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Exercise Interventions for
the Individual With
Osteoporosis
Eric J. Chaconas, PT, DPT, CSCS,1 Ovidio Olivencia, PT, DPT,2 and Brian S. Russ, PT2
1
Department of Physical Therapy, University of St. Augustine, St. Augustine, Florida; and 2Department of Physical
Therapy, Nova Southeastern University, Ft. Lauderdale, Florida
ABSTRACT
OSTEOPOROSIS IS A COMMON
CONDITION THAT CAN AFFECT
BOTH MEN AND WOMEN, TYPICALLY AFTER THE FOURTH
DECADE OF LIFE. OFTEN, PHYSICIANS ADVISE PATIENTS DIAGNOSED WITH OSTEOPOROSIS TO
EXERCISE, BUT FREQUENTLY
OFFER NO SPECIFICS. BY GAINING
A SOUND UNDERSTANDING OF THE
MECHANISM INVOLVED WITH
OSTEOPOROSIS, THE EXERCISE
PROFESSIONAL WILL BE BETTER
SUITED TO DESIGN EXERCISE AND
INJURY PREVENTION PROGRAMS
FOR THIS CLIENT POPULATION. THE
PURPOSE OF THIS MANUSCRIPT IS
TO DEFINE OSTEOPOROSIS,
REVIEW THE DIAGNOSTIC PROCESS, AND DISCUSS TREATMENT
OPTIONS WITH AN EMPHASIS ON
EXERCISE INTERVENTIONS.
INTRODUCTION AND
EPIDEMIOLOGY
steoporosis is a systemic skeletal disorder that results in
low bone mass and microarchitectural deterioration of bone tissue (17,31). As a result, individuals
with osteoporosis are at higher risk
for fracture when compared with the
general population (17,31). Most commonly, osteoporosis affects postmenopausal women, primarily older than
70 years, although the possibility of
osteoporotic fracture increases after
O
the age of 50 years. Additionally, it
is estimated that 1 in 12 men in this
age group are also affected with osteoporosis and at risk for fracture
(31,38). In the United States, approximately 1.5 million fractures occur
annually because of osteoporosis.
A number of risk factors are thought to
contribute to the development of osteoporosis (17,31,38). Age, sex, body mass
index, low bone mineral density
(BMD), low birth weight, genetics, hormonal changes, alcohol use, long-term
corticosteroid use, cancer, certain disease states, smoking, and calcium and
vitamin D deficiency have all been
reported (17). Research suggests a number of treatment options, including
pharmaceuticals, diet, vitamin supplementation, and exercises.
Fracture of the hip, vertebrae, and wrist
are common in individuals with osteoporosis and are responsible for
increased rates of mortality, morbidity,
chronic pain, and altered quality of life
(15). Costs associated with osteoporotic
fracture treatment are high, primarily
with fractures of the hip (15,17). The
estimated number of hip fractures seen
worldwide could rise from 1.7 million in
1990 to 6.3 million by 2050, with a projected cost exceeding 131 billion dollars
(16,22). Although multiple interventions designed to stimulate bone growth
have been suggested, exercise plays an
important role in the management and
treatment of individuals with osteoporosis (15,31). The purpose of this paper
is to review the process of diagnosing
Copyright Ó National Strength and Conditioning Association
osteoporosis, the associated risk factors,
and recommended treatment options
with an emphasis on exercise interventions and general conditioning.
DIAGNOSIS
The adult skeleton undergoes a continued process of breakdown (resorption) and bone formation. Calcium is
constantly being added by osteoblasts
and removed by osteoclasts. When
calcium is removed faster than it is
added, the skeletal bone becomes
porous, lighter, and fragile. The process of resorption and remodeling
must remain in balance to avoid
bone loss. Disparity in this process
leads to trabecular and cortical bone
loss and the development of osteoporosis (22). For example, a hormone
imbalance, specifically a deficiency in
estrogen, leads to an increase in
resorption without subsequent bone
formation (22).
Bone quality is determined by a number of factors. Bone geometry, cortical thickness, porosity, trabecular
bone morphology, and intrinsic properties of the bony tissue play a role
in bone strength (22). Prevention of
an osteoporotic facture is dependent
on accurate diagnosis leading to fracture probability estimates (15). Loss
of bone mass is a significant risk factor for fracture and can be determined by various techniques, such
KEY WORDS:
bone density; exercise; osteoporosis
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49
Osteoporosis Exercise
as dual-energy x-ray absorptiometry
(DXA), quantitative ultrasound, magnetic resonance imaging, quantitative
computed tomography, and peripheral quantitative computed tomography (25). Currently, the gold
standard for determining BMD is
DXA (15,22). Initially introduced in
1987, DXA is a well-standardized
technique that delivers low doses of
radiation to the patient while delivering
a high degree of precision (22). The DXA
uses 2 x-ray beams to determine bone
mineral content. Scan outcomes are
then compared with standardized
results obtained from a young adult
reference population (16,22). Results
are then expressed in terms of T scores
and Z scores and compared with an
age-matched reference population.
T scores are expressed in standard deviations from the mean and compared
with young adult white female values.
Based on the World Health Organization, T score results are defined as
follows: normal, 0 to 20.99; osteopenia, 21 to 22.49; and osteoporosis,
equal to or less than 22.5 (29).
Z scores compare the patient’s results
to a population of similar sex, age, and
height and are useful for determining
the likelihood of a secondary cause of
osteoporosis, such as malignancy.
Z scores are expressed in terms of
standard deviations from the population mean with a Z score ranging from
1.5 to 2.0 below the mean indicating
possible secondary osteoporosis.
PHYSICAL PRESENTATION
Osteoporosis is a slow process where
bone breakdown exceeds bone growth.
This process is most commonly
asymptomatic but occasionally the
earliest signs and symptoms can be
an acute bout of back pain (12). The
most common sites for osteoporotic
fractures and back pain are the thoracic (T7-8) and lumbar (T12-L1)
spine segments (20). Patients experiencing vertebral compression fractures demonstrate reduced vertebral
height with an associated slouched
and kyphotic posture. The kyphotic
posture is because of the vertebral
bone loss and anterior collapse
50
of the vertebrae (8). The exaggerated
curvature of the vertebral column
often involves a compensatory cervical
and in some cases lumbar hyperlordotic posture (10). These compensatory adaptations of the lumbar and
cervical spine are often associated
with tight hip flexors and pectoralis
minor muscles, respectively. Moreover, clients with vertebral compression fractures have the tendency to
walk with a stooped posture and
often sit for extended periods. These
postures lead to further muscular
tightness and perpetuate postural
dysfunctions that may place greater
compressive forces on the anterior
aspect of the vertebra.
People with osteoporosis often demonstrate decreased muscle strength
(9). Sinaki et al. (32) found that females with osteoporosis demonstrate
weakness of the back extensor musculature compared with females without osteoporosis. Lui-Ambrose et al.
(24) found that females with osteoporosis had greater knee extensor muscle weakness compared with agematched controls. The relationship
between osteoporosis and muscle
strength can be attributed to many
factors including sensory input of
osteocytes through muscle strain,
the individual’s activity level, and
hormonal influences (37). Muscle
weakness can also speed up bone
demineralization, increasing the risk
for osteoporotic fractures (2). Furthermore, trunk and lower extremity
weakness can lead to gait and balance
impairments, which can increase the
risk for falls and fractures.
OSTEOPOROSIS INTERVENTIONS
Osteoporosis is often treated by pharmacologic therapy, complementary
and alternative medications (CAM),
and exercise. The overall goal of these
interventions is to maintain adequate
levels of calcium, promote bone
growth, reduce bone breakdown,
and mitigate impairments.
PHARMACOLOGIC THERAPIES
The pharmacologic treatment of osteoporosis may include bisphosphonates,
VOLUME 35 | NUMBER 4 | AUGUST 2013
calcitonin, estrogen replacement,
and/or estrogen receptor modulators
(5,25). Bisphosphonates are a group
of drugs, including Fosamax (Merck
& Co, Whitehouse Station, NJ),
Boniva (Roche Laboratories, Nutley,
NJ), and Actonel (Warner Chilcott
Laboratories, Rockaway, NJ), which
inhibit osteoclast activity and bone
breakdown (5,27,28). These drugs
improve BMD and have been shown
to reduce the risk of hip, vertebral,
and wrist fracture. Calcitonin is
another group of drugs commonly
used with patients presenting with
osteoporosis. Calcitonin (Cibacalcin
[Novartis Pharmaceuticals Corporation, East Hanover, NJ], Miacalcin
[Novartis], and Calcimar [Aventis
Pharmaceuticals, Bridgewater, NJ])
functions by inhibiting osteoclast
activity and increasing renal calcium
excretion (13).
Osteoporosis is often treated with
estrogen replacement therapy (ERT).
Medications such as Premarin (Pfizer,
New York, NY), Ogden (Pfizer), and
Estrace (Warner Chilcott Laboratories, Rockaway, NJ) stabilize bone cell
turnover and promote bone formation
(5). The evidence clearly demonstrates the benefits of ERT in the prevention of fractures; however, because
of elevated risks for breast cancer,
venous thrombosis, stroke, and coronary diseases, ERT is no longer the
preferred treatment for osteoporosis
(6). Recently, selective estrogen receptor modulators, such as Evista (Eli
Lilly, Indianapolis, IN), have gained
popularity because of fewer side
effects. Drugs, such as Evista, preferentially bind to estrogen receptors in
bone while bypassing other receptors
that are associated with cardiovascular diseases and cancer (7).
COMPLEMENTARY AND
ALTERNATIVE MEDICATIONS
Complementary and alternative medications are drugs that are used either
in combination with or in place of a
conventional treatment (5). Calcium
supplements are often used to complement the pharmacological treatment of osteoporosis (18). Short
clinical trials of calcium supplementation in postmenopausal women provided the necessary amount of
calcium in the blood to reduce bone
loss and decrease the risk for fracture
(35). The recommended dietary
intake of calcium for postmenopausal
women is approximately 1,200–1,500
mg/d (4). Another CAM is vitamin
D, which promotes bone mineralization by increasing the absorption of
calcium from the digestive tract (23).
Vitamin D promotes bone growth by
maintaining adequate amounts of
calcium in the blood necessary for
bone formation. The recommended
dietary intake of vitamin D for postmenopausal women and the elderly
is 800 IU (36). However, it is important to note that Levis and Theodore
(21) found conflicting evidence about
the role of vitamin D in the prevention of fractures. Furthermore, they
found moderate evidence suggesting
that treating osteoporosis with calcium supplements alone does not
reduce vertebral and nonvertebral
fractures.
EXERCISE INTERVENTIONS
FOR OSTEOPOROSIS
Exercise plays an essential role in the
treatment of osteoporosis. Anaerobic
and aerobic training have been shown
to be effective methods of exercise for
improving BMD and reducing bone
loss (14,30,33). Wolff’s law states that
human and animal bone adapts to
new or unusual mechanical stress by
altering the bone architecture (11).
Bone tissue will adjust by increasing
osteoblast formation in the areas
affected by mechanical stress. Conversely, with a lack of mechanical
stress, the bone will progressively
weaken because of resorption exceeding bone growth. For bone formation
to occur, a minimal essential strain
(MES) is required. MES is the minimal
threshold required for human bone formation (1,11). It is estimated that the
MES for the human bone is approximately 1/10 of what is required for
a fracture (11). Exercise can provide
the necessary essential strain to maintain and promote bone growth.
Exercise has been found to be an
effective treatment for osteoporosis
in postmenopausal women. Wolff
et al. (39) conducted a systematic
review of published articles that
examined the effect of exercise on
BMD. The study concluded that exercise training prevented or reversed
bone loss by close to 1% per year in
both premenopausal and postmenopausal women. In 2002 Bonaiuti
et al. (3) conducted a systematic
review of 18 randomized controlled
trials that examined the effects of exercise on BMD. This study found that
aerobic, weight bearing, and resistance
training exercises effectively improve
BMD at the spine and wrist. Howe
et al. (15) conducted an update to
this review in 2011 that found postmenopausal women who participated
in different modes of exercises had
statistically significant increases in
BMD compared with control groups
who did not exercise. This review
found that dynamic weight-bearing
exercises such as jogging, jumping,
and vibration exercises improved
BMD at the hip. This review also
found non–weight-bearing exercises,
such as knee extension and flexion,
shoulder press, bicep curls, seated
row, and lat pull downs with high
loads improved BMD at specific sites,
such as the lumbar spine and hip regions. Furthermore, Howe et al. (15)
concluded that the most effective program for improving BMD at the spine
was the combination of dynamic
weight bearing and non–weight bearing high-load exercises. Howe et al.
(15) defined “high-load” exercises as
80% of 1 repetition maximum (1RM).
Moreover, strength training with low
load and high repetition (e.g., 16 repetitions with 40% 1RM) demonstrated
no additional benefits on BMD. It
should be noted that to avoid risk of
injury, high-load exercises should be
added to a program gradually.
Metcalfe et al. (26) conducted a randomized controlled trial investigating
the effects of exercise on BMD in
postmenopausal women. This study
consisted of a hormone replacement
therapy (HRT) group, HRT and exercise, exercise without HRT, and
a control group without exercise or
HRT (all groups were provided with
calcium supplements). The exercise
group participated in a program,
which consisted of weight-bearing exercises (stepping/stair climbing with
weighted vest), stretching (pectoral
stretch and back bends), abdominal
strengthening, balance (single leg),
and strength training with large muscle groups (lat pull downs, military
press, back extensions, leg press, and
squats). The subjects trained 3 times
per week for 1 year. The results of this
study demonstrated an increase in
BMD ranging from 0.6 to 2.1% for
the intervention groups and a loss of
1% for the control group. The exercise
group with HRT demonstrated the
largest gain in BMD in the hip compared with any other group. This
study demonstrated that a combination of weight-bearing exercises,
strength training (high loads), balance
exercises, HRT, and calcium supplements produces the greatest gains in
BMD.
Stengels et al. (34) investigated the
impact of power versus strength
resistance training on BMD in 53
postmenopausal women. The study
consisted of a slow resistance training
(4-second concentric and 4-second
eccentric contraction) group and fast
resistance training (fast concentric
and 4-second eccentric contraction)
group. For more than 1 year, the
groups exercised 4 days a week. Their
routine consisted of 2 days of resistance training, 1 day of gymnastic
exercises, and 1 day of home exercise
training. All participants were provided vitamin D and calcium supplements. The results of this study
demonstrated that the fast resistance
training group was more effective
than the slow resistance training
group at preventing bone loss at the
hip and at the spine. This study demonstrated the benefits of power training and fast concentric contractions
on BMD and the prevention of bone
loss for postmenopausal women.
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Osteoporosis Exercise
Table
Beginner example exercise program, including exercise mode and dosage for an individual with osteoporosis
Exercise type
Exercise movement
Exercise dose
Warm-up
Choice of treadmill, stationary bike, elliptical machine,
stair stepping
50% maximum heart rate,
5–10 min
Resistance training alternating upper/
lower-body exercise each session
Lower body: horizontal leg press, hamstring curls, hip
abduction, hip adduction
50% of 1RM, 10–15 reps,
2–3 sets
Upper body: bench press, upright row, latissimus pull
down, overhead press
50% of 1RM, 10–15 reps,
2–3 sets
Prone press-up (Figure 1) and quadruped stabilization
(Figure 2)
20 reps, 2 sets
Thoracic extension on foam roll (Figure 3)
10 reps
Thoracic extension with pectoral stretch (Figure 4)
20-s holds, 5 reps
Thoracic extension in prone position (Figure 5)
10-s holds, 5 reps
Spine-specific exercises
reps 5 repetitions; 1RM 5 1 repetition maximum.
SUMMARY OF EXERCISE EVIDENCE
There is ample evidence that exercise
improves BMD in patients with osteoporosis (15,39). The evidence demonstrates that exercises with axial loading,
such as jogging, jumping, and vibration
exercises, promote the best gains in
BMD at the hip (26). However, combining dynamic exercises with a resistance
program that involves multiple joints,
large muscles, and spinal loading have
demonstrated effectiveness for maintaining and promoting bone formation at
the hip and at the spine (34). However,
to best maintain and stimulate BMD, an
exercise program needs to incorporate
the principles of specificity, overload,
and progression. That is, the exercise
program should demand an adaptation
to a specific region, should present a load
large enough to exceed what is accustomed, and the exercise routine should
be progressed and varied (1). The exercise program should also directly load
the musculoskeletal system in areas
prone to fractures, such as the hip, spine,
and wrist. Progression should be slow
and gradual to avoid injury, and all
clients with osteoporosis should receive
medical clearance before initiating an
exercise program.
EXERCISE PRECAUTIONS
Special care needs to be taken when
designing an exercise program for an
52
individual with osteoporosis. For
instance, a resistance training program
that exceeds the ability of bone to adapt
to new stress may lead to undesired
results, such as stress fractures, bone
inflammation, spurs, or even complete
fractures. The exercise program should
be designed to load the musculoskeletal
system slowly and provide sufficient
time for bone growth and adaptation
to occur. This can best be achieved by
small increases in resistance over
extended periods (less than 5% per
week). Symptoms of delayed-onset
muscle soreness should be expected.
However, undesirable symptoms, such
as dull, deep continuous pain and/or
antalgic gait or posture should not be
expected. These symptoms could be
Figure 1. Prone press-up: start with the
client lying flat on a table
and begin to straighten
elbows with palms in front
of shoulders while keeping
the pelvis on the table.
VOLUME 35 | NUMBER 4 | AUGUST 2013
Figure 2. (A) Quadruped spinal stabilization exercise starting position: client maintains position
on hands and knees with a
neutral spine and contracted
transversus abdominis. (B)
Quadruped spinal stabilization exercise end position:
while maintaining abdominal
contraction and neutral spine
position, lift the arm to
shoulder height while lifting
the opposite side leg to the
same level.
The program would be performed
with the frequency of 4 sessions per
week and progress as indicated after
a period of 4–6 weeks.
Figure 3. Thoracic extension on foam
roll: supine position with foam
roll underneath the mid thoracic spine with a horizontal
orientation. The client moves
the upper thoracic spine into
an extension position.
Figure 5. Prone extension: prone position
with pillow under lumbar
region. Perform scapular
retraction and lift the upper
trunk off the table. Care
should be taken to avoid
extension of the lumbar spine.
signs of serious bone or tendon injury. It
is imperative to discontinue the program if symptoms persist and seek
immediate medical attention from
a qualified healthcare practitioner.
Clients diagnosed with osteoporosis
should also be encouraged to avoid
slouched postures that typically consist
of rounded shoulders and a forward
head because this position encourages
flexion of the spine and stress on anterior vertebral body. If receiving pharmacologic treatment for osteoporosis,
special precautions should be taken
when participating in an exercise
program. For instance, bisphosphonates (Acotonel) may cause acid
reflux if the client lies down soon
after the administration. Individuals
taking
bisphosphonates
should
remain upright for at least 30 minutes
before participating in any exercise
that requires lying down (19). Finally,
postmenopausal women who take
large doses of calcium and vitamin
D supplements should be aware of
potential adverse effects of these supplements, such as low blood pressure,
constipation, headaches, dizziness,
weakness, fatigue, and gastrointestinal
disturbance (5). As previously stated,
it is recommended that all individuals
with osteoporosis receive clearance
from a medical doctor before initiating an exercise program.
Figure 4. Thoracic extension with pectoral stretch: supine position
with foam roll underneath
spine with a longitudinal orientation. The client allows for
horizontal abduction of the
arms to provide a stretch to
the pectoral musculature.
SAMPLE EXERCISE PROGRAM
The following is an example of a sample exercise program (Table) that
would benefit a patient with osteoporosis, assuming the individual is not
experiencing additional injury or
dysfunction to the musculoskeletal
system. The described program is
not all-inclusive and should always
be performed with respect to pain. If
adverse musculoskeletal symptoms
are reported during the program, the
client should be referred to the appropriate healthcare provider. The example provided is designed for a beginner
with respect to exercise dosage and
movements performed. All resistance exercises would be initially performed with pulley-based resistance
equipment at moderate intensity.
The extremity exercises chosen integrate both compound movements in
which loading occurs through multiple
joints as well as foundational isolated
joint movements. It should be noted
that during all exercises, spinal flexion
is avoided because of the inherent risk
of vertebral compression fracture.
A neutral or slightly extended spine is
maintained throughout the routine.
The specific focus on the hip musculature provides a strength foundation for
proximal stability with the understanding that functional movements will be
integrated once a strength base is
established. The resistance level should
be progressed gradually up to 85% of
1RM. Intensity of the exercise program
can also be progressed by decreasing
rest time between sets from 2 minutes
to less than 30 seconds. Specific spine
exercises are included in the program
to improve spinal dynamic stabilization
and spinal extension strength as well as
to help the patient avoid a flexed spine
posture.
CONCLUSION
Strong evidence exists that exercise
should be considered an essential
portion of the treatment plan for
any individual diagnosed with osteoporosis. As part of the rehabilitation
team, the exercise professional should
have a client obtain medical clearance
before initiating an exercise program.
Although the research supports exercise as an intervention for osteoporosis,
there is no definitive conclusion on
how to progress the osteoporotic client.
Based on the available information, the
authors recommend a combination of
weight bearing and non–weight-bearing exercise starting with lower loads
(40–67% 1RM) and higher repetitions
with a gradual progression toward
higher loads (80–85% 1RM) and lower
repetitions. By using the information
presented in this article, the exercise
professional should be able to design
and implement an exercise program
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53
Osteoporosis Exercise
that will protect an individual from
injury and inhibit or potentially reverse
the negative effects of osteoporosis.
Conflicts of Interest and Source of Funding:
The authors report no conflicts of interest
and no source of funding.
Eric J.
Chaconas is an
assistant professor in the
Department of
Physical Therapy at the University of St.
Augustine.
Ovidio
Olivencia is an
instructor in the
Department of
Physical Therapy at Nova
Southeastern
University.
Brian S. Russ is
an instructor in
the Department
of Physical
Therapy at
Nova Southeastern
University.
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