Bone Health and Parkinson’s Disease

Despite often being seen as static and unchanging, bones are dynamic, living tissues that constantly adapt to their environment. In particular, the effects of Parkinson’s disease (PD) have a profound impact on bone health, contributing to conditions like osteoporosis and increasing the risk of fractures. Because individuals with Parkinson’s face various challenges, including motor symptoms that limit physical activity, the importance of maintaining bone density becomes even more critical. While osteoporosis and fractures are common concerns for aging populations, people with PD are particularly vulnerable. Fortunately, treatment options and management strategies are available to help improve bone health and reduce the risk of serious complications.

What are bones?

Over 200 bones form the human skeleton, which supports the body and gives us our shape while protecting our delicate internal organs. Bones also act as storage for key minerals, namely calcium and phosphorus (Johns Hopkins Medicine, n.d.).

There are a few different types of bone cells, including:

Osteoblasts: form new bone tissue, help heal and remodel bones
Osteoclasts: reabsorb bone tissue when not needed any longer
Osteocytes: help maintain bone tissue

When we are young, osteoblasts work quickly, allowing a child’s skeleton to grow in size rapidly. As we age, this growth slows down – consider that a child’s bones completely renew themselves every two years, but it takes an adult’s seven to ten years to do the same (Royal Osteoporosis Society, n.d.).

Bone Density and Strength

Bone mineral density (BMD) refers to the amount of calcium and other minerals in bone; generally, the more mineral density, the stronger the bone and more resistant it is to fractures. The most common way to measure BMD is through something called dual energy X-ray absorptiometry, or DXA/DEXA. This low-radiation test compares you to other people to determine your relative BMD. Sufficient bone density is crucial; without it, conditions like osteopenia (a mild loss of bone mineral density) can progress to osteoporosis, a more severe form of BMD loss (NIAMS, 2023).

Osteoporosis

Osteoporosis occurs when the body loses bone faster than it can replace it, and typically develops from a combination of advancing age, lack of exercise, and poor nutrition. These factors reduce bone mineral density at the rate of 1% each year after one turns 40 (Harvard Health, 2024).

It is a very serious condition, as brittle bones are more likely to break from minor bumps and traumas, such as picking up a bag of groceries or falling from a short distance. The 2009 Canadian Community Health Survey reported that an estimated 1.5 million Canadians aged 40 and over (10%) have osteoporosis, with women having the condition four times more than men (Government of Canada, 2024).

Unfortunately, individuals with Parkinson’s are much more likely than average to be diagnosed with osteoporosis – up to 91% of women and 61% of men with PD. The reason for this appears to be multifaceted, including reduced physical activity and nutritional deficiency, especially vitamin D. Female gender (due to menopause, which results in a sharp decline in estrogen, thus speeding up bone loss), advanced age, low body mass index, and longer Parkinson’s disease duration were all linked to more severe osteoporosis (Invernizzi et al., 2009).

Furthermore, the common Parkinson’s medication levodopa has been found to slow the rate of bone formation, contributing to lowered bone mineral density (American Parkinson Disease Association, 2022).

Bone fractures from bone mineral density loss can be a difficult health challenge for elderly individuals in particular. Historically, about one-third of those who experience a hip fracture have died within one year; however, recent advancements in rehabilitation have reduced the odds of death (Downey et al., 2019). In fact, hip fractures are the most serious type of bone fracture, with 60% of people never regaining their previous level of independence (Harvard Health, 2024). Individuals with PD also tend to have worse outcomes from hip fractures than those without the disease (Walker et al., 2013).

The organization Osteoporosis Canada recommends both men and women aged 65+ have routine bone mineral density tests to screen for osteoporosis. However, for those at greater risk of the condition, they recommend screening start sooner. You can use a fracture risk tool like FRAX (Fracture Risk Assessment Tool) at https://bit.ly/FRAXbone to calculate your ten-year probability of a bone fracture (HealthLink BC, 2023).

Strategies to Improve Bone Mineral Density

Exercise

Because of challenging motor symptoms, people with PD may be less likely to engage in weight bearing physical exercise, which includes any activity in which you hold your body up against gravity (such as walking, running, playing a sport, etc.). One of the best things anyone, including people with Parkinson’s, can do to strengthen their bones is to get moving (American Academy of Orthopedic Surgeons, 2020)!

Many people know exercise is great for muscles and the cardiovascular system, but they may not know that exercise is one of the most potent ways to change their bones. In fact, when archeologists look at skeletal remains of Medieval people, they can make inferences about the types of jobs these individuals had based on their bones (Nikita & Radini, 2022).

Exercises that promote weight-bearing and mechanical stress on bones are essential for bone health, as they stimulate bone remodeling and the creation of new bone tissue – a principle known as Wolff’s Law (1892). Higher-impact activities, such as weightlifting, running, and jump rope, require more bone adaptation than lower-impact exercises like yoga, swimming, and cycling. An important caveat is that higher-impact activities tend to be more dangerous for individuals who are prone to falls, which people with PD can be. Always consult your doctor before beginning any new exercise program (American Academy of Orthopedic Surgeons, 2020). Below are some example exercises you can try. Be sure to hold on to support as needed for safety.

Wherever possible, add in weights by:

Using hand weights,
Using canned soup or water bottles if hand weights aren’t available,
Wearing a backpack (snuggly!) with weights inside if unable to be hands-free due to holding on for balance. Depending on how heavy the backpack is, you may want to wear it on your front for comfort.

Exercises for upper extremity bone health:

Overhead presses
Medicine ball smashes (or pillow smashes)
Triceps dips
Wall pushups (or regular pushups for an added challenge!)
Wall robo planks (or regular robo planks for an added challenge!)
Inchworms (more challenging as this requires you to get on and off the floor!)
Exercises in the four-point kneeling position, such as bird dog

Exercises for lower extremity bone health:

Marching whilst holding a bridge position
Sit-to-stands
Squats or squat variations, such as walking squats and crab walk squats
Multidirectional lunges or lunge variations such as curtsey lunges and Romanian lunges
Deadlifts (single leg deadlifts if wanting a challenge!)
Hip thrusters
Any jumps and hops (more challenging!)

If you are unsure how to perform these exercises safely or need guidance on adapting them to your needs, consider consulting a physiotherapist. Parkinson Society BC offers a free Virtual Physiotherapy service for those who qualify. Visit www.parkinson.bc.ca/physio to learn more.

In the past, doctors cautioned people with osteoporosis and BMD loss against high-impact exercises, in fear that they could cause fractures. An Australian study published in 2018 called the LIFTMOR Randomized Controlled Trial challenged this idea. This trial studied whether high-intensity resistance and impact training (HiRIT) is safe and effective for improving bone health and reducing fracture risk in postmenopausal women with low BMD. Just over 100 women were split into two groups: one did supervised HiRIT (including weightlifting exercises, like squats and deadlifts) twice a week for 30 minutes, and the other did low-intensity exercises at home. The study period lasted eight months. In the end, the HiRIT program significantly improved bone density, balance, mobility, and strength compared to the low-intensity group, while still being safe and well-tolerated. Though not the first study to explore exercise and bone health, the LIFTMOR trial was notable for its focus on high-intensity training in individuals with low bone mass (Watson et al., 2018).

Exercise can do more than just build healthy bones – it can also increase osteocalcin (OCN), a hormone released by osteoblasts. While OCN may not directly increase bone mineral density, it plays a key role in brain function. Studies show that higher circulating OCN levels are linked to better cognitive performance. However, lower levels have been found in people with neurodegenerative diseases like Parkinson’s (Bian et al., 2024).

Recently, scientists have discovered that OCN is involved in the development of dopaminergic neurons. When rats with Parkinson’s were treated with injected OCN, their motor symptoms improved, dopamine-producing neurons were protected, and inflammation in the brain reduced (Guo et al., 2018).

Though more research is needed to determine the therapeutic potential of osteocalcin in humans with PD, exercise is a safe and natural way to boost its levels (Ahn & Kim, 2016).

Get Adequate Nutrition

Sufficient calcium intake is crucial not only for building and maintaining healthy bones, but also for essential functions like hormonal regulation, maintaining a steady heartbeat, and blood clotting. If your dietary calcium intake is inadequate, your body will draw calcium from your bones to support these critical functions, further weakening your bones. Vitamin D is another important vitamin for bone health, as it helps the body absorb calcium (Davis Phinney Foundation, 2021).

To learn more about calcium, vitamin D, and other essential nutrients for healthy bones, please see the booklet titled ‘Three Steps to Unbreakable Bones: Vitamin D, Calcium and Exercise’ from the International Osteoporosis Foundation at: https://bit.ly/3stepsbones

Reduce or Eliminate Smoking and Alcohol Use

Smoking cigarettes reduces the body’s ability to absorb calcium while lowering estrogen levels. Nicotine also slows the production of osteoblasts, which repair and rebuild bone. Alcohol has similar effects on the body. Reducing your alcohol and tobacco use, or eliminating it entirely, can be one of the healthiest choices for bone health (Davis Phinney Foundation, 2021).

While Parkinson’s disease presents unique challenges to bone health, there are promising strategies and treatments that can help improve outcomes. With ongoing research, advances in care, and a focus on maintaining overall wellbeing, individuals with PD can find ways to manage their bone health more effectively.

This article has been reviewed for accuracy by Parkinson Society BC’s very own neuro physiotherapist, Shelly Yu.

Sources

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. https://doi.org/10.1589/jpts.28.2227

American Academy of Orthopedic Surgeons (2020). Exercise and Bone Health. https://orthoinfo.aaos.org/en/staying-healthy/exercise-and-bone-health

American Parkinson Disease Association (2022). The Importance of Bone Health and Parkinson’s Disease. https://www.apdaparkinson.org/article/bone-health-and-parkinsons-disease

Bian, X., Wang, Y., Zhang, W., Ye, C., & Li, J. (2024). GPR37 and its neuroprotective mechanisms: Bridging osteocalcin signaling and brain function. Frontiers in Cell and Developmental Biology, 12. https://doi.org/10.3389/fcell.2024.1510666

Davis Phinney Foundation (2021). What You Need to Know about Osteoporosis and Parkinson’s. https://davisphinneyfoundation.org/osteoporosis-and-parkinsons/

Downey, C., Kelly, M., & Quinlan, J. F. (2019). Changing trends in the mortality rate at 1-year post hip fracture: A systematic review. World Journal of Orthopedics, 10(3), 166–175. https://doi.org/10.5312/wjo.v10.i3.166

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Guo, X., Shan, C., Hou, Y., Zhu, G., Tao, B., Sun, L., Zhao, H., Ning, G., Li, S., & Liu, J. (2018). Osteocalcin ameliorates motor dysfunction in a 6-hydroxydopamine-induced Parkinson’s disease rat model through AKT/GSK3β signaling. Frontiers in Molecular Neuroscience, 11, 343. https://doi.org/10.3389/fnmol.2018.00343

Harvard Health (2024). Strength training builds more than muscles. https://www.health.harvard.edu/staying-healthy/strength-training-builds-more-than-muscles

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Invernizzi, M., Carda, S., Viscontini, G. S., & Cisari, C. (2009). Osteoporosis in Parkinson's disease. Review, 15(5), 339–346. https://doi.org/10.1016/j.parkreldis.2009.02.009

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National Institute of Arthritis and Musculoskeletal and Skin Diseases (2023). Bone Mineral Density Tests: What the Numbers Mean. https://www.niams.nih.gov/health-topics/bone-mineral-density-tests-what-numbers-mean

Nikita, E., & Radini, A. (2022). Occupational patterns in Anglo‐Saxon and Medieval East Midlands, England: Insights from activity‐related skeletal changes. International Journal of Osteoarchaeology. Advance online publication. https://doi.org/10.1002/oa.3186

Royal Osteoporosis Society (n.d.). Age and bone strength. https://theros.org.uk/information-and-support/osteoporosis/causes/age-and-bone-strength

Walker, R. W., Chaplin, A., Hancock, R. L., Rutherford, R., & Gray, W. K. (2013). Hip fractures in people with idiopathic Parkinson's disease: Incidence and outcomes. Movement Disorders, 28(3), 334–340. https://doi.org/10.1002/mds.25297

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 randomized controlled trial. Journal of Bone and Mineral Research, 33(2), 211–220. https://doi.org/10.1002/jbmr.3284

Wolff, J. (2010). The classic: On the inner architecture of bones and its importance for bone growth (Ueber die innere Architectur der Knochen und ihre Bedeutung für die Frage vom Knochenwachsthum). Clinical Orthopaedics and Related Research, 468, 1056–1065. https://doi.org/10.1007/s11999-010-1239-2

This content was published in the Spring 2025 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.

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