Osteoporosis becomes increasingly important after menopause because the fall in oestrogen accelerates bone remodelling and shifts the balance towards bone resorption. The result is progressive loss of bone mineral density (BMD), deterioration of bone strength and a higher risk of fragility fractures, particularly at the spine, hip and wrist. Importantly, osteoporosis should not lead to unnecessary avoidance of exercise. Appropriately prescribed loading is an important component of fracture prevention and long-term physical function (The North American Menopause Society [NAMS], 2021; Morin et al., 2023).

For physiotherapists, the practical question is not simply whether a postmenopausal woman should exercise but what type of loading provides a meaningful skeletal stimulus while remaining appropriate for her fracture risk, strength, balance and previous fracture history.

Why Bone Loss Accelerates After Menopause

Bone is metabolically active tissue that continuously undergoes remodelling. Osteoclasts resorb old bone, while osteoblasts form new bone. Oestrogen normally helps regulate this process. After menopause, declining oestrogen increases bone turnover and favours resorption, so more bone may be removed than replaced. Postmenopausal bone loss is therefore an important contributor to later osteoporosis and fracture risk (NAMS, 2021).

The clinical problem is larger than a DXA value. A fragility fracture can reduce mobility, confidence and independence, while muscle weakness and impaired balance further increase the likelihood of falling. Exercise prescription should consequently address bone strength, muscle strength, balance, posture and functional capacity, rather than focusing on BMD alone. Current Canadian guidance recommends progressive resistance training alongside balance and functional exercise for people at risk of osteoporosis-related fracture (Morin et al., 2023).

Why Resistance and Impact Loading Work

Bone adapts to mechanical loading. When muscles contract strongly or the skeleton experiences ground-reaction forces, mechanical strain is transmitted through bone. Osteocytes sense these changes and participate in signalling processes that influence bone formation and remodelling. A useful clinical principle is therefore that bone requires an adequate mechanical stimulus; very light or repetitive activity may improve general health without providing the same osteogenic challenge as progressive resistance or appropriately selected impact exercise.

Exercise research in postmenopausal women supports this principle. Meta-analysis shows that exercise can produce favourable effects on lumbar-spine, femoral-neck and total-hip BMD, although responses vary according to the programme and skeletal site (Mohebbi et al., 2023). More recent evidence specifically examining resistance training also supports its ability to improve BMD in postmenopausal women (Zhao et al., 2025).

Resistance and impact loading provide related but different stimuli. Resistance exercise loads bone through strong muscle forces, whereas impact exercise creates rapid ground-reaction forces through activities such as stamping, jogging, hopping or jumping. Combining these approaches, when clinically appropriate, is widely recommended for skeletal health (Brooke-Wavell et al., 2022).

Resistance Training That Is Heavy Enough to Matter

Progressive resistance training should challenge the major muscle groups and load clinically important skeletal regions, especially the hips and spine. Useful movements include squats or sit-to-stands, hip-hinge or deadlift patterns, lunges or step-ups, rowing movements, chest or overhead presses and exercises targeting the spinal extensors.

The word 'progressive' is essential. Beginning with light resistance is appropriate when teaching technique, but continuing indefinitely with a resistance that feels easy is unlikely to provide the strongest possible skeletal stimulus. UK osteoporosis consensus guidance recommends gradually progressing towards a load that can be lifted for approximately 8–12 repetitions maximum (RM), building towards two to three sets. Resistance exercise is generally performed on 2–3 non-consecutive days per week (Brooke-Wavell et al., 2022).

An important example is the LIFTMOR randomised controlled trial. Postmenopausal women with low bone mass completed supervised high-intensity resistance and impact training twice weekly. The programme ultimately used deadlifts, squats and overhead presses at greater than approximately 80–85% of one-repetition maximum, together with impact loading. Improvements were reported in lumbar-spine BMD and physical function compared with a low-intensity control programme (Watson et al., 2018).

This study does not mean every person with osteoporosis should immediately begin heavy barbell training. Participants were screened, taught technique and closely supervised. Its clinical importance is that osteoporosis does not automatically mean resistance exercise must remain light.

Impact Loading: Who Should Jump and Who Should Not?

Impact exercise is particularly relevant because bones respond well to relatively brief, varied loading rather than only long-duration repetitive activity. Moderate-impact options may include heel drops, stamping, stair climbing, jogging, low-level jumping, hopping or skipping depending on the person's ability.

The UK Strong, Steady and Straight consensus recommends building towards approximately 50 moderate impacts per session, often divided into shorter sets, for people with osteoporosis who do not have vertebral or multiple low-trauma fractures. Variety in direction, speed and movement is encouraged (Brooke-Wavell et al., 2022).

However, impact prescription must reflect fracture history. In people with vertebral fractures, multiple fragility fractures, marked frailty or poor balance, high-impact activity may be inappropriate. Lower-impact weight-bearing exercise such as purposeful walking, marching, stair activity or controlled heel drops may be a safer starting point while strength and balance are improved.

Walking remains valuable for cardiovascular health, mobility and physical activity, but walking alone should not be presented as a complete osteoporosis exercise programme. For optimal skeletal and fracture-risk management, it should usually sit alongside resistance, balance and, when appropriate, impact loading.

How Physiotherapists Progress Loading Safely

A physiotherapist should first establish whether the patient needs general bone-health exercise or a more closely supervised osteoporosis programme. Assessment should include previous fragility fractures, DXA findings where available, falls, balance, strength, spinal posture, pain, functional limitations, comorbidities and confidence with exercise.

A practical progression may move from the following:

movement technique and basic strength → progressively heavier resistance → low-level weight-bearing impact → more demanding impact where appropriate → long-term independent training.

Progression should be based on quality as well as quantity. If a patient can complete the prescribed resistance with excellent technique and little challenge, resistance can gradually increase. Impact can similarly progress from marching or controlled heel drops towards faster stepping, jogging or small jumps where fracture risk, balance and lower-limb capacity permit.

Spinal technique deserves particular attention. Current osteoporosis guidance advises caution with repetitive or loaded end-range spinal flexion, especially in individuals with vertebral fracture risk. Hip-hinge strategies, neutral-spine lifting, spinal extensor strengthening and safe transfer techniques can allow meaningful loading without encouraging unnecessary fear of movement (Brooke-Wavell et al., 2022; National Osteoporosis Guideline Group [NOGG], 2025).

These principles are consistent with therapeutic-exercise practice: resistance, complexity and functional load should be progressed according to tissue capacity, movement quality and the person's overall clinical presentation (Kisner et al., 2023).

When Exercise Needs Modification or Medical Review

Exercise is important in osteoporosis management, but it is only one part of fracture prevention. Medical evaluation is particularly important after a new fragility fracture, unexplained height loss, sudden severe spinal pain or when osteoporosis has not yet been appropriately investigated or treated.

Additional caution or individualised physiotherapy is appropriate with the following:

recent or unhealed fracture;
previous vertebral or multiple fragility fractures;
recurrent falls or marked balance impairment;
severe pain during loading;
major neurological or functional change; or
substantial uncertainty about safe exercise technique.

People at sufficiently high fracture risk may require pharmacological osteoporosis treatment in addition to exercise. Current guidelines therefore position exercise, adequate nutrition and falls prevention as complementary to—not substitutes for—appropriate medical management (Morin et al., 2023; NAMS, 2021).

Viva-Ready Summary

Postmenopausal oestrogen decline accelerates bone turnover and contributes to osteoporosis.
Bone responds to mechanical strain, so exercise must provide an adequate and progressive loading stimulus.
Progressive resistance training is a major component of osteoporosis management and should generally be performed at least twice weekly.
When appropriate, resistance can progress towards a challenging 8–12 RM for 2–3 sets.
Impact loading provides an additional osteogenic stimulus; moderate-impact activities can be used in suitable patients.
Vertebral fractures, multiple fragility fractures, poor balance and frailty require modification of impact and closer supervision.
Exercise also improves muscle strength and balance, addressing important contributors to falls and fracture risk.
Exercise complements osteoporosis medication when pharmacological treatment is clinically indicated.

One-line recall point:
After menopause, bone needs progressive resistance plus appropriate impact—not simply more movement—to receive a meaningful osteogenic stimulus.

References

American College of Sports Medicine. (2025). ACSM's guidelines for exercise testing and prescription (12th ed.). Wolters Kluwer.

Brooke-Wavell, K., Skelton, D. A., Barker, K. L., Clark, E. M., De Biase, S., Arnold, S., Paskins, Z., Robinson, K. R., Lewis, R., Tobias, J. H., Ward, K. A., Whitney, J., & Leyland, S. (2022). Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine, 56(15), 837–846. https://doi.org/10.1136/bjsports-2021-104634

Kisner, C., Borstad, J., & Colby, L. A. (2023). Therapeutic exercise: Foundations and techniques (8th ed.). F. A. Davis.

Mohebbi, R., Shojaa, M., Kohl, M., von Stengel, S., Jakob, F., Kerschan-Schindl, K., Lange, U., Peters, S., Thomasius, F., Uder, M., & Kemmler, W. (2023). Exercise training and bone mineral density in postmenopausal women: An updated systematic review and meta-analysis of intervention studies with emphasis on potential moderators. Osteoporosis International, 34(7), 1145–1178. https://doi.org/10.1007/s00198-023-06682-1

Morin, S. N., Feldman, S., Funnell, L., Giangregorio, L., Kim, S., McDonald-Blumer, H., Santesso, N., Ridout, R., Ward, W., & collaborators. (2023). Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. Canadian Medical Association Journal, 195(39), E1333–E1348. https://doi.org/10.1503/cmaj.221647

The North American Menopause Society. (2021). Management of osteoporosis in postmenopausal women: The 2021 position statement of The North American Menopause Society. Menopause, 28(9), 973–997. https://doi.org/10.1097/GME.0000000000001831

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: The LIFTMOR randomised controlled trial. Journal of Bone and Mineral Research, 33(2), 211–220. https://doi.org/10.1002/jbmr.3284

Zhao, F., Su, W., Sun, Y., Wang, J., Lu, B., & Yun, H. (2025). Optimal resistance training parameters for improving bone mineral density in postmenopausal women: A systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 20, 523. https://doi.org/10.1186/s13018-025-05890-1