Effetti dell’esercizio fisico nel paziente osteoporotico sarcopenico

Attività fisica ed
osteoporosi / sarcopenia
Jacopo A. Vitale
Ph.D in Scienze dello Sport @UNIMI
Ricercatore @IRCCS Istituto Ortopedico Galeazzi
Strength & Conditioning Coach
jacopo.vitale@grupposandonato.it

If any single drug had the same
range of health benefits as physical
activity it would be sold as a…
MIRACLE CURE!
Dear patient,
take this pill for 30 minutes
on 5 days a week…you’ll see!
A new pill to prescribe: physical activity*
* http://www.acsm.org/public-information/acsm-journals/guidelines.
Pedersen et al., 2015. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci.

Evidence-based pathways
of PA in delay of disease *

PSYCHIATRIC DISEASES
(depression, anxiety, stress,
schizophrenia)
MUSCULO-SKELETAL DISORDERS
(osteoarthritis, osteoporosis,
back pain, sarcopenia)
CANCER
(breast, prostate, colon, endometrial
and many others…)
PULMONARY DISEASES
(chronic obstructive pulmonary
disease, asthma, cystic fibrosis)
CARDIOVASCULAR DISEASES
(hypertension, coronary heart disease, heart
failure, cerebral apoplexy, and
claudication intermittent)
METABOLIC DISEASES
(obesity, hyperlipidemia, metabolic
syndrome, polycystic ovarian
syndrome, type 2 diabetes, type 1
diabetes)
NEUROLOGICAL DISEASES
(dementia, Parkinson’s disease,
multiple sclerosis)

HOW MUCH AND
WHICH KIND OF PA IN ≥
65 yo INDIVIDUALS?

Physical activity for elderly (65 yo.)*
• WHO: 150 minutes of moderate-intensity aerobic physical activity per week.
• ACSM: 3 times/week, 30/60 minutes every session.
• Aerobic activity should be performed in bouts of at least 10 minutes duration.
• Not only aerobic activities. Muscle strength and vigorous PA too.
• Work to enhance balance ability and prevent falls.

SPECIFIC PA FOR
OSTEOPOROTIC
INDIVIDUALS?

Evidence-based medicine*
* McNair P, Lewis G. 2012. Levels of evidence in medicine. Int J Sports Phys Ther.

EBC: Evidence-Based Coaching
4 crucial aspects to consider to take
the best evidence-based decisions:
• Science Evidence.
• Research Evidence.
• Previous experience of coach.
• Previous experience of patient.

Osteoporosis: incidence and burden *
• In EU, Japan, and USA 75.000.000 individuals (200.000.000 women world-wide).
• Causes more than 8.9 million fractures annually (1 every 3 seconds).
• 3.5 million women and 1 million men have osteoporosis in Italy.
• In Italy 5.000.000 individuals, 80% post-menopausal women.
• ISTAT data: in 2010, 38% Italian individuals no physical activity…
• Prevention / Treatment of osteoporosis through physical activity!
* http://www.who.int/chp/topics/Osteoporosis.pdf

Osteoporosis and physical activity*
* McMillan LB, et al. 2017. Prescribing Physical Activity for the Prevention and Treatment of Osteoporosis in Older Adults. Healthcare (Basel).

Activity induces an
anabolic or homeostatic
effect on bone via
mechanotransduction*
Duncan, R.; Turner, C.H. Mechanotransduction and the Functional Response of Bone to Mechanical Strain. Calcif. Tissue Int. 1995, 57, 344–358.
Fluid movement within the extracellular matrix of bone exerts force on osteocytes and bone
lining cells. This subsequently triggers the release of nitric oxide and prostaglandin, which lead
to division and differentiation of osteoprogenitor cells.
Pre-osteoblasts consequently mature to osteoblast cells and affix to the surface of the matrix
to begin the production of new bone.
Effects of PA on bone growth*
+++ Inibition of anti-anabolic factors
(DKK1 and sclerostin)

Effects of PA on bone growth*
Messengers that influence Bone Cell Proliferation and Differentiation.
Anabolic chemical messengers include:
• Growth Hormone (GH).
• Insulin-like growth factor-1 (IGF-1).
• Leptin.
• Thyroid hormone T3.
• Acidic fibroblast growth factor (aFGF) (?)
• Transforming growth factor β (TGFβ) (?)
Pulsatility of GH is essential for its ability to stimulate cellular proliferation in the bone.*
In contrast, constant delivery of growth GH does not have anabolic effects on the bone.
PHYSICAL ACTIVITY can be also considered a strong SYNCHRONIZER

What kind of physical activity?
MAIN VARIABLES:
- Mode.
- Intensity.
- Frequency.
- Duration.
- Balance training.
- Risk of fall.
- Posture
- Vibration exercise (?)
- Social Isolation.

An extensive body of research à 5 principles.
• Principle 1: Dynamic rather than static mechanical stimulation.
• Principle 2: Adaptive bone response requires supra-threshold intensity.
• Principle 3: Osteogenic response is proportional to strain frequency.
• Principle 4: Adaptive bone response requires brief but intermittent exercise.
• Principle 5: Adaptive bone responses require an unusual pattern of bone loading.
What kind of physical activity? *

Physical activity for osteoporosis*
• Weight-bearing endurance and resistance activities…but not only!
• Only-walking activities are not enough.
• Activities designed to maintain balance and prevent falls too.
• Include both moderate to vigorous resistance exercise targeting the lower body
and balance exercises.
• Activities with mechanical and gravitational stress.
McMillan LB, et al. 2017. Prescribing Physical Activity for the Prevention and Treatment of Osteoporosis in Older Adults. Healthcare (Basel).

• Confidence.
• Fear/anxiety.
• Depression.
• Altered body image.
• Low self-esteem.
• Beliefs about physical activity.
Before I was diagnosed, I would pick up my
grandkids, hold them and were 50, 60 pounds…since
the diagnosis, I’m just much more careful.
I’m like, ‘No, I’m not going to do that’, you know.
Psychological and social factors*
67 y.o osteoporotic patient *
• Kerr C. The importance of physical function to people with osteoporosis. Osteoporos Int. 2017.
• McMillan LB, et al. 2017. Prescribing Physical Activity for the Prevention and Treatment of Osteoporosis in Older Adults.

• Additional resistance may be applied gradually and conservatively (up to 10 lbs.)
• Therapy bands may be used to facilitate range-of-motion exercises
• Avoid impact exercise, spinal flexion against resistance, spinal extension,
high compressive forces on the spine, quick trunk rotation.
• PROBLEM: these exercises are often performed in static position.
1 TO 3 SETS.
5 TO 8 REPETITIONS.
4 TO 6 WEIGHT-BEARING, LOWER-BODY STRENGTH EXERCISES.
2 OR 3 DAYS/WEEK.
RESISTENCE TRAINING

Home-fitness or home-based exercises.

WHAT TO (not) DO MORE?
Swimming Cycling
• Nor clear evidences for effects on osteoporosis.
• Good for pain management.
• No weight-based and gravity.
Vibration exercise

Tennis
Golf
Attention to racket sports à fast trunck rotation

SO…
WHICH IS THE BEST
PROPOSAL OF PHYSICAL
ACTIVITY ?

BEST PROPOSALS should include:
• Kerr C. The importance of physical function to people with osteoporosis. Osteoporos Int. 2017.
• McMillan LB, et al. 2017. Prescribing Physical Activity for the Prevention and Treatment of Osteoporosis in Older Adults.
Healthcare (Basel).
• Weight-based and resistence exercises.
• Lower and upper-body muscles.
• Balance training.
• Posture stability.
• ROM enhancement.
• Group classes / social aspects.
1. TAI CHI
2. DANCE

« una vecchia che balla » …e non si rompe !

From BONE
to MUSCLE
• Drey M, Sieber CC, et al. Osteosarcopenia is more than sarcopenia and osteopenia alone. Aging Clin Exp Res. 2016;28:895-9.
• Hassan EB, Duque G. Osteosarcopenia: A new geriatric syndrome. Aust Fam Physician. 2017 Nov;46(11):849-853.
Osteo- and sarcopenia: osteosarcopenia*

PHYSICAL ACTIVITY FOR
SARCOPENIC
INDIVIDUALS
What about SARCOPENIA ?
ü Evolving, controversial terms
ü No universal diagnostic criteria
ü Etiopathogenesis not clear

The increased interest in sarcopenia is clearly seen by the number of publications
published in the last few years compared to previously
Esponentially increasing interest
• Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, et al. Epidemiology of sarcopenia among
the elderly in New Mexico. Am J Epidemiol. 1998;147:755–63.
• Morley JE, Baumgartner RN, Roubenoff R, Mayer J, Nair KS. Sarcopenia. J Lab Clin Med. 2001;137:231–43.
2018 in
Pubmed:
603 MATCHES

Definition and diagnosis
No definition of sarcopenia has received universal acceptance.
STRENGTH: concentric, eccentric, isometric, maximal, sub-max, ...
MASS: total volume, BMI, circumferences, fibers types, fat fraction…
PERFORMANCE: gait, balance, steps, lower vs upper body,…

Assessment methods *

Quantitative evaluation à DXA whole body
Right and left upper limb lean mass (kg)
Right and left lower limb lean mass (kg)
ASMMI calculation
+
Comparison with cut-off values
DXA Whole body

Normal aging is associated
with a 1% loss
of muscle from 30 y.o.
5–13 % of older persons
over 60 years of age
have low muscle mass.
• Shaw SC, Dennison EM, Cooper C. Epidemiology of Sarcopenia: Determinants Throughout the Lifecourse. Calcif Tissue Int.
2017;101(3):229-247.
Epidemiology of sarcopenia *
DIFFERENCES BETWEEN LOWER AND UPPER LIMBS

Prevalence: varies with definition, diagnostic technique and population.
11% - 50% in persons aged > 80 years
• Shaw SC, Dennison EM, Cooper C. Epidemiology of Sarcopenia: Determinants Throughout the Lifecourse. Calcif Tissue Int.
2017;101(3):229-247.
Epidemiology of sarcopenia *

The factors leading to sarcopenia are multifactorial
* Ziaaldini MM, Marzetti E, Picca A, Murlasits Z. Biochemical Pathways of Sarcopenia and Their Modulation by Physical
Exercise: A Narrative Review. Front Med (Lausanne). 2017 Oct 4;4:167.
Causes leading to Sarcopenia *

SPECIFIC PA FOR
SARCOPENIC
INDIVIDUALS?

Sarcopenia AND physical activity *
In general, similar (BUT NOT IDENTICAL) compared to PA for osteoporosis.
• Weight-bearing (?) resistance activities.
• Only-walking is not enough.
• Maintain balance and prevent falls too.
• Both moderate to vigorous resistance exercise.
• Activities with mechanical and gravitational stress (bone-to-muscle).
• Home-based activities have to be studied…
MUSCLE CHANGES ARE FASTER!
12 weeks are enough for improvements in function and strength but
not for muscle size / volume (at least 24 weeks).
*Steffl M1, Bohannon RW2, Sontakova L1, Tufano JJ1, Shiells K3, Holmerova I3. Relationship between sarcopenia and physical
activity in older people: a systematic review and meta-analysis. Clin Interv Aging. 2017 May 17;12:835-845.

Attention to DETRAINING effect*
* Henwood TR, Taaffe DR. Detraining and retraining in older adults following long-term muscle power or muscle strength
specific training. J Gerontol A Biol Sci Med Sci. 2008 Jul;63(7):751-8.
* Correa CS, Cunha G, Marques N, Oliveira-Reischak Ã, Pinto R. Effects of strength training, detraining and retraining in muscle
strength, hypertrophy and functional tasks in older female adults. Clin Physiol Funct Imaging. 2016 Jul;36(4):306-10
Effects of strength training (12 w) and detraining (12 w) in elderly women.

Sarcopenia and risk of falls in
osteoporotic women
Final Fat fraction
Muscle volume (MOC wb) Muscle quality (RM) Risk of falls (OAK device)

Effetti dell’esercizio fisico nel paziente osteoporotico sarcopenico

Effetti dell’esercizio fisico nel paziente osteoporotico sarcopenico

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Effetti dell’esercizio fisico nel paziente osteoporotico sarcopenico