnover markers indicate bone formation (osteoblastic activity) and bone resorption (osteoclastic activity) and are tested via blood or urine samples. If bone turnover marker results indicate an issue, they can be re-tested every 3 - 12 months. Since there are several bone turnover marker tests available, I recommend selecting one marker to test bone formation and one marker to test bone resorption so that you can compare the same tests over time. Most functional bone experts prefer the P1NP (Procollagen type I N-propeptide) and CTX (C-terminal telopeptide of type I collagen) blood tests.

Am I really at risk?

From the 2024 Epidemiology of Osteoporosis and Fragility Fractures by the International Osteoporosis Foundation (4):

Spinal fractures, also known as vertebral compression fractures, are the most common type of osteoporotic fracture. Interestingly, most people with vertebral fractures are unaware that they have fractured as only about one-third are clinically diagnosed.

Hip fractures are the second most common site of fractures and are associated with up to a 20-24% mortality rate. More than 95% of hip fractures are caused by falling, usually by falling sideways.

People with multiple fractures are at greater risk of future fractures.

Although low bone mass density (BMD) increases the risk for fracture, most fractures occur in postmenopausal women and elderly men without a BMD diagnosis of osteoporosis.

The top insights from these current findings:

Everyone can benefit from improving their bone health.
Reducing compressive load on the anterior vertebrae and fall prevention are critical components in every bone health program.

Factors that contribute to bone health

Many factors affect bone health, including:

hormones
nutrition
gut health (if you're gut health isn't optimal, you won't be able to properly absorb bone-building nutrients from even the best diet)
sleep quality and quantity
stress levels
postural alignment
flexibility and mobility
strength
some medications
some diseases & health conditions
never reaching a good peak bone mass (typically occurs at age 30)

Due to these multiple factors, it's important to incorporate a holistic approach to bone health.

Improving bone health and reducing the risk of injury

As a health coach, I recommend a multi-faceted approach to maximize your bone health. In no particular order, your bone health team might include:

general physician
integrative/functional practitioner (doctor of osteopathy, naturopath, TCM practitioner, women's health specialist, etc.)
hormone specialist (endocrinologist, women's health specialist)
sleep specialist
functional nutritionist
health coach
personal trainer or strength coach
physical therapist
postural alignment specialist
massage therapist, structural integration therapist, chiropractor, MAT practitioner, body worker
acupuncturist
yoga teacher, meditation teacher
therapist
life coach

While a life coach or health coach can help you identify a plan of action to assemble your dream team, always follow your intuition and find practitioners that resonate with you.

Things you can implement now

If you've received a recent diagnosis of osteopenia or osteporosis, it can feel overwhelming (I know this from personal experience!). As you begin the lengthier process of assembling your team, here are some things that you can implement right away:

strength training (make sure your form is perfect and include a recovery day between sessions or body parts, don't forget toe and ankle strength!)
core training (note that some core exercises might put you at an increased fracture risk so train smartly)
balance and agility training
proper movement mechanics and postural alignment training (find resources online or work with a specialist)
flexibility & mobility training (targeted/adapted stretching, myofascial release, and therapeutic yoga can be great)
good office ergonomics (set up your computer & workspace for optimal alignment and movement mechanics)
mindful breathing and meditation (start with 2 minutes of sitting meditation or try a gentle 5-minute walk while breathing only through your nostrils)

Check out the free resources on breathing, fitness, alignment, yoga, nutrition and lifestyle on this website. And remember, stress contributes to bone loss so take a DEEP BREATH and give yourself some love. You've got this!

More bone health resources

I've collected a large amount of research on exercise and bone health which you can access on my Exercise and Bone Health Research page.

You may find one or more of these modalities helpful. Please remember that proper alignment is critical and that you'll need to adapt each approach to your unique needs.

Therapeutic Yoga, including Mukunda Stiles' Joint-Freeing Series
Gokhale Method
The Meeks Method
The Egoscue Method
Foundation Training
12 Yoga Poses for Osteoporosis (This is a set of poses studied by Dr. Loren Fishman et al. and shows that, contrary to previous studies, yoga can be safe for individuals with osteoporosis.)
Onero Online (Please note: This program is NOT the same as the LIFTMOR exercises performed at Onero™ Clinics (see below). The LIFTMOR/Onero™ exercises should be performed under direct supervision by a qualified practitioner to reduce the risk of injury and fractures.)

The LIFTMOR Trial and Onero™ Bone Clinics
Onero™ is an evidence–based exercise program supervised by Professor Belinda Beck, one of the authors of the LIFTMOR study, conducted at Griffith University, and published in the Journal of Bone Mineral Research (5). The LIFTMOR trial proved that high intensity strength training is highly effective at increasing bone mass, improving posture and decreasing falls. Like the LIFTMOR findings, ongoing data collection at The Bone Clinic sites indicates that Onero™ increases bone mass, improves posture and decreases falls in clinic patients. Results show that 86% of patients increased bone mass at the lumbar spine and 69% of patients increased bone mass at the hip. However, it's important to note that participants are ALWAYS supervised and slowly work up to performing the exercises in proper form with heavier weights, with the ultimate goal of lifting 80-85% of their 1-rep max. If these exercises (or any exercise or movement!) are done in bad form, the risks of injury and bone fracture greatly increase, so in-person supervision is critical. To learn more and find an accredited Onero™ practitioner, go to Onero Academy. Head to my Exercise and Bone Health Research page for more LIFTMOR Trial details and other research.

Strength, mobility, proper posture and movement are critical for bone heath but, if you have bone or spinal issues, always consult with a qualified doctor or physical therapist to find the most appropriate exercise prescription for you.

If you're interested in a consultation with me regarding your bone health, contact me here.

Update on Trabecular Bone Score. Archives of Endocrinology and Metabolism, 2022 Nov 10;66(5):694–706. https://pmc.ncbi.nlm.nih.gov/articles/PMC10118821/
Trabecular Bone Score: What it is and why you should know about it, Dr. Meredith Stephens. Anatomy Trains, 2021 Jun 22. https://www.anatomytrains.com/blog/2021/06/22/trabecular-bone-score-what-it-is-and-how-knowing-it-may-help-you-by-dr-meredith-stephens/
Radiofrequency echographic multi-spectrometry for the in-vivo assessment of bone strength. Aging Clinical and Experimental Research, 2019 Oct;31(10):1375-1389. https://pubmed.ncbi.nlm.nih.gov/31422565/
Epidemiology of osteoporosis and fragility fractures. International Osteoporosis Foundation, 2024, Feb 8. https://www.osteoporosis.foundation/facts-statistics/epidemiology-of-osteoporosis-and-fragility-fractures
High-intensiy Resistance and Impact Training improve Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. The Journal of Bone Mineral Research, 2018 Feb;33(2):211-220. https://pubmed.ncbi.nlm.nih.gov/28975661/