EXERCISE IN OSTEOPOROSIS DrAsteriosPapanikolaou 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
Preventive exercise Recommended Alife 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 Principle of Specificity Principe of Reversibility Principle of Progression Principle of Initial Value 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: Notfor 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 andGlycemic 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 NonpharmacologicAntiarrythmicIntervension Improved Sleep Possible Enhanced Immune Function Reduced Cancer Risk ( colon , breast, prostate, lung)
SPEED Program in Osteoporotic-KyphoticWomen, 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 on Bone Mineral Density T Scores
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
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 extensiveskeletal 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, butdid 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
Balance system, for Fall Risk Screeningand Conditioning Program
Conclusion Patient’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.