October 2017: Osteoporosis



Content courtesy of the National Swimming Pool Foundation

Recent publications which show how water works for osteoporosis.

Historically, aquatic exercise has never been considered as a viable method to combat bone loss. Think about it. Any exercise program designed to retard the rate of bone loss (or increase the rate of bone growth) must consider: the frequency and duration of the activity, the ground reaction forces (GRF) created during the activity, the amount of muscle-bone tension created during the activity, and the patient’s age at the time of activity. 

Because immersion can diminish weight bearing forces by more than 90%, aquatic-based exercise has always been seen as a poor substitute for weight-bearing tasks, such as walking. However, this perspective has changed dramatically over the last decade for multiple reasons.

First, individuals who are unable to weight bear easily or comfortably under gravity’s full brunt, can easily do so when immersed to chest-level in water. 

Second, individuals who choose to not exercise regularly on land, due to pain, fatigue or other factors, may be willing to do so in the water. 

Third, the study of aquatic plyometrics has shown clinicians that it is possible to execute speed, power and other explosive activities in water; and moreover, that these activities result in similar athletic gains as their land-based counterparts, without the incidence of injury. 

Lastly, while the argument that exercise in the water will produce less weight-stressors is technically true, this argument ignores all other mechanisms by which the body lays down bone. For example, muscle pull on bone is an excellent stimulus for bone growth. Exercise in the viscous medium of a swimming pool produces drag… and drag produces resistance… and resistance creates muscle pool. End result? More bone.

While it is true that immersion can diminish weight bearing forces by more than 90%, aquatic-based exercise is no longer considered a non-starter when working with patients with bone loss. In fact, you might say it has come full circle; aquatic exercise has finally achieved the “gravity” it deserves. Looking to support this contention? Look no further than the reference provided here.


Ahn, N., & Kim, K. (2016). Effects of 12-week exercise training on osteocalcin, high-sensitivity C-reactive protein concentrations, and insulin resistance in elderly females with osteoporosis. Journal of Physical Therapy Science, 28(8), 2227–2231. Retrieved from https://www.jstage.jst.go.jp/article/jpts/28/8/28_jpts-2016-176/_article

Bergamin M, Ermolao A, Tolomio S, Berton L, Sergi G, Z. M., Bergamin, M., Ermolao, A., Tolomio, S., Berton, L., Sergi, G., & Zaccaria, M. (2013). Water- versus land-based exercise in elderly subjects: Effects on physical performance and body composition. Clinical Interventions in Aging, 8, 1109–1017. http://doi.org/10.2147/CIA.S44198

Bonnyman, a. M., & MacIntyre, N. J. (2011). State of the Evidence Regarding the Effect of Water Exercises on Bone Outcomes in Postmenopausal Women with Osteoporotic Vertebral Fractures. Critical Reviews™ in Physical and Rehabilitation Medicine, 23(1-4), 195–212. http://doi.org/10.1615/CritRevPhysRehabilMed.v23.i1-4.140

Burr, J., Shephard, R., Cornish, S., Vatanparast, H., & Chilibeck, P. (2012). Arthritis, osteoporosis, and low back pain: evidence-based clinical risk assessment for physical activity and exercise clearance. Canadian Family Physician Médecin de Famille Canadien, 58(1), 59–62. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3264014&tool=p...

Cuesta-Vargas, A. I., García-Romero, J. C., Arroyo-Morales, M., Diego-Acosta, Á. M., Daly, D. J., Diego-Acosta, A. M., … Daly, D. J. (2011). Exercise, Manual Therapy, and Education with or Without High-Intensity Deep-Water Running for Nonspecific Chronic Low Back Pain. American Journal of Physical Medicine & Rehabilitation, 90(7), 526–611. https://journals.lww.com/ajpmr/Abstract/2011/07000/Exercise,_Manual_Therapy,_and_Education_with_or.2.aspx


Howe, T. E., Shea, B., Dawson, L. J., Downie, F., Murray, A., Ross, C., … Creed, G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women. Conhrane Database of Systematic Reviews, 7(7), 1–3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000333/full

Moreira, L. D. F., Fronza, F. C. A. O., dos Santos, R. N., Zach, P. L., Kunii, I. S., Hayashi, L. F., … Castro, M. L. (2013). The benefits of a high-intensity aquatic exercise program (HydrOS) for bone metabolism and bone mass of postmenopausal women. Journal of Bone and Mineral Metabolism, 32(4), 411–419. Retrieved from https://link.springer.com/article/10.1007/s00774-013-0509-y

Morgan, Amy L., Jennifer Weiss, and E. T. K. (2015). Bone Turnover Response to Acute Exercise with Varying Impact Levels: A preliminary investigation. International Journal of Exercise Science, 8(2), 6. Retrieved from https://digitalcommons.wku.edu/ijes/vol8/iss2/6/

Murtezani, A., Nevzati, A., Ibraimi, Z., Sllamniku, S., Meka, V. S., Abazi, N., … Abazi, N. (2014). The effect of land versus aquatic exercise program on bone mineral density and physical function in postmenopausal women with osteoporosis: A randomized controlled trial. Ortopedia Traumatologia Rehabilitacja, 16(3), 319–325. http://899.indexcopernicus.com/abstracted.php?level=5&ICID=1112533

Pernambuco, C. S., Borba-Pinheiro, C. J., Vale, R. G. de S., Di Masi, F., Monteiro, P. K. P., & Dantas, E. H. M. (2013). Functional autonomy, bone mineral density (BMD) and serum osteocalcin levels in older female participants of an aquatic exercise program (AAG). Archives of Gerontology and Geriatrics, 56(3), 466–471. http://doi.org/10.1016/j.archger.2012.12.012

Pinto, S. S. S. S. S., Alberton, C. L. C., Bagatini, N. N. C. N. C., Zaffari, P., Cadore, E. L., Radaelli, R. R. R., … Kruel, L. F. M. (2015). Neuromuscular adaptations to water-based concurrent training in postmenopausal women: effects of intrasession exercise sequence. Age (Dordrecht, Netherlands), 37(6), 9751. http://doi.org/10.1007/s11357-015-9751-7
Rachner, T. D., Khosla, S., & Hofbauer, L. C. (2011). Osteoporosis: Now and the future. The Lancet, 377(9773), 1276–1287. http://doi.org/10.1016/S0140-6736(10)62349-5

Roghani, T., Torkaman, G., Movasseghe, S., Hedayati, M., Goosheh, B., & Bayat, N. (2013). Effects of short-term aerobic exercise with and without external loading on bone metabolism and balance in postmenopausal women with osteoporosis. Rheumatology International, 33(2), 291–298. http://doi.org/10.1007/s00296-012-2388-2

Sanders, M. E., Takeshima, N., Rogers, M. E., Colado, J. C., & Borreani, S. (2013). Impact of the s.w.e.a.T.TM water-exercise method on activities of daily living for older women. Journal of Sports Science & Medicine, 12(4), 707–715. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873661/

Simas, V., Hing, W., Pope, R., & Climstein, M. (2017). Effects of water-based exercise on bone health of middle-aged and older adults: a systematic review and meta-analysis. Open Access Journal of Sports Medicine, 2017(8), 39–60. http://doi.org/10.2147/OAJSM.S129182