1. Exercise is essential for building and maintaining bone density throughout life. Weight-bearing and resistive exercises stimulate bone growth, especially in childhood and adolescence. 2. Therapeutic exercise programs for osteoporosis patients should be tailored based on factors like bone mineral density, fitness level, and fracture risk. Exercises should progressively build strength, balance, and flexibility to prevent falls and fractures. 3. Even gentle, non-strenuous exercises can benefit older osteoporosis patients and those with fractures by improving balance, cardiovascular health, and reducing falls. Programs combining exercise, nutrition, fall prevention and medical treatment can optimize bone health and quality of life.

1. EXERCISE IN OSTEOPOROSIS DrAsteriosPapanikolaou Physical and Rehabilitation Medicine

2. Bone Health Increased physical activity, - especially weight bearing and - resistive exercises stimulates bone building via the piezoelectric effect of contracted muscle on bone

3. 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

4. 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

6. Whole body vibration Benefit in residents of long term facilities in Balance Muscle strength Bone mass

8. 1. Preventive exercise2. Therapeutic exercise

9. Preventive exercise Recommended Alife long dedication to: physical activity exercise

10. Preventive exercise Proposed: Children aged 8 and older… 60 min. daily Adults … 30 min. daily

11. 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

12. 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)

13. 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

14. Therapeutic exercise Principles Principle of Specificity Principe of Reversibility Principle of Progression Principle of Initial Value Principle of Diminishing Returns

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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

23. 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.

24. Regular Program of Exercise The Activity Pyramid

25. 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

26. 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

27. Regular Program of ExerciseHealth Benefits NonpharmacologicAntiarrythmicIntervension Improved Sleep Possible Enhanced Immune Function Reduced Cancer Risk ( colon , breast, prostate, lung)

28. 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)

29. 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.

30. Suggested Rehabilitation Guidelines Based on Bone Mineral Density T Scores

31. T score Reduction to −1 SD(Normal)

32. T Reduction to −1 to −2.5 SD (Osteopenia)

33. T Reduction to −1 to −2.5 SD (Osteopenia)

34. T score Reduction to −1 to −2.5 SD (Osteopenia)

35. 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

36. 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

37. 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

38. 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.

39. Non Strenuous Progressive Exercises for severe Osteoporosis

40. Static and Dynamic Correct Postures

41. 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.

42. 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

44. Fall reduction strategies Fall etiologies: - Decreased neuromuscular coordination - Sarcopenia, 71% of elderly hip fractures - Mental status, confusion, dizziness - Medication - Environmental factors, pure lighting, loose rugs

45. Fall reduction strategies Using proper footwear Appropriate environmental adaptations Assistive devices, canes, walkers, wheelchairs Orthoses

46. Exercises for Preventing Falls Education to eliminate fall risks Exercises improving balance, such as gait training, coordination and functional exercises and muscle strengthening

48. Gait Analysis and Training System, with EMG Biofeedback, Goniometer, Force Distribution Platform, Video

50. Balance system, for Fall Risk Screeningand Conditioning Program

51. 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.