TFTF High Level Copy

Introduction to this section

The benefit of all forms of exercise is widely acknowledged and accepted in our society. Introducing safe exercise guidelines for persons with chronic diseases always are a challenge and until recently, exercise guidelines for osteoporosis have been lacking. Several years ago, the CSEP (Canadian Society for Exercise Physiology) Guidelines were updated and it highlighted the need for condition-specific guidelines as the revised CSEP guidelines for 65-years + are clearly too broad and are insufficient for bones.

This led to an initiative called Too Fit to Fracture, spearheaded by researchers, clinical experts and stakeholders to review the state of research on exercise in osteoporosis and create a more specific exercise prescription guideline. Read more below on the process.

If 65 years of age or older to achieve health benefits & improve functional abilities:
Accumulate 150 minutes of moderate – to vigorous- intensity aerobic physical activity per week Muscle strengthening of major muscle groups – at least 2 days per week Perform physical activities to enhance balance & prevent falls More physical activity leads to greater health benefits

This led to the Too Fit To Fracture Guidelines (TFTF).

Too Fit To Fracture Delphi Consensus Process

A Delphi process is a research method to obtain expert opinion on the question representing the crux of the research. In this project we asked whether, given two different client profiles (one with simple OP and one with more complex OP), the current CSEP guidelines were appropriate. Below is a summary of the recommendations.

Table: “Are national physical activity guidelines appropriate for this case?” (% of R1, n=39)*

  • Weight-bearing aerobic activity most often;
  • Progressive resistance training designed to increase muscle strength i.e., 8-12 repetitions at an intensity rating of 5-8 on a 0-10 scale
  • Balance training strongly for all – 2 hours per week or 20 min per day;
  • Daily exercise to increase muscular endurance in spinal extensors;
  • 150 min/wk moderate intensity aerobic activity, bouts ≥10 min (cautious with vigorous)
  • Progressive resistance training designed to increase muscle strength, emphasis on form/alignment instead of intensity;
  • Balance training strongly for all – 2 hours per week or 20 min per day;
  • Daily exercises to increase muscular endurance in spinal extensors;
  • Perform exercises in positions where spine is least loaded when possible: loads in supine<standing<seated;
  • PT/OT guidance on appropriate exercise, alignment, transitions, use of assistive aids, positioning for pain control.

Therapeutic Goals for Osteoporosis

Prevent fractures via:

Published Too Fit to Fracture Exercise Guidelines for Osteoporosis

Below is a summary of the recommended exercise components that should be included in a well-rounded exercise plan for clients with osteoporosis. We will refer to this table/guidelines throughout the remainder of the workshop content and apply it to case studies.


Learn more about TFTF

Optional Webinar: Too Fit to Fracture

Note: Watch only to 27:00.

Giangregorio L, Papaioannou A, Macintyre N, et al. Too fit to fracture: Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis Int. 2014;25(3):821-35.

Giangregorio L, McGill S, Wark J, 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 Int. 2015;26(3):891-910.