By: Dr. Patricia Graham
Osteoporosis is the most common metabolic bone disease in the United States, with approximately 25 million Americans at risk, and most of them 88 percent women.
It is described as a decrease in bone mass, when loss of bone outpaces formation of bone. This bone fragility can increase the risk of fracture with minor trauma and falls.
Approximately 1.5 million fractures each year are attributed to osteoporosis in the U.S., with the most common fractures in the spine, the hip and the wrist. In fact, a woman’s risk of developing an osteoporotic fracture is equal to her combined risk of developing heart disease, stroke and breast cancer. Men, however, are not immune to this condition.
Screening for osteoporosis can begin with an X-ray, but for diagnosis, bone densitometry testing (DEXA Scan) is the most accurate test.
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‘The benefits of exercise in increasing bone density in the spine and extremities are well known. With proper screening and treatment programs, persons with osteoporosis risk factors or diagnosis can obtain the maximum benefits of exercise programs and decrease injury risks.’ Dr. Patricia Graham
Physiatrist The Medical Center at Princeton |
Medical management for osteoporosis should include efforts to increase dietary calcium. For a pre-menopausal woman 1,000-1,300 mg/day is recommended, and for post menopausal women, without hormone replacement, 1,500 mg/day. Factor in adult absorption of only 70 percent of calcium in diet and supplements when calculating your intake.
Vitamin D supplementation of 400-800 IU/day maximizes calcium absorption.
Additional medications are needed to slow bone loss after the diagnosis of osteoporosis, however, and can include estrogen replacement or enhancement therapy, calcitonin nasal spray and/or a class of drugs known as bisphosphanates (alendronate or risedronate).
An exercise program with weight-bearing exercises for the legs, arms and back can build bone density, strengthen muscles and improve posture and gait, and optimally begins before osteoporosis is diagnosed.
Whether the program is for slowing the onset or progression of osteoporosis, it should begin with a careful medical screening. Precautions must be set to avoid exacerbating medical conditions with progressively more vigorous exercise programs, as well as injury to the musculoskeletal system (even in younger persons).
An osteoporosis evaluation should examine the factors for developing osteoporosis. Increasing age, female gender, race, menopausal status and heredity (family history of fractures after age of 50) are important, as are small body frame and decreased muscle strength.
Inadequate nutrition (poor calcium intake, eating disorders, malabsorption and excessive caffeine or carbonated drinks) can contribute as well. A history of hyperthyroidism, arthritis, radiation therapy or prolonged limb immobilization after fracture are risk factors; medications such as steroids, anti-convulsants (phenytoin), and tamoxifen (in pre-menopausal women) are too.
Tobacco abuse and sedentary lifestyle contribute, and should also be discussed. Your doctor’s evaluation should also focus on safe capacity for exercise. Heart and lung function should be addressed a recent increase in the frequency or intensity of angina, or asthma attacks, may require evaluation by a specialist. Therapists follow strict medical precautions in treating this type of patient.
Physical examination should assess posture, range of motion (especially of back, hips and shoulders), loss of body height, muscle strength, sensation, balance and gait patterns. Recent falls and new bone pain may require an X-ray to rule out a new fracture. Muscle spasm and pain with joint movement or muscle stretch should be treated as part of a comprehensive osteoporosis program.
For instance, a history of recent fracture, low back pain, "frozen" shoulder or fibromyalgia are examples of musculoskeletal problems that usually require a pain management program with a physical therapist prior to weight-bearing exercises. In cases of severe kyphosis (rounding of the thoracic spine, often associated with compression fracture), bracing may be advised, with limitations set for the back exercise program.
Based on the medical evaluation, the exercise treatment plan begins with a referral to a supervised community exercise program for osteoporosis, or a prescription for physical therapy from your doctor, with medical precautions clearly stated for either setting. To maximize comfort, function and bone-building benefit, an exercise program must be tailored to the individual patient, with pain medications to facilitate progress if needed. Lifestyle changes are monitored in follow-up visits.
The hallmarks of an exemplary physical therapy program include:
Treating pain or previous injury, if present
Preventing falls through posture and gait training and, if needed, appropriate bracing and walking devices
Slowing further bone loss through bone-loading and muscle-strengthening exercises.
Pain relief is provided with heat, massage and proper body mechanics, which can facilitate early entry into an exercise program and prevent injury thereafter. Postural training is essential to slow the progression of kyphosis, and decrease risk of falls (with exercises which expand the anterior chest wall, and align spine, shoulders and hips). As posture improves and pain levels decrease, back braces are often discarded.
The exercise program should increase trunk strength and posture by strengthening back extensor muscles and, with isometric exercises, the abdominal wall. The back should be supported and stable during all exercises. If osteoporosis of the spine is diagnosed, one should avoid back flexion, side bending and rotation exercises initially, which can increase the risk of compression fractures.
Examples of these exercises include abdominal crunches, sit-ups, and bringing the knees to the chest. Exercising supine, standing, prone or side-lying is recommended until trunk strength is well-developed. Weight bearing exercises, such as treadmill walking, will increase forces through the skeleton, and slow bone loss.
Weight lifting and working out with resistive exercise equipment also contribute to greater bone density, but must be approached cautiously by those with known severe osteoporosis, and especially after osteoporosis-related fractures.
Many sports activities improve bone density. An active outdoor walking exercise program is an excellent way to continue weight-bearing exercise, and is easily tailored to individual needs and capacity. Caution when walking on slippery or sloped surfaces is advised.
While jogging is an aerobic activity that can improve bone density, it can be traumatic in women with arthritis or low bone density of the spine or hip. Racquet games provide a terrific cardiovascular workout, but are not recommended in patients with severe osteoporosis, as quick rotation of the spine can result in a compression fracture. A strenuous golf swing can have the same result.
By contrast, low impact aerobic dancing is recommended because it is less likely to jar the spine. Swimming is quite good for building endurance and strong back muscles for good posture, but unfortunately does not benefit bone density as weight-bearing land exercises do.
The benefits of exercise in increasing bone density in the spine and extremities are well known. With proper screening and treatment programs, persons with osteoporosis risk factors or diagnosis can obtain the maximum benefits of exercise programs and decrease injury risks.
Dr. Graham is a physiatrist with Princeton Orthopaedic Associates, and a consultant to the World Health Organization Disability and Rehabilitation Team (Geneva). Health Matters appears Fridays in the Lifestyle section of The Princeton Packet and is contributed by The Medical Center at Princeton.