2. 2
What is Osteoporosis?
A condition in which the infrastructure
of bone becomes thin and weakened.
Weakened bone is at higher risk for
fracture to occur from minimal
stresses.
4. 4
Who Gets Osteoporosis?
ANYONE could be at risk for Osteoporosis
Most people are identified after age 50
Some diseases & conditions increase risk
Even men & children are at risk
5. 5
Risk Factors You Can’t Change
•Age
•Gender (4/5 cases are female)
•Postmenopausal status
•Family history, race (Caucasian or Asian),
Vit D genetics
•Small frame (<127 lb = osteoporosis risk)
•Hyperparathyroidism, RSD, cancer, organ
replacement
•Necessary medications (steroids,
antiseizure, anticoagulants, synthroid, many
chemotherapies, some diuretics)
(National Osteoporosis Foundation, 2002)
6. 6
Additional Risk Factors
Diseases that Are Often Treated with
Glucocorticoid Medications*
Asthma
Bursitis
Crohn’s Disease
Chronic Active
Hepatitis
Dermatitis (Severe)
Glaucoma
Lupus Erythematosus
Multiple Sclerosis
Osteoarthritis
Psoriasis
Rheumatoid Arthritis
*Partial List (National Osteoporosis Foundation, 2002)
7. 7
Risk Factors You Can Change
• Diet – inadequate calcium and vitamin D,
too much or too little protein
• Some bone-damaging medications
• Unhealthy lifestyle choices
• Alcohol (more than 2 drinks/day)
• Smoking (any!)
• Too little exercise
• Under-eating (<127 lb = osteoporosis risk)
(National Osteoporosis Foundation, 2002)
8. 8
Age in Years
10 20 30 40 50 60 70 80 90
Active
Growth
Slow
Loss
Rapid
Loss
Less Rapid
Loss
Bones build mass beginning at birth and peak by
age 20-30
Peak bone mass is attained between 25 & 30 y/o
• 50% accrued during teen years
• Declines by 1 – 1.5%/ year after peak
• Declines by 3 – 5%/ year 1st 5 yr/ menopause
Bone Development
(National
Osteoporosis
Foundation, 2002)
9. 9
Calcium and Bone
Recommended daily calcium intake
• Children and Young Adults
• 1-10 years 800 mgs
• 11-24 years 1,200 mgs
• Adults 1,000 mgs
• Pregnant and Lactating Women 1,200 mgs
• Postmenopausal Women Not on ERT 1,500 mgs
• Men over the age of 65 1,500 mgs
(National Osteoporosis Foundation, 2002)
Excess salt displaces calcium
– Is added to almost all canned foods!
High phosphates leach calcium from bone!
– Soda – the worst culprit
10. 10
Bone Nutrition - Beyond Calcium
Vitamin D
• At least 800 units daily (Boonen S et al, 2006; Pfeifer M et al, 2002)
• 30 minutes of sun to hands & face daily sufficient in sub-tropical
latitudes but only the “sunny” 6 months in temperate latitudes
Magnesium
• 400-600/day – allows calcification as a natural calcium
chelator (Barzel US, 1998)
• Depleted by stress, physical exertion
Protein Intake and Bone - moderation is the key
• Women (35-59 y/o) w/ protein intake >95g/day (5 servings red
meat/wk) vs those <59 g/day had increased risk of forearm fractures
(Feskanich D et al, 1996)
• High amounts of protein intake (~200 g/day) associated with
decreased bone density (Barzel US 1998)
• Low protein diets (<50g/day) associated with decreased bone density
(Chiu JF et al 1997)
11. 11
Drug Options – FDA approved
Anti-resorptives (slow bone resorption)
• Bisphosphonates (alendronate, risedronate,
ibandronate, pamidronate) (Wasnich RD et al, 2004;
Chestnut III CH et al, 2004, Chan SS et al, 2004)
• Selective estrogen receptor modulators
(raloxifene)
• Calcitonin (Miacalcin)
• Estrogen (Writing Group WHI, 2002; Nerhood RC 2001)
• Risks with long-term use may outweigh benefits, may
be safer with lower doses
• Always needs to be given with progesterone when
uterus present
Anabolic (bone forming)
• Parathyroid hormone (teraparatide) (Heaney RP,
2003)
12. 12
Why Do Bones Weaken?
Bones depend on calcium, other
chemicals, and vitamins to keep
them strong.
Bones grow as a response to physical
stress being put on them.
The density (hardness) of bones
requires a good diet, some sunlight,
and exercise in order to stay strong
and not break.
13. 13
It’s a Big Problem
Osteoporosis affects more than 10
million people in the US
8 million women
2 million men (but they are catching
up)
24 million others have low bone
mass, called osteopenia
Osteopenia is a precursor to
osteoporosis
(National Osteoporosis Foundation, 2002)
14. 14
Why is It a Problem?
Osteoporosis, by itself, is not a
problem. It doesn’t cause pain and
you will not know you have it!
The problem is that it makes bones
very brittle and brittle bones can
break easily.
A broken bone is called a FRACTURE.
15. 15
Fracture Numbers
Every year there are 1.5 million bone fractures in
this country
300,000 hip fractures
700,000 vertebral fractures
250,000 wrist fractures
Women have a greater lifetime risk of sustaining
a hip fracture than breast, ovarian , and uterine
cancer combined
Fracture care costs $3 BILLION every year!
(National Osteoporosis Foundation, 2002)
16. 16
Fractures HURT
Fractures cause:
Pain
Limited mobility
• Prolonged bedrest causes:
Loss of strength
Pneumonia
Disability
Death
• 20% of those with hip fractures die within one year
• Increased mortality with each vertebral fracture
(National Osteoporosis Foundation, 2002)
17. 17
Determinants of
Osteoporotic Fracture
Number of
osteoporosis
risk factors
Forward
bending
(trunk flexion)
Poor balance,
or accidents
resulting in
falls
Vertebral Fracture Hip Fracture
18. 18
Fracture Force Risks During
Bending and Lifting
Compression loads imposed on
the L3 motion segment (lower
back) by 30º of trunk flexion
– 1800 N with arms at chest
– 2610 N with arms in front, holding 2
kg in each hand (Schultz et al 1982)
300 to 1200 N enough to fracture
an osteoporotic vertebra (Edmondston et
al 1997)
Practical Application - bend and
lift in everyday life with the trunk
in relative neutral!
19. 19
Exercise and Vertebral Fractures
(for women with a previous fracture)
Type of Exercise
Spinal Extension (Back
arches/lifts)
Spinal Flexion
(Crunches)
Combined Flexion and
Extension
No exercise
New Fractures
16%
89%
53%
67%
(Sinaki and Mikkelson, 1984)
20. 20
How Do I Know if I Have It?
There are many types of screening tests
available in the community. Many use a
finger or a foot to estimate possible risk.
The gold standard (the absolute test) for
determining the amount of bone density
an individual has is a DEXA test. It is like
an X-ray without the radiation.
You lie on a table and a scanner passes
over you. A computer determines how
much bone you have by the information
read by the scanner.
21. 21
What’s a T-score?
The amount of bone you have is
determined by how much has been lost
since childhood, assuming you had lots of
calcium and activity at that time
A T-score is a statistical number which
says whether you are above or below
“normal”
T-scores are such numbers as -1.4 or -3.0
or even + 1.0 sometimes.
22. 22
T-scores
Normal T-scores range from +1 to -1
Osteopenia T-scores
-1.0 to -2.5
Osteoporosis T-score
less than -2.5 (up to -6.0)
23. 23
What Should I Do First?
There are 3 major things you can do
1. Talk to your doctor about a Bone Density
Test
2. Talk to a physical therapist about your
activity level and an exercise program to
combat osteoporosis
3. Talk to a dietician to make sure your diet
is providing your bones with enough
calcium and is balanced correctly
24. 24
What If I Already Have Osteoporosis?
Talk to your physician and pharmacist
about medications available to help you
Make sure your diet includes enough
calcium, not too much caffeine or alcohol,
and adequate, but not excessive, protein.
Spend at least 30 minutes/day in sunlight
and/or eat foods which are fortified with
Vitamin D
and………………..
25. 25
See a Physical Therapist
PTs are able to develop an exercise
program for you that will be appropriate
for your condition
PTs will evaluate your posture, your
strength, your range of motion, your
balance, and your general endurance
status
PTs will develop a balanced program which
should help keep you fit as well as safe
PTs can answer your questions or refer
you to others who will
26. 26
Studies on Exercise
Appropriate exercise may slow the
rate of bone loss
Sedentary lifestyles and immobility
lower bone density
Effects of exercise are improved
when combined with proper nutrition
and medication
27. 27
Exercise Effect on Bone –
Works only when “Regular”
Postmenopausal women exercised
3 times per week for 9 months
Stair-climbing for ~ 30 minutes
each session
Spinal bone density 4% in
exercisers
Spinal bone density to baseline
within 9 months for those who
stopped exercising
(Dalsky 1988)
28. 28
Resistance Training
Increases Bone Density Best
Landmark study (Nelson & Fiaterone 1994)
– Sedentary 50-70 y/o postmenopausal women
– Resistance training 2 X/wk on 5 machines for 1
year
– Significant bone density increases in spine, hip,
total body
Many other studies validate, including:
– Cussler EC 2003
– Kerr D 2001
– Kelley GA 2001
29. 29
Principles of Exercise for
People with Lowered Bone Mass
Posture is critical in all activities
Weight bearing is important
Walking, Dancing, Stair climbing
Resistance exercise is the best way
to strengthen bone & muscle groups
Balance exercise to decrease fall risk
Avoid activities or positions that
move the body into bent (flexed)
postures
30. 30
Exercise Intervention Works
After Vertebral fracture
– 6 months of supervised exercise back strength
and psychological status (Gold et al: 2004)
For kyphosis and balance
– 12 weeks of SAFE yoga (no forward bending!!!)
improves balance & posture (Greendale et al, 2002)
For osteoporosis and back pain
– 10 weeks of combination group and
individual exercise increases height,
improves back posture and strength (Lindsey
et al, 1995)
31. 31
Eclectic Treatment Focus Essential
Frailty Injury Cooperative Interventions
Trial Analysis revealed that a year after
the intervention:
– Fall rate decreased 10% in those who did
strength exercises only
– Fall rate decreased by 17% in those who
received “balance” exercises only
– Fall rate decreased by 31% in those who did
both plus the Tai Chi.
(Wolfson L et al: Balance and strength training in older adults:
intervention gains and Tai Chi maintenance. 1996)
– Those who increase all balance scores
show a 60% reduction in fall risk.
(Tinetti ME et al: A multifactorial intervention to reduce the risk of falling
among elderly people living in the community. 1994)
32. 32
Prevention of Bone Loss and
Minimizing Fracture Risk
Healthy lifestyle choices
– Exercise
– Nutrition
Early treatment
– Screening
– Individualized therapies
Physical Therapy
– Resistive weight bearing exercise
– Correct body mechanics
– Balance interventions
– Treat mechanical pain & dysfunction
33. See a Physical Therapist
for More Details!
http://www.apta.org
Click the “Find a PT” button
34. 34
Find Out More About Osteoporosis
Web sites for up to date information:
www.geriatricspt.org/clients/resources.cfm
www.nof.org
www.surgeongeneral/library/bonehealth
www.osteo.org
www.fore.org
35. 35
References
1. Barzel US, Massey LK. Excess dietary protein can adversely affect bone. J
Nutr. Jun 1998;128(6):1051-1053.
2. Boonen S, Vanderschueren D, Haentjens P, Lips P. Calcium and vitamin D
in the prevention and treatment of osteoporosis - a clinical update. J
Intern Med. Jun 2006;259(6):539-552.
3. Chan SS, Nery LM, McElduff A, et al. Intravenous pamidronate in the
treatment and prevention of osteoporosis. Intern Med J. Apr
2004;34(4):162-166.
4. Chesnut III CH, Skag A, Christiansen C, et al. Effects of oral ibandronate
administered daily or intermittently on fracture risk in postmenopausal
osteoporosis. J Bone Miner Res. Aug 2004;19(8):1241-1249.
5. Chiu JF, Lan SJ, Yang CY, et al. Long-term vegetarian diet and bone
mineral density in postmenopausal Taiwanese women. Calcif Tissue Int.
Mar 1997;60(3):245-249.
6. Cussler EC, Lohman TG, Going SB, et al. Weight lifted in strength training
predicts bone change in postmenopausal women. Med Sci Sports Exerc.
Jan 2003;35(1):10-17.
7. Dalsky GP, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ Jr.
Weight-bearing exercise training and lumbar bone mineral content in
postmenopausal women. Ann Intern Med. Jun 1988;108(6):824-828.
8. Edmondston SJ, Singer KP, Day RE, Price RI, Breidahl PD. Ex vivo
estimation of thoracolumbar vertebral body compressive strength: the
relative contributions of bone densitometry and vertebral morphometry.
Osteoporos Int. 1997;7(2):142-148.
9. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Protein consumption
and bone fractures in women. Am J Epidemiol. Mar 1 1996;143(5):472-
479.
36. 36
References (Cont)
10.Gold DT, Shipp KM, Pieper CF, Duncan PW, Martinez S, Lyles KW. Group
treatment improves trunk strength and psychological status in older
women with vertebral fractures: results of a randomized, clinical trial. J
Am Geriatr Soc. Sep 2004;52(9):1471-1478.
11.Greendale GA, McDivit A, Carpenter A, Seeger L, Huang MH. Yoga for
women with hyperkyphosis: results of a pilot study. Am J Public Health.
Oct 2002;92(10):1611-1614.
12.Heaney RP. Advances in therapy for osteoporosis. Clin Med Res. Apr
2003;1(2):93-99.
13.Herbold NH, Frates SE. Update of nutrition guidelines for the teen: trends
and concerns. Curr Opin Pediatr. Aug 2000;12(4):303-309.
14.Kelley GA, Kelley KS, Tran ZV. Resistance training and bone mineral
density in women: a meta-analysis of controlled trials. Am J Phys Med
Rehabil. Jan 2001;80(1):65-77.
15.Kelley GA, Kelley KS, Tran ZV. Exercise and lumbar spine bone mineral
density in postmenopausal women: a meta-analysis of individual patient
data. J Gerontol A Biol Sci Med Sci. Sep 2002;57(9):M599-604.
16.Kerr D, Ackland T, Maslen B, Morton A, Prince R. Resistance training over 2
years increases bone mass in calcium-replete postmenopausal women. J
Bone Miner Res. Jan 2001;16(1):175-181.
17.Lindsey C, Reisine S, Fertig J. Evaluation for the effects of exercise on
posture, back strength, pain & mood in postmenopausal women with
osteoporosis & back pain. Paper presented at: WCPT, 1995; Washington,
DC.
18.National_Osteoporosis_Foundation. America's Bone Health: The
State of Osteoporosis and Low Bone Mass in Our Nation.
Washington, DC: National Osteoporosis Foundation; 2002.
37. 37
References (cont)
19.Nelson ME, Fiatarone MA, Morganti CM, Greenberg RA, Evans WJ. Effects
of high-intensity strength training on multiple risk factors for osteoporotic
fractures: a randomized controlled trial. JAMA. Dec 28
1994;272(24):1909-1914.
20.Schultz AB, Andersson GBJ, Haderspeck K, et. al. Analysis and
measurement of lumbar trunk loads in tasks involving bends and twists. J
Biomechanics. 1982;15(9):669-675.
21.Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the
incidence of vertebral fractures: a prospective 10 year follow-up of
postmenopausal women. Bone. Jun 2002;30(6):836-841.
22.Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion
versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-
596.
23.Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to
reduce the risk of falling among elderly people living in the community. N
Engl J Med. Sep 29 1994;331(13):821-827.
24.Wasnich RD, Bagger YZ, Hosking DJ, et al. Changes in bone density and
turnover after alendronate or estrogen withdrawal. Menopause. Nov-Dec
2004;11((6 Pt 1)):622-630.
25.Wolfson L, Whipple R, Derby C, et al. Balance and strength training in
older adults: intervention gains and Tai Chi maintenance. J Am Geriatr
Soc. May 1996;44(5):498-506.
26.Writing Group for the Women's Health Initiative Investigators. Risks and
benefits of estrogen plus progestin in healthy postmenopausal women:
principal results From the Women's Health Initiative randomized
controlled trial. JAMA. Jul 17 2002;288(3):321-333.
Editor's Notes
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
Nancey A. Bookstein, PT, Ed.D Carleen Lindsey, PT, MSc
