“You Have to Keep Moving, Be Active”: Perceptions and Experiences of Habitual Physical Activity in Older Women With Osteoporosis

Perceived barriers.

The major perceived barrier to PA was weather conditions; all informants talked about how they had to be extremely careful in the wintertime. Icy and snowy sidewalks were the main reason for increased fear of falling, and the informants described how they sometimes had to stay indoors and refrain from daily walks to avoid the risk of fall-related fractures. Other barriers included travels that made regular exercise difficult, taking care of grandchildren, and lack of motivation to exercise, especially strength training. Concerns from others, mostly worried family members discouraging them from certain activities, also were mentioned: [A]nd then it's icy and there are hills…. It's outside the stores, it's everywhere, you know. And that stops me from walking. (I7,70y)

Another important challenge was to approach the conflicting advice, or lack of advice, about PA and osteoporosis given by health care professionals. Most women described how their physicians emphasized activity restrictions rather than promoting PA, and many of the informants stated that their physicians had not even mentioned the importance of PA and exercise for people diagnosed with osteoporosis. This conflicting advice, or lack of advice, was perceived as confusing and in conflict with the information from physical therapists or other health care professionals and with information in newspapers or on websites targeting individuals with osteoporosis: The doctor only said that if you're in a lot of pain, take painkillers, but she didn't say anything about physical activity…. “Well, it's good if you go out for a walk,” she says, just like that. I mean, I haven't gotten any other information. (I16,68y)My doctor told me, “It's icy, don't go out walking now.” OK, so what am I supposed to do? Walk indoors? (I7,70y)

The women wanted safe and effective exercise guidelines from health care professionals who had knowledge of osteoporosis, and lack of specific advice and lack of individual support were perceived as barriers.

Accepting body limitations.

The informants described both age-related changes and diagnosis-specific limitations to PA, such as bodily and mental fatigue, reduced flexibility, and functional limitations caused by previous fractures. These limitations were often referred to as facts that one simply had to accept as a part of life, being an older person with osteoporosis: You know, your body says “no.” It's not as strong as it used to be…. And that's, of course, something you have to accept. It's just…well…just, how life is. (I15,80y)

Living with uncertainties and concerns.

Living with a fragile body evoked feelings of uncertainty or fear regarding PA. Several informants mentioned that they needed more knowledge about the appropriate type of exercise for people with osteoporosis. Some women specifically expressed uncertainty concerning whether or how well their bones could withstand different types of PA. They also described how they pictured their brittle bones: [Y]ou wonder if it's good for you to run up the stairs from the Metro, fast, fast, fast, or is it bad? Sometimes you wonder…will the bone break? (I17,76y)I've been thinking, maybe I should try strength training…. But, God no, I think, I'm probably like a biscuit. Yes, a cracker…. No, maybe it doesn't work. (I2,74y)

One informant expressed a strong fear of potential injury after receiving activity restrictions from her physician when she was first diagnosed with osteoporosis. She described her fear of moving as a phobia resulting in activity restriction: Yes, he really scared me. I wasn't allowed to carry more than a gallon of milk; I had to use a shopping cart…. I walked around like a zombie the first 3 weeks [laughter]…. I was so scared of everything,…and it was stuck in my mind for a long time.… Before I got diagnosed, I walked every day…almost a kilometer, morning and night, without problem, but then, you know, I got like a phobia. (I1,69y)

Many informants expressed concerns about the future development of their osteoporosis, including how they would be restricted in terms of PA due to pain or lack of flexibility or strength and how they could end up sitting in a wheelchair. They also talked about fear of losing their independence. When talking about their worries about the future, they often referred to negative role models, mostly older relatives with severe osteoporosis. For some women, these worries gave greater motivation for PA: [B]ut then I think about her, I really don't want to be like her, so I have to push myself a bit more…. That's how I think. (I16,68y)

Finding strategies and solutions.

Informants described 3 different strategies to face the challenges of being physically active with osteoporosis. The first strategy was to be careful and take special precautions in how to perform certain activities, such as climbing stairs or lifting heavy items. This strategy was connected to fear of fractures and fall-related concerns and included avoiding outdoor activities with high demands on balance performance or activities with a high risk of falling, such as cross-country skiing, skating, or bicycling: I don't go skiing anymore. I used to do it a lot, but…I'm too stiff now and…fall. No, I let it be. (I2,74y)

The second strategy, mentioned only by a couple of the informants, was to conserve energy, a strategy connected to age-related fatigue. The third strategy, risk taking, was mentioned by several women, and implied not to be too careful but rather to challenge fear and dare to do somewhat risky activities as a way to strengthen their self-efficacy: I don't believe that you should keep thinking “Oh no, now I've got osteoporosis, now I have to be careful.”… Maybe it's good to try. …I fell from the lowest step on a ladder, about this high, and I fell pretty hard, but…I think it's the same with everything, you can't get hung up on…the mishaps and flaws…no. (I8,79y)[A]nd maybe defy fear a little too, find out it's not so dangerous. You won't fall. (I2,74y)

The informants described how they had made adjustments in their PA behavior. For some women, these behavior changes meant that they overall had decreased their PA; others had found new alternatives that enabled them to continue to be active on the same PA level. Solutions mentioned were finding new alternative activities, such as yoga or sitting gymnastics, or beginning to use walking aids, such as walkers or poles, when going out walking for exercise. Ice grips for shoes and poles with spikes were used to be able to maintain walking habits during the winter season. The women seemed to be able to incorporate the proactive strategies into their daily life without much difficulty: Remember that life isn't over because you've got osteoporosis. No. There are so many things you can do. (I2,74y)

Identity as an active person.

Most women perceived themselves as being an active person. Physical activity had always been a natural part of their lives, and still was. They had been engaged in different sport activities as children or young adults, and some had spent a large part of their professional career in physically active workplaces. They had integrated exercise routines and walking in their daily life, and they perceived regular PA as very important. Some informants even described a craving for PA: I've always done it and liked it. Liked walking, I still do. (I2,74y)Yes, it's a kind of habit, like a craving. I get out of bed, get my jacket, and go out walking. It's one of those routines you get. (I16,68y)

Belief in the health effect of physical activity.

Physical activity was perceived to have an important impact both on health in general and on bone health and fracture risk. Many women had searched for and obtained information about the benefits of PA for people with osteoporosis through the media and Internet and from patient organizations. Reasons for engaging in PA were to stay healthy with osteoporosis, to prevent further physical decline, and to combat the effects of aging: It's important [PA]. Because when you sit down, start solving crosswords, day in and day out, it's no good…. [laughter] But crosswords are good too, for the brain…. But, well, you know what I mean, sitting too much, too much sedentary…that's not good for your body, the joints, and it's not just the osteoporosis, but in general. (I1,69y)

The informants' own experiences of positive effects of PA contributed to a general positive attitude toward PA and exercise. Both physical and mental effects were described, and walking in particular was connected to positive emotions and mental well-being. Some women also had experiences with specific exercises or everyday activities that helped them to control or prevent musculoskeletal pain: Walking, it clears your mind, I think. It feels good, you get out and…and then it feels so good to get back in again. (I2,74y)

Some of the informants talked about how the knowledge of the possible impact of PA on future development of their disease made them feel guilty when they were not as active as they felt that they could be: I think about how I know I can influence this [physical decline] myself, and then at the same time realize how stupid I am…. Now, I'm talking to myself. When I know this, and have these images in my mind…and, at the same time, can at least delay it…. Then you must be an idiot not doing what you're supposed to do…[laughter]…. Well, isn't that the case?…At my age, I should know better, anyway. (I10,68y)

The belief in the impact of PA on health also evoked feelings of unfairness in some women. They felt disappointed about being diagnosed with osteoporosis despite their active lifestyle: I think it's strange I have to face this, because I've been active all my life…but it probably has something to do with hormones. (I16,68y)

Sense of mastery and self-efficacy.

Added PA routines gave the women a sense of control over their bone health, and positive PA experiences contributed to a sense of mastery. Being able to take long walks or perform difficult activities generated increased PA self-efficacy. The women who had participated in the balance-training program declared how the specific training helped to strengthen their PA confidence: Because if you have different diagnoses, it can make you scared of doing certain things. But if you've done this [balance training],…then you see that you can do it…. To me, that was positive. (I7,70y)By any means, I'll keep going, be on my feet…well, I won't give up that easy. (I6,78y)

Support from others was described as a possible way to overcome challenges, and encouragement and advice from physical therapists were important facilitators for PA and regular exercise. Some informants emphasized the importance of training partners, and being engaged in a group activity was considered a facilitator: I'm glad to have physical therapists pushing me saying, “Come on, just a little bit more,” because I know you have to push it a little to move forward. (I16,68y)It's much easier in a group, then it's always someone who pushes…and then you don't want to be the one to skip class, so you go. (I7,70y)

On your own terms.

Despite their chronic disease, many informants considered themselves healthy and did not perceive osteoporosis as important to their sense of identity or self. Even though most women described how they had made adjustments in their PA behavior, their general perception was that it did not stop them from being physically active, and they did not perceive themselves as being ill: Because I'm not sick. It's just that I trip sometimes and break. (I14,81y)

Many informants expressed a wish to be seen as an individual by their caregivers. This wish included getting individualized advice and treatment. Individuality also was important in their general view of PA; participation had to be on their own terms. They said that it is only the individual herself who can decide what intensity or type of PA to engage in, and they described how they had chosen a type of PA that they enjoyed and thereby managed to sustain motivation and adherence to the activity: It's your own body, you're the only one who knows how much you can manage. (I7,70y)

In contrast to the perception that group activities and training partners are facilitators for PA, several women mentioned that they preferred to walk alone so they could choose the pace and route they preferred: I have a friend, she has a walker, too, because she's got aching feet. But she's not fit at all, not at all, and can't walk very far…we have to sit down. And that's why I rather walk alone if I want to go for a long walk, I can choose the pace myself. (I12,86y)