No Bones About It

Working Safely with Clients Who Have Osteoporosis

By Ruth Werner
[Critical Thinking]

Key Point 

• Bone-thinning diseases like osteoporosis can present unique challenges for massage therapy and may require accommodations for pressure or client accessibility.



Eighteen years ago, I wrote a column on osteoporosis, or bone thinning, for Massage & Bodywork magazine. Since then, I have entered the demographic most at risk for this disease, so it’s now more meaningful to me. In addition, we have seen some significant changes in how this condition is discussed, especially in its prevention and treatment options. 

Osteoporosis and its precursor, osteopenia, remain important public health issues. The National Center for Health Statistics reported in 2017–2018 that more than 55 percent of adults in the US over age 50 have either osteoporosis or lower-than-optimal bone mass. About 1.5 million people over age 65 have an osteoporosis-related hip fracture each year, and a million compression fractures of the vertebrae are recorded annually.1 Half of all females and one-quarter of all males will have a fracture related to osteoporosis at some point in their lives. This disease is also expensive; estimates say that by 2025, we will be spending $25.3 billion each year for treatment and other costs connected to 3 million yearly fractures.2

I’ve been teaching about osteoporosis for many years, and it’s been fascinating to observe how our understanding of the process of bone growth and degeneration has evolved. There are a million tangents I would love to share about this, like: Does milk make a difference? Why is the process accelerated during early perimenopause? What about all the contradictory data about vegetarian versus omnivore diets and osteoporosis risk? 

However, I am limited by both word count and relevance, so although the interplay between age, childbirth history, diet, exercise, hormones, steroid use, and osteocyte, osteoblast, and osteoclast behavior is amazing to unpack, I can’t make an argument that it is vital for massage therapists to understand it in full detail. If this piques your interest though, I strongly suggest looking at the resources provided at the end of this column.

Following is a fresh look at osteoporosis, a common condition that is sometimes possible to prevent and always difficult to reverse. 

Bones Are Not Inert

Bone growth and maintenance is a carefully coordinated dance between adding to our bone mass and subtracting from it. That balancing act is guided by our moment-to-moment needs. This is the essence of Wolff’s Law: bones adapt according to mechanical loading. They become stronger with demand, and in the absence of mechanical stress, they demineralize and get weaker. 

Our bones start to grow before we are born. The cartilage scaffolding that provides the framework for the mineral deposits that become bone tissue begins to develop early in gestation. Calcium, phosphorus, and other minerals form around those cartilaginous structures in different patterns: porous trabecular bone in epiphyses and vertebral bodies, and denser cortical bone in the long bone shafts and in our small wrist and foot bones. Our flat bones have outer layers of cortical bone and an inner layer of trabecular bone. 

We use calcium and other minerals for bone density, but they have other important functions as well, like blood clotting, muscle contractions, and cellular repair. During childhood and into early adulthood, more is added to our bone mass than is taken away, but those processes are constantly in flux. The minerals we use in daily activities are replaced by what we take in through our diet, and turnover occurs in lengthy, predictable cycles.

When Bones Get Thin

Somewhere around age 30–35, the balance between increasing and decreasing bone mass shifts and we begin to lose bone faster than we replace it. At that point, we can, through diet and weight-bearing stress, work to maintain bone density, but we can’t usually increase it. As we age, losses accelerate. Changes develop faster in trabecular bone than in cortical bone, which is problematic because trabecular, or “spongy,” bone is more porous to begin with, so it has less mineral matter to give up. Furthermore, our femoral heads and vertebral bodies are made of trabecular bone. When these structures lose important internal support, they may collapse (Image 1).  

Patterns in bone loss are often more extreme for females, who are more at risk for osteoporosis for several reasons:

• They usually have lower bone density than males in the first place.

• They may have had the added demands of childbearing and breastfeeding.

• The hormonal changes that begin with perimenopause impact the cells (osteocytes, osteoblasts, and osteoclasts) that sculpt bones throughout life. 

Genetics, age, lifestyle, and hormonal shifts are not the only factors in osteoporosis. It can also develop as a complication of medications—steroidal anti-inflammatories, lithium and related drugs, heparin, methotrexate, anti-seizure drugs, and several others can affect bone density. Chemotherapy and radiation treatment for cancer can also cause bone thinning. Autoimmune diseases, gastrointestinal issues, and any condition that involves being sedentary or confined to bed also contribute. When these are combined with age, hormonal changes, and other factors, the risk is even higher.  

Diagnosing Osteoporosis

We have several ways to measure bone density and fracture risk. The most common is dual-energy X-ray absorptiometry (DEXA), which indicates the presence of minerals by how they absorb photons. Two-dimensional DEXA scans give good information about bone health, but the risks related to osteoporosis also depend on bone quality and whether a person is prone to falling, and these factors play into treatment strategies. New tests and analytical models are also in use and becoming more common. It is useful to get this information as early as possible since early intervention may be able to slow—if not reverse—the bone-loss process.


Osteopenia and osteoporosis typically have no symptoms until the main complication occurs: a bone fracture. Then symptoms include deep pain, limited movement, and if it occurs at the hip, confinement to bed, where life-threatening thromboembolism, heart failure, or pneumonia may develop. Even when people recover from hip fractures and can walk again, their susceptibility to falls remains high, and that remains a risk for early death.  

People with osteopenia are more susceptible to fractures than others with many injuries, but those with osteoporosis can sustain a fracture with very minimal force. These are sometimes called fragility fractures, and they can occur with any low-energy trauma, such as a fall from standing height or less. A person who has had one such fracture is at increased risk for others, especially when this is associated with balance and falling. 

Treatment Options

Genetics play a large role in osteoporosis. Experts estimate that 60–80 percent of peak bone mass is determined by genetics, and 20–40 percent is determined by factors that include nutrition, physical activity, tobacco and alcohol use, medications, and so on.3 This means it’s especially important to take control of the things we can influence for the best possible outcomes, especially for people with a family history of osteoporosis.

Osteoporosis prevention measures ideally begin in childhood and adolescence, when adding to bone density through nutrition and exercise is crucial, and then continue throughout adulthood. Bone-healthy behaviors like weight-bearing physical activity, avoiding tobacco and excessive alcohol use, and getting adequate calcium, vitamin D, and other supportive minerals in absorbable forms are all steps that can reduce the risk of osteoporosis and related complications. 

Testing for osteoporosis is recommended for females aged 65 or older and males aged 70 or older, unless a family history or other risk factors might suggest earlier onset. If osteopenia or osteoporosis are found, it may be necessary to use medication in addition to diet and physical activity to promote good bone health.

Medications for this condition include but are not limited to:

• Bisphosphonates, which inhibit osteoclasts’ ability to work, so bone resorption is slowed. These have been refined to avoid some of the early side effects that led, paradoxically, to osteomalacia of the jaw. 

• Calcitonin, in addition to the calcitonin naturally secreted by the thyroid. This hormone inhibits osteoclast activity.

• Selective estrogen receptor modulators (SERMs) in the form of raloxifene. This drug promotes estrogenic effects, which support bone density.

Implications for Massage Therapy

As massage therapists, we are role models for good self-care. Being conscientious about managing our osteoporosis risks is one way we can demonstrate our commitment to making lifestyle choices that promote health and longevity. 

Elderly people, the main demographic for advanced osteoporosis, are enthusiastic consumers of massage therapy. And because this condition is virtually silent before a fracture occurs, massage therapists with older clients must be alert to the risks of osteoporosis. This is another good reason to ask about any updates to medical conditions or medications with every session, because the answers can give us a clue about a client’s general well-being and their bone health in particular. 


People with fragile bones can sustain fractures even with very low levels of pressure. The vertebrae, the femoral head and pelvis, and the wrist are areas of particular concern. We have in the medical record a case report of a man who received massage and then was subsequently diagnosed with a vertebral pedicle fracture at L54—this is exactly the kind of thing we need to avoid. Another case report found a woman who used an electrical automated massage chair developed severe mid-back pain and was diagnosed with an acute osteoporotic vertebral compression fracture.5 Both of these people had to be treated with surgery and extensive follow-up care to recover from these massage-related adverse events. 

The medications used to treat osteoporosis may also carry some caution. As with all medications, the most important follow-up question is, “What kinds of side effects do you have?” This provides guidance for the appropriate accommodations. Bisphosphonates and other drugs occasionally cause muscle and joint pain, for instance, and can affect kidney health. These symptoms can influence some decisions about bodywork depth, duration, and frequency.


Massage therapy can offer benefits to people who have—or who are at risk for—osteoporosis in several ways. 

We have some limited data on massage therapy for improved balance, which can suggest better protection against falls, but this research has not been done with osteoporosis patients.

For younger clients and those who have no symptoms, massage therapy can help increase awareness of postural habits and self-care practices that might help a client avoid the worst of osteoporosis outcomes later in life. While improving forward-shoulder rolling or head-forward patterns doesn’t improve bone density, it can promote muscular patterns that decrease dysfunction and pain. Massage therapists are also in a position to model good self-care and give good advice about screening for clients who might be at risk. This is important because new treatment options make it possible to live without pain and slow the progression of osteoporosis, but the sooner treatment begins, the better the results. 

And for people with established osteoporosis and accompanying muscle tension around the damaged areas, we know massage therapy can reduce pain and improve range of motion, as long as it can be done without putting the client at risk for further injury.


Clients with diagnosed osteoporosis are not good candidates for any kind of bodywork that might compress their bones and cause accidental fractures. This refers to the vertebrae, of course, but also to the femoral neck and head, pelvis, ribs, forearms, and wrists. So, while a person might seek deep massage to help with muscle pain, that pressure must be given with an angle and direction that does not directly compress underlying bones. 

Clients with established osteoporosis that has led to bone changes may need extra bolstering and support to be comfortable on a table. Someone with severe kyphosis, for instance, may need pillows, towels, or other cushions for comfort. A client with a recently fractured hip may have limitations in their range of motion, which could affect how they can safely move to get on and off the table. And the risk of falling is always an issue for clients with osteoporosis. We can help minimize this by removing tripping hazards like power cords, loose carpets, and unnecessary or poorly lit obstacles to navigate around. 


Only very preliminary and small-scale research into the intersection of massage therapy and osteoporosis has been published at this time. One promising study was a 2013 clinical trial of 48 postmenopausal participants. Subjects were randomized into two groups: intervention and control. The intervention group got two-hour sessions of traditional Thai massage twice a week for four weeks, while the control group did not. After pausing for two weeks, the groups were switched: the participants who had been in the control group got massage, and the others did not. Measurements were taken at the beginning and end of each four-week series. Some things did not change, but one metabolic marker that indicates bone growth activity was markedly higher in the participants who received massage, especially among the older subjects in the study. According to the researchers, “While the improvement in the marker of bone formation cannot readily be extrapolated to an enhancement of bone mass or reduced fracture risk, our finding at least suggests that Thai traditional massage is likely to be beneficial to bone, particularly in women of advancing age among whom osteoporosis is a common health problem.”6 

It is not reasonable to suggest that traditional Thai massage prevents or delays osteoporosis based on this single study, but it certainly suggests further possibilities to explore. 

Massage therapists with older clients will almost certainly have some among them who are at risk for, or who already live with, osteoporosis. With care and knowledge, our work can help to make these challenges a bit more manageable by reducing pain, improving range of motion, and providing caring touch for a population that truly needs our best work. 


1. Cleveland Clinic, “Compression Fractures,” accessed December 2023,

2. Bone Health & Osteoporosis Foundation, “Osteoporosis Fast Facts,” accessed December 2023, 

3. Linus Pauling Institute, “Bone Health In Depth,” accessed December 2023, 

4. Zhiping Guo et al., “Isolated Unilateral Vertebral Pedicle Fracture Caused by a Back Massage in an Elderly Patient: A Case Report and Literature Review,” European Journal of Orthopaedic Surgery & Traumatology 23, no. 2 (2013): 149–53,

5. C. H. Jeon et al., “Case Report: Electrical Automated Massage Chair Use Can Induce Osteoporotic Vertebral Compression Fracture,” Osteoporosis International 30, no. 7 (April 2019): 1533–6,

6. Sunee Saetung, La-or Chailurkit, and Boonsong Ongphiphadhanakul, “Thai Traditional Massage Increases Biochemical Markers of Bone Formation in Postmenopausal Women: A Randomized Crossover Trial,” BMC Complementary and Alternative Medicine 13, no. 69 (March 2013): 


Ayers, C. et al. “Effectiveness and Safety of Treatments to Prevent Fractures in People with Low Bone Mass or Primary Osteoporosis: A Living Systematic Review and Network Meta-analysis for the American College of Physicians.” Annals of Internal Medicine 176, no. 2 (February 2023): 182–95.

Bone Health & Osteoporosis Foundation. “Side Effects of Bisphosphonates (Alendronate, Ibandronate, Risedronate and Zoledronic Acid).” Accessed December 19, 2023.

Centers for Disease Control and Prevention. “Does Osteoporosis Run in Your Family?” Accessed December 19, 2023.

International Osteoporosis Foundation. “Fragility Fractures.” Accessed December 19, 2023.

Khosla, S., and L. C. Hofbauer. “Osteoporosis Treatment: Recent Developments and Ongoing Challenges.” The Lancet. Diabetes & Endocrinology 5, no. 11 (November 2017): 898–907.

Geng, C. “What to Know About Reversing Osteoporosis.” Medical News Today. Accessed December 14, 2023.

OrthoInfo. “Osteoporosis.” Accessed December 19, 2023.

Panula, J. et al. “Mortality and Cause of Death in Hip Fracture Patients Aged 65 or Older—A Population-based Study.” BMC Musculoskeletal Disorders 12, no. 105 (2011).

Rowe, P., A. Koller, and S. Sharma. Physiology, Bone Remodeling. Treasure Island, Florida: StatPearls Publishing. Accessed December 19, 2023.

Silver, N. “Can Osteoporosis Be Reversed?” Healthline. Accessed December 14, 2023. 

Skjødt, M. K., M. Frost, and B. Abrahamsen. “Side Effects of Drugs for Osteoporosis and Metastatic Bone Disease.” British Journal of Clinical Pharmacology 85, no. 6 (June 2019): 1063–71.

Stanford Health Care. “Osteoporotic Fractures.” Accessed December 19, 2023.

Tanski, W., J. Kosiorowska, and A. Szymanska-Chabowska. “Osteoporosis—Risk Factors, Pharmaceutical and Non-Pharmaceutical Treatment.” European Review for Medical and Pharmacological Sciences 25, no. 9 (2021): 3557–66.

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved  continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at, now in its seventh edition, which is used in massage schools worldwide. Werner is available at