Osteoporosis

Physical therapy
for Osteoporosis
By Dr. Rajal Sukhiyaji
1

Contents :-
 Definition / Description
 Prevalence
 Sign and symptoms
 Causes
 Risk factors
 Physical examination
 Diagnosis
 Pharmacological option in osteoporosis
 Physical therapy
 Alternative / holistic management
 Exercise safety
 References
2

What is osteoporosis?
 Osteon is bone and porosis is hole in
Greek.
 Osteoporosis is a “ Systemic skeletal
disorder “ characterized by “ Low bone
mass “ , microarchitectural deterioration
of bone tissue leading to bone fragility ,
and consequent increase in fracture risk .
 It leads to abnormally porous bone that is
compressible , like a sponge.
 The spine , hips and wrists are common
areas of bone fractures from
osteoporosis.
3

Prevalence :-
 Osteoporosis is the most prevalent bone disease in the world.
 According to the International Osteoporosis Foundation, 1 in 3 women
over 50 will experienced osteoporotic fractures, as will 1 in 5 men .
 Female to male ratio 1 : 6 .
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Types of bone cells :-
 Two types :-
1) Osteoclasts
2) Osteoblasts
 Bone Remodeling :-
Five phases –
1) Activation
2) Resorption
3) Reversal
4) Formation
5) Quiescence (Resting phase)
5

Types of osteoporosis :-
 2 types :-
a) Primary osteoporosis
I. Type-1 : Postmenopausal osteoporosis
II. Type-2 : Age – associated osteoporosis
b) Secondary osteoporosis
Loss of bone is caused by an identifiable agent or disease process such as
inflammatory disorder , bone marrow cellularity disorder and corticosteroid use.
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Clinical signs and symptoms :-
 Fractures caused by osteoporosis are often painful. Osteoporosis is often called the
‘Silent disease’ or ‘Silent thief’ as many people don’t recognize they have it until a
fracture occurs.
 Back pain: Episodic, acute , low thoracic/high lumbar pain
 Compression fracture of the spine
 Bone fractures
 Decrease in height
 Kyphosis
 Dowager’s hump
 Decreased activity tolerance
 Early satiety
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Causes :-
 Hereditary , congenital :-
Osteogenesis imperfecta
Neurologic disturbances
Gonadal dysgenesis
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 Acquired ( Primary & secondary )
 Generalized :
 Localized
 Inflammatory arthritis
 Fractures and immobilization in cast
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Primary
Idiopathic
Postmenopausal
Age related
Secondary
Nutrition
Sedentary lifestyle ,
immobility , smoking
Gastrointestinal diseases
Malignancy
Drugs
Endocrine disorder

Risk factors :-
[ National Osteoporosis Foundation Physician guidelines for risk factors for
osteoporotic fracture. ]
 Current cigarette smoking
 Low body weight (<127 pounds)
 Alcoholism
 Estrogen deficiency
 Prolonged amenorrhea (>1 year)
 Early menopause (<45 year) or bilateral ovariectomy
 Lifelong low calcium intake
 Recurrent falls
 Poor health / fragility
 Inadequate physical activity
 Family history of osteoporosis
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Physical examination :-
Osteoporosis
• Height loss
• Body weight
• Kyphosis
• Humped back
• Tooth loss
• Skinfold thickness
• Grip strength
Vertebral fracture
• Arm span-height
difference
• Wall- occiput
distance
• Rib-pelvis distance
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 h
No single maneuver is sufficient to rule in or rule
out osteoporosis or vertebral fracture without
further testing.
13

Diagnosis :-
 Bone Mineral Density (BMD) test :-
 The most common test.
 Results are reported using T-scores.
 T-scores are relative to how much higher or
lower your bone density is compared to that of a
healthy adult.
 T-score :- It is the number of standard deviation
(SD) above or below a reference value.
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Category T-score
Normal -1.0 or Above
Osteopenia(Low bone mass) -1.0 to -2.5
Osteoporosis -2.5 or Less
Severe osteoporosis -2.5 or Less with one or
more fragility fracture
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Laboratory Tests :-
• Blood Calcium levels
• 24-hour urine calcium measurement
• Thyroid function tests
• Parathyroid hormone levels
• Testosterone levels in men
• 25-hydroxyvitamin D test to determine whether the body has enough vitamin D
• Biochemical marker tests
16

Pharmacological option in osteoporosis :-
Antiresorption :-
 Act on osteoclasts and stabilize bone
 Calcium
 Estrogen
 Calcitonin
 Bisphosphonates
 Selective estrogen receptor
modulators
 Thiazide diuretics
Formation :-
 Act on osteoblasts and increase
bone formation
 Vitamin D
 Anabolic steroids
 Parathyroid hormone
 Growth factors (investigation)
 Fluoride (investigation)
17

Clinical picture of osteoporosis :-
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Goals :-
1) To educate proper posture.
2) Teach safe ways of moving and lifting.
3) To prevent a decline in bone mass and prevent fractures.
4) To increase the strength in bones.
5) To maintain or improve balance.
6) To improve flexibility.
7) To help decrease the stress placed on the bones by tight muscles.
8) To improve overall mobility.
9) To control pain and gradually returning back to regular activities.
Physical therapy :-
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 If patient has fracture related to osteoporosis, treatment will start with
focus on decreasing pain.
 For that modalities like,
I. Ice
II. Heat
III. Ultrasound
IV. Electric current
After that , start with more advanced exercises involving strengthening
,balance, weight bearing and flexibility exercises.
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 Exercise :-
1) Extension exercises
2) Chin tucks
3) Scapular retractions
4) Thoracic extensions
5) Hip extension
 These all exercises will improve posture , balance and strength also.
 Note :- Flexion exercises are CONTRAINDICATED. Anterior compressive forces to
the vertebra can contribute to compression fractures.
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 Vertebroplasty (kyphoplasty):-
 It is recently been used for the management of
vertebral fractures. This procedure involves the
injection of Acrylic cement (such as
Polymethylmethacrylate) into a partially collapsed
vertebral body.
 63% of osteoporotic patient decrease their use of
opiates and analgesics for pain control.
 7% increase their use
 30% remain the same.
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Orthoses is also used in osteoporotic spine
 It promote extension of spine.
 Hip protectors :-
 Hip protectors are an external hip protection system
that aims to reduce the hip facture.
28

Non-strenuous exercises for patient with
severe osteoporosis :-
 Upper back and shoulder extension exercises perform with spine supported.
29

 Back extension exercise in sitting position. This position avoids or minimizes pain
in patient with severe osteoporosis.
30

Physical therapy :-
Physical therapy intervention for individuals with osteoporosis, or even osteopenia,
should include:
 Maintain posture
 Strengthening exercise
 Weight bearing exercise
 Balance exercise
 Flexibility exercise
31

Maintain Posture :-
 Stooped upper spine posture- called
kyphosis – common
 Losing height as a result of these fractures is
a common occurrence in osteoporosis.
 Goal :- To get body lined up from head to
toe, with weight going through hips.
 Physical therapist role :- Give instruction
that all times to try to “ BE TALL “.
32

Correct posture during lifting any
object…….
34

Strengthening exercise :-
 Gentle weighted exercises , using either elastics or weights for upper and lower
extremities.
 These exercises help to improve the individuals overall physical function and
postural control.
36

Extension exercises in prone position with a pillow under the abdomen
to avoid hyperextension.
To increase the effect of back extension strengthening, weight is added.
37

 Exercise for improving strength in lumbar extensors and gluteus
maximus muscles.
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Home based arm loading exercises :-
 The following exercises increase bone mineral density
in the wrist and load the forearm in various directions.
It should be done three times a week and repeated 10–
15 times on each occasion.
Arm press :-
 Stand facing a wall, about 50cm away from it, with your
feet slightly apart, arms bent at the elbows and hands
at shoulder height.
 Lean your body forwards towards the wall by bending
your elbows in a controlled movement.
 Push your body back to the starting position.
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 Wrist curl :-
 This is an easy exercise that will work for forearm
muscles. It can do with a light weight or water bottle, and
progress further by increasing the weight – (the safe limit
is 5kg (11lbs) in each hand.
 Tip :- Keep your elbows in contact with your thighs,
parallel to wrists. This will make the exercise more
effective.
 Turn your forearm over and repeat using an overhand
grip.
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Weight bearing exercises :-
 Walking outdoors or on a treadmill
 Gentle non-pounding forms of dance
 Stair climbing
 These all are useful activities to put weight through
the bones and encourage an upright posture while
also improving cardiovascular health.
 High impact activities such as running, jumping, and
pounding forms of dance should be strictly avoided.
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Balance :-
 Poor balance can lead to a fall which can easily fracture an
osteoporotic bone. Exercises to improve your balance ,
 Standing with feet close together
 Standing on one foot, or standing with one foot in front of
the other.
 Closing eyes can make any of these activities even more
difficult.
 By challenging balance, reaction time to unexpected
situations such as tripping will improve and likelihood of
falling will decrease.
 Safe environment is most important.
 As balance gets better, more challenging exercises will be
provided.
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Flexibility exercise :-
 By improving and maintaining flexibility, the stress put
on bones by tight muscles will decrease and the ability
to practice good posture and body mechanics will be
improved.
 Good flexibility also improves your mobility, which in
turn improves you balance and decreases your risk of
falls.
 Stretching for upper back and chest will be prescribed
to decrease the developing a stooped posture.
 Stretches for hips, calves, and neck are also
important.
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 Pectoral stretching exercise performed in standing position. This is used to
reduced kyphotic posture.
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Other flexibility exercises
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Alternative/Holistic Management (current
best evidence)
 Alternative management of osteoporosis includes diet, vitamin supplementation, and
herbal supplementation.
 Diet has a direct correlation to bone growth and as we age we may not be absorbing
the adequate amount of calcium.
 By using calcium-rich foods, such as milk, cheese, almonds, broccoli, and cauliflower ,
we can get the enough amount of calcium.
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 leafy green vegetables are a great addition to the diet with osteoporosis it has
been shown that oxalate acid that is found in spinach prevents absorption of
calcium in the stomach.
 Vitamin supplements may also be necessary when managing osteoporosis.
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 According to the University of Maryland Medical Center (UMMC), 1,500
milligrams of calcium, taken in 3 doses of 500 milligrams per day, is an effective
supplement to strengthen the bones and prevent further bone loss.
 Other vitamins that are recommended to retain bone strength are vitamins D
and K.
 Herbal supplements are another form of management. The University of
Maryland Medical Center reports that several herbs, such as black cohosh, oat
straw, and kelp can help with management of osteoporosis.
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 Yoga :-
Yoga can stimulate the bones to retain calcium, provided the body gets
enough calcium. ( According to yoga expert, Mary Schatz, M.D )
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Exercise safety :-
 There are some important dos and don’ts should be aware of, to enable to take
up a more active lifestyle in a safe and effective way.
 It is important not to rush into unaccustomed exercise too quickly.
 Exercise must be taken regularly to have any benefit.
 Avoid combining flexion and rotation of the trunk to reduce stress on vertebra.
 Think carefully about undertaking activities that may increase the chance of a
fall.
 Always maintain an upright posture.
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References :-
1. National Osteoporosis Foundation. Having a Bone Density
Test.http://www.nof.org/articles/743 (Accessed 28 March 2013).
2. Mayo Clinic. Osteoporosis treatment: Medication can
help.http://www.mayoclinic.com/health/osteoporosis-treatment/WO00127 (Accessed 28
March 2013).
3. Goodman. Fuller. Boissonnault. Pathology; Implications for the Physical Therapist. 2nd.
Philadelphia: Saunders, 2003.
4. Jensen ME, Evans AJ, Mathias JM, et al. Percutaneous polymethylmethacrylate
vertebroplasty in treatment of osteoporotic vertebral body compression fracture.
5. S. Brent Brotzman, Kevin E. Wilk, Clinical Orthopaedic Rehabilitation
6. Randall L. Braddom, Physical Medicine & Rehabilitation
7. Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercise
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