EXERCISE IN OSTEOPOROSIS

Dr Asterios Papanikolaou Physical and Rehabilitation

Medicine

Bone Health

• Increased physical activity, - especially weight bearing and - resistive exercises stimulates bone building via the piezoelectric effect of contracted muscle on bone

Life span Bone Phases

• Growth phase, during childhood and adolescence

• Maintenance phase, young and middle adulthood

• Mid-life phase, ages 50-70, bone lose phase• Frailty phase, after age 70

Exercise in the Elderly

• need not to be strenuous to confer benefit• T’ai chi, gentle slow movements confer benefits in balance, strength, cardiovascular fitness, respiratory function, flexibility and decrease injury • Reduction in Multiple Falls 55%, 3 times/weekly• Delayed Bone Density Loss, in postmenopausal

female

Whole body vibration

Benefit in residents of long term facilities in

• Balance• Muscle strength• Bone mass

1. Preventive exercise

2. Therapeutic exercise

Preventive exercise

Recommended

A life long dedication to:

• physical activity• exercise

Preventive exercise

Proposed:

• Children aged 8 and older… 60 min. daily

• Adults … 30 min. daily

Therapeutic exercise

• Essential element of the rehabilitation program for the patients with osteoporosis • Tailored to the patient’s level of fitness and anticipated propensity to fracture

Therapeutic exercise

• the term Therapeutic: relates to the treatment of disease, or physical disorder

• the term Exercise: refers to bodily exertion for the sake of training, or improvement of health, (including those to develop Endurance, Strength, Flexibility, and Proprioception)

Therapeutic exercise

• Hippocrates (460 to 370 B.C.)reportedly advocated exercise as an important factor in the healing of injured ligaments• Hindus and Chinese (1000 B.C.)used Therapeutic Exercise in the treatment of athletic injuries

Therapeutic exercise Principles

1. Principle of Specificity2. Principe of Reversibility3. Principle of Progression4. Principle of Initial Value5. Principle of Diminishing Returns

Therapeutic exercise1. Principle of Specificity

• Exercise should stress the specific physiologic system being training

• to patients with Normal Bone Mass: should stress sites most at risk of fracture (i.e., hip, spine, wrist

• Osteopenia and Osteoporosis: exercise for Osteogenesis

• High-impact exercises (jumping and strength training), better than low-to-moderate (brisk walking), and has positive bone mass effect at spine and hip, in as little as 5 to 10min./day

Therapeutic exercise 1. Principle of Specificity

• High-Impact exercise: Not for very low bone mass and multiple fractures. They need skeletal protection while building strength, and increase balance and flexibility

• Isometric, core-strengthening ex. With the spine in neutral position: for all patients.

• Spinal flexion: not for low bone mass

Therapeutic exercise2. Principle of Reversibility

• The Positive effect of ex., will slowly be lost if the program stops

• A Lifelong dedication to exercise and Physical Activity to prevent bone changes with aging, and abandonment of exercise goals

• Sarcopenia (muscle mass loss 5% per decade, after age 30, and more after 65), may be reversed by exercise.

• Emphasize bone strengthening, while it still has adaptive ability, especially in the elderly and persons with disability

Therapeutic exercise2.Principle of Reversibility

• Passive Standing: is not recommended for active adults exercise

• Passive Standing: is a rehabilitative strategy to prevent bone loss to severe disability such a spinal cord injury through the use of a standing frame or standing wheelchair.

Therapeutic exercise3. Principle of Progression

• To Increase Bone Mass, the stimulus must exceed previous bone-loading activity.

• Progressive Resistive Increase in the Intensity exercises, are site specific (i.e. hip) for the bone health and improved functional capacity.

• Slowly increasing time or intensity 10% weekly to avoid mechanical bone stress

Therapeutic exercise4.Priciple of Initial values

• Patients who initially have low capacity will have the greatest functional improvement from a given program

• Attention for Inactive Participants, to begin with short sessions, of low intensity and progress

Therapeutic exercise5. Principal of Diminishing Returns

• There is a biologic ceiling to exercise-induced improvements in function. As this ceiling is approached, greater effort is needed to achieve minimal gain.

• Optimal Calcium Intake for all; (if no contraindications), with Physical Activity, improve bone mass. Calcium supplements in postmenopausal women reduce bone loss by 2%, and 23% spine fractures.

Therapeutic exercise5. Principle of Diminishing Return

• Vitamin D supplements may reduce spine fracture by as much as 7%.

• Adequate Caloric Intake and Glycemic Index must support exercise

• Weight loss, with Adipose tissue loss, and depletes estrogen production stores, may cause amenorrhea in females increasing the risk of osteoporosis and stress fractures

Therapeutic exercise5.Principle of Diminishing Return

• The prevention of falls and fractures, through an ongoing exercise program, with proper nutrition, strength, and aerobic capacity, should be coupled with adjunctive measures such as the provision of adequate support for the spine, pain management, and psychological support when developing objectives for long term goals.

Regular Program of Exercise The Activity Pyramid

Regular Program of ExerciseHealth Benefits

• Reduction in All-Cause Mortality• Primary and Secondary Prevention of

Cardiovascular Disease• Blood pressure Regulation• Lipid Management• Weight Control• Type 2 Diabetes Mellitus Prevention

Regular Program of ExerciseHealth Benefits

• Improved Psychological Well-being and Quality of Life

• Maintenance of Bone Density • Increased Fibrinolytic Activity • Decrease Inflammatory Marker (CRP)• Improved Endothelial Function

Regular Program of ExerciseHealth Benefits

• Nonpharmacologic Antiarrythmic Intervension• Improved Sleep• Possible Enhanced Immune Function• Reduced Cancer Risk ( colon , breast, prostate,

lung)

SPEED Program

• in Osteoporotic-Kyphotic Women, through a Spinal Proprioceptive Extension Exercise Dynamic (SPEED) Program, intervention with a spinal weighted kypho-orthosis (WKO)

• Significant Reduction in Risk of Falls and Back Pain

• Balance, gait, and risk of falls improved significantly with the 4-week SPEED program (using CDP = computerized dynamic posturography)

SPEED Program REDUCING RISK OF FALLS IN OSTEOPOROTIC-KYPHOTIC WOMEN

• FIGURE 1. An 86-year-old woman with osteoporosis and kyphosis. Left, Radiograph of spine shows osteoporotic• and postural changes. From Sinaki M. Musculoskeletal challenges of osteoporosis. Aging (Milano). 1998;• 10:249-262, with permission. Middle, Severe kyphotic posturing, which made ambulation difficult. Right, Same• patient wearing weighted kypho-orthosis. Middle and Right from Sinaki M. Rehabilitation of osteoporotic• fractures of the spine. Phys Med Rehabil. 1995;9:105-123, with permission from Elsevier.

Suggested Rehabilitation Guidelines Based onBone Mineral Density

T Scores

T score Reduction to −1 SD (Normal)

• No treatment

• Patient education, preventive measures

• Lifting techniques

• Proper diet (calcium and vitamin D)

• Jogging (short distances)

• Weight training

• Aerobics

• Abdominal and back-strengthening exercises†

•

Conditioning of erector spinae muscles

T Reduction to −1 to −2.5 SD (Osteopenia)

• Consultation for treatment

• Patient education, preventive interventions

• Pain management

• Back-strengthening exercises

• Limit load lifting (≤10-20 lb)

• Aerobic exercises: Walking 40 min/day

• Strengthening exercises: Weight training three times a week

• Postural exercises: WKO combined with pelvic tilt and back extension

• Frenkel exercises, prevention of falls

• T’ai chi if desired

• Antiresorptive agents; if required

T Reduction to −1 to −2.5 SD (Osteopenia)

• Pharmacologic intervention

•

Pain management

• Range of motion, strengthening, coordination

• Midday rest, heat or cold, stroking massage, if needed

• Back extensor strengthening

• Walking 40 min/day, as tolerated; Frenkel exercises

• Aquatic exercises once or twice a week

• Fall prevention program

• Postural exercises: WKO program with pelvic tilt and back extension

• Prevention of vertebral compression fractures (orthoses, as needed)

• Prevention of spinal strain (lifting ≤5-10 lb)

• Evaluation of balance, gait aid

• Safety and facilitation of self-care through modification of bathrooms (grab bars), and kitchen (counter adjustment), occupational therapy consultation

• Start strengthening program with 1-2 lb and increase, as tolerated, to 5 lb in each hand

• SPEED program, if needed

• Hip protective measures

(SD, Standard deviation; SPEED, spinal proprioceptive extension exercise dynamic; WKO, weighted kypho-orthosis.)

T score Reduction to −1 to −2.5 SD (Osteopenia)

T Reduction to -2.5 SD or more (Osteoporosis)

• Pharmacologic intervention• Pain management• Range of motion, strengthening, coordination• Midday rest, heat or cold, stroking massage, if

needed• Back extensor strengthening• Walking 40 min/day as tolerated; Frenkel

exercises• Aquatic exercises once or twice a week • Fall prevention programme

T Reduction to -2.5 SD or more (Osteoporosis)

• Postural exercises : WKO program with pelvis tilt and back extension

• Prevention of vertebral compression fractures (orthoses as needed)

• Prevention of spinal strain (lifting ≤ 5- 10 lb)• Evaluation of balance, gait aid• Safety and facilitation of self-care through

modification of bathrooms and kitchen, occupational therapy consultation

T Reduction to -2.5 SD or more (Osteoporosis)

• Start strengthening program with 1-2 lb and increase, as tolerated, to 5 lb in each hand

• Speed program, if needed• Hip protective measures

New Hypothesis on the Most Effective Exercise to Reduce the Risk for Vertebral Fracture

Back strengthening exercises, performed in a prone position rather than in vertical position, (nonloading), can decrease risk of vertebral fractures through improvement of horizontal trabecular connections. The exercise needs to be progressive, resistive, and nonloading to avoid vertebral compression fracture.

Non Strenuous Progressive Exercises for severe Osteoporosis

Static and Dynamic Correct Postures

FIGURE 41-7 A, Lateral radiograph of the spine in a 77-year-old man with persistent back pain. No evidence of metastatic lesion was identified. B, Magnetic resonance image demonstrating extensive skeletal metastases from T3 through lower lumbar spine, with involvement of nearly every vertebral body. The most extensive involvement is at T3, T8 through T11, T12, and L4.

Spinal Cord Injury and Exercise Intensive exercise preserve bone mass of upper limbs, but did not stop demineralization of lower body

Danger to damage joints or bone fractures when pushing wheel chair or do transfers

Recommended exercises: weight bearing using a standing frame or harness, treadmill training, Parastep, and functional electrical stimulation

The PASIPD questionnaire: (Physical Activity Scale for individuals with Physical Disabilities) can be useful in assessing levels of activity.

Need more controlled studies using physiological loads to examine the effects of the above methods

http://www.h-p-cosmos.com/images/illustrations/h-p-cosmos_saturn_wheelchair_ill.jpg

Fall reduction strategies

• Fall etiologies: - Decreased neuromuscular coordination - Sarcopenia, 71% of elderly hip fractures - Mental status, confusion, dizziness - Medication - Environmental factors, pure lighting, loose rugs

Fall reduction strategies

• Using proper footwear • Appropriate environmental adaptations• Assistive devices, canes, walkers, wheelchairs• Orthoses

Exercises for Preventing Falls

• Education to eliminate fall risks• Exercises improving balance, such as gait training, coordination and functional exercises and muscle strengthening

Gait Analysis and Training System, with EMG Biofeedback, Goniometer, Force Distribution Platform, Video

http://www.zebris.de/fotos-inhalt/Webgalerie/bildergalerie_produkte/fdmt_laufbandplattform/Reports_FDMT_Prospekt.jpg

Balance system, for Fall Risk Screeningand Conditioning Program

ConclusionPatient’s education, can contribute to prevention, better understanding and management, of the consequences of osteoporosis.Posture and exercise programs, body mechanics, increasing strength and aerobic capacity, fall reduction strategies, is an essential component of both short-term and long-term interventions, for both men and women, which lead to a better quality of Aging.