To strengthen women’s bone health and prevent the risk of fractures following a fall, KK Women’s and Children’s Hospital (KKH) has introduced a physiotherapy-led bone health programme for women diagnosed with osteoporosis and osteopenia (low bone density). To date, 58 per cent of women who have participated in the programme for at least two years have maintained or experienced improvement in spine and hip bone mineral density.
The KKH BoneBuilding programme is targeted at women with low, moderate and high risk of falls, and comprise a combination of weight-bearing aerobic exercises, muscle-strengthening, flexibility and balance exercises aimed at improving muscle strength, flexibility, balance and bone health. Exercises are prescribed and modified by an attending physiotherapist and assisted by a therapist assistant (Table 1).
Programme registration is by medical professional referral only, and patients will need to be diagnosed with low bone density via dual energy x-ray absorptiometry of the hip and spine.
Eligible participants will first be screened and assessed to ascertain their baseline fitness and risk of falling, before being enrolled into the appropriate class under the programme. During each class, individualised modifications and advice are also provided to accommodate each patient’s condition.
Table 1. Classes in the KKH BoneBuilding programme
- Low to moderate risk of falls
- Moderate risk of falls, but are able to carry out exercises within a group without assistance
- Moderate to high risk of falls, who require supervision during exercise
- Pain or other musculoskeletal conditions which may inhibit their ability to exercise
Class duration||60 minutes||60 minutes||45 minutes|
Class size||Maximum 12||Maximum 12||Maximum 10|
Class format||Classes are group-based and conducted by a physiotherapist. Modifications of exercise can be done for different participants depending on their physical limitations and medical conditions.|
Types of exercise|
- Low impact aerobics
- Strengthening exercises using various equipment such as resistance bands and a gym ball
- Balance exercises
- Low impact aerobics
- Strengthening exercises using a gym ball and weights
- Balance exercises
- Gym-based aerobics, such as stationary bike and treadmill
- Strengthening exercises using machines and free weights
- Balance exercises
Osteoporosis: An invisible disease
Table 2. Four stages of osteoporosis
|Healthy bone||Osteopenia||Osteoporosis||Severe osteoporosis|
Osteoporosis occurs where bone loss happens at a greater rate than bone-making. In recent years, the KKH Physiotherapy Department has seen a stable trend in the number of women presenting with osteoporosis or osteopenia (low bone density). The number of patients participating in the KKH BoneBuilding programme has increased from 100 to up to 140 a week over the past eight years. The incidence of osteoporosis is expected to rise as the local population ages.
While osteoporosis can occur at any age, women who have undergone menopause – which typically takes place at 45 to 55 years of age – are at higher risk due to declining oestrogen levels which cause bone loss to increase exponentially.
The resulting weakening of the bones can increase the likelihood of bone fractures following a fall. As the gradual weakening of bones cannot be felt, most women with low bone density are unaware of their condition, and even those who have been diagnosed may not realise the cause for concern until a bone fracture occurs.
Bone fractures are a complication of osteoporosis that is debilitating and potentially fatal, with hip and vertebrae fractures being the most common. Associated complications include chronic pain, disability and even death.
Singapore has one of the highest incidence of hip fractures in women in Asia exceeding 300 per 100,000 women1, and the risk of hip fractures in women has increased by five times since the 1960s. The number of hip fractures is projected to increase from 1,300 yearly in 1998 to 9,000 yearly in 20502.
More than half of those with a hip fracture will require assistance with walking, and more than half will continue to require assistance with activities such as dressing and toileting a year following a hip fracture3.
Maintaining bone density through multi-modal exercise
Studies have shown that multi-modal exercise is beneficial in maintaining bone density in post-menopausal women4, 5, 6. Exercise is also beneficial for senior adults’ physical fitness, balance and strength, which can help to reduce the risk of falling. Weight-bearing exercises place carefully considered stress on the bones, stimulating bone formation and slowing down bone loss.
Resistance exercises, which involve using weights, body weight and resistance bands, improve participants’ bone density through the tugging of muscles on their bones, and improve their muscle strength and endurance. The increase in muscle mass from strength training effectively maintains bone density.
Such exercises, done regularly and progressively over the long term, provide continual stimulation to the muscles and bones to improve strength and bone health, which can help to reduce a person’s risk of falls and fractures.
Refer a patient
Medical professionals can refer women patients to the Physiotherapy Department at KKH for osteoporosis management, including the bone health programme. Patients will first need to undergo a bone density test to ascertain a diagnosis of osteopenia or osteoporosis.
Upon confirmation of a diagnosis, medical professionals can make a referral via a written memo addressed to
“KKH Physiotherapy Department” and faxed to
+65 6394 1589. The memo would need to include the patient’s contact details. Appointment enquiries can be sent via email to
Ms Elizabeth Chan, Senior Principal Physiotherapist, Physiotherapy Department, KK Women’s and Children’s Hospital
Elizabeth graduated with a Bachelor of Physiotherapy and Master of Science in cancer care, and specialises in oncology physiotherapy. Elizabeth also led patient exercise classes and health ambassador training workshops, as part of the Osteoporosis Patient Targeted and Integrated Management for Active Living (OPTIMAL) secondary fracture prevention programme instituted in all public hospitals in Singapore. Currently, Elizabeth is one of the physiotherapists conducting the KKH BoneBuilding Programme.
Ms Catherine Chua, Head and Senior Principal Physiotherapist, Physiotherapy Department, KK Women’s and Children’s Hospital
Catherine holds a master’s degree in physiotherapy from Melbourne University, Australia, and specialises in women’s health. During her 21 years in KKH, Catherine oversaw the management of operations and manpower for the physiotherapy section, which became a department in 2016. She is also a member of the SingHealth professional committee and Allied Health Professional Council Complaint Committee. Catherine spearheaded the start of the BoneBuilding programme.
- Cooper, C. and Ferrari, S. (2017). IOF compendium of osteoporosis (1st edition). Switzerland: International Osteoporosis Foundation.
- International Osteoporosis Foundation (2017).
- Singapore Department of Statistics (2018). Population Trends 2018.
- García-Gomáriz, C., Blasco, J. M., Macián-Romero, C., Guillem-Hernández, E., & Igual-Camacho, C. (2018). Effect of 2 years of endurance and high-impact training on preventing osteoporosis in postmenopausal women: randomized clinical trial. Menopause (10723714), 25(3), 301–306.
- Basat H, Esmaelizadeh S, Eskiyurt N (2013).The effects of strengthening and high-impact exercises on bone metabolism and quality of life in postmenopausal women: A randomized controlled trial.
- Tolomio, S., Ermolao, A., Lalli, A., & Zaccaria, M. (2010). The effect of a multicomponent dual-modality exercise program targeting osteoporosis on bone health status and physical function capacity of postmenopausal women. Journal of women & aging, 22(4), 241-254.