Physiotherapy in Osteoporosis for undergraduate students

1. Sreeraj S R
OSTEOPOROSIS
THE ROLE OF
PHYSIOTHERAPY IN
THE PREVENTION AND
TREATMENT Dr Sreeraj S R

2. Sreeraj S R

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DEFENITION
• Osteoporosis is a metabolic bone disorder characterized by
low bone mass and microarchitectural deterioration leading
to skeletal fragility and increased fracture risk (Consensus
Development Conference 1993).
• Osteoporosis causes loss of quality of life and loss of life
in individuals, who otherwise may be in excellent health.

4. Sreeraj S R
FACTORS INFLUENCING THE RISK OF FRACTURE
• Bone density and falls are two major determinants of the
risk of fracture.
• A slow rate of bone loss starts around 40 years in both
sexes and superimposed on this is an accelerated loss of
bone in women at the menopause when oestrogen production
ceases.
• Here rates of loss may be as great as 5±6% per year and are
highest in the years immediately post-menopause.

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RISK FACTORS FOR OSTEOPOROSIS
• A family history of
osteoporosis/hip fracture
• Post menopausal without hormone
replacement therapy
• Late onset of menstrual periods
• A sedentary lifestyle
• Inadequate calcium and Vitamin
D intake
• Cigarette smoking
• Excessive alcohol
• High caffeine intake
• Amenorrhea (loss of menstrual
periods)
• Thin body type
• Caucasian or Asian race

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MEDICAL CONDITIONS PREDISPOSING TO SECONDARY
OSTEOPOROSIS
• Anorexia nervosa
• Rheumatological conditions e.g.
rheumatoid arthritis,
ankylosing spondylitis
• Endocrine disorders e.g.
Cushing's syndrome, primary
hyperparathyroidism
• Malignancy
• Gastrointestinal disorders
(malabsorption, liver disease,
partial gastrectomy)
• Certain drugs (corticosteroids,
heparin)
• Immobilization (paralysis,
prolonged bed rest, functional
impairment)
• Congenital disorders (Turner's
syndrome, Kleinfelter's syndrome)

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MEASUREMENT OF BONE MINERAL DENSITY
• Dual energy X-ray absorptiometry
(DXA) is currently the technique
of choice to measure bone density
• It has excellent measurement
precision and accuracy, is
relatively inexpensive and widely
available.
• The WHO (1994) had defined bone
mass clinically based on T-
scores.

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SIGNS AND SYMPTOMS OF OSTEOPOROSIS
• There typically are no symptoms in the early stages of bone
loss. Back pain, caused by a fractured or collapsed vertebra
• Loss of height due to Vertebral compression fractures can
cause loss of height and this may occur suddenly or
gradually over time.
• A stooped posture with thoracic kyphosis or the `dowager's
hump'.
• A bone that breaks much more easily than expected.

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PHYSIOTHERAPY ASSESSMENT
• Posture and range of motion
• Muscle strength and endurance
• Aerobic capacity
• Balance
• Pain and function

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PHYSIOTHERAPY MANAGEMENT
DEVISING AN EXERCISE PROGRAM BASED ON DXA DETERMINED FRACTURE RISK.

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EXERCISE PRESCRIPTION FOR BONE LOADING
• Loading of the skeleton occurs from the pull of contracting muscle and
from ground reaction force during weight bearing activity.
• large-scale epidemiological studies suggest that physical activity is
associated with a lower risk of fracture in both men and women.
• In humans, high impact exercises which generate ground reaction forces
greater than two times body weight are more osteogenic than low impact
exercises.
• Walking is not an effective exercise of choice for skeletal loading in
healthy ambulant individuals.
• Non-weight bearing activities, such as cycling and swimming, do not
stimulate bone adaptation despite increases in muscle strength.

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EXERCISE DOSAGE
• For an elderly or previously sedentary population, exercise should be gradually
introduced to minimize fatigue and prevent soreness and should be performed 2±3
times per week.
• For aerobic exercise, sessions should last between 15±60 min. The average
conditioning intensity recommended for adults without fragility fractures is between
70% and 80% of their functional capacity. Individuals with a low functional capacity
may initiate a program at 40±60%.
• Adults commencing a weight-training program may perform a few weeks of
familiarization followed by a single set of 8±10 repetitions at an intensity of
40±60% of 1RM. This can be progressed to 80%, even in the very elderly
• Periodic progression of exercise dosage is needed otherwise bone adaptation will
cease. Increasing the intensity or weight-bearing is more effective than increasing
the duration of the exercise. A periodic increase in a step-like fashion may be
better than progression in a linear fashion

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FACTORS THAT WILL INFLUENCE THE CHOICE OF EXERCISE
• These include the patient's age, previous fractures, co-
morbid musculoskeletal or medical conditions, lifestyle,
interests and current fitness level.
• Exercises to avoid in osteoporotic patients include high-
impact loading, abrupt or explosive movements, trunk
flexion, twisting movements and dynamic abdominal exercises.

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POSTURE AND FLEXIBILITY
• In patients with osteopenia or osteoporosis, treatment should aim to
minimize the flexion load on the spine, promote extended posture and improve
chest expansion.
• Increased physical activity is associated with a reduced risk of vertebral
deformity
• Postural re-education and dynamic stabilization for the trunk and limb
girdles are particularly important to normalize mechanical forces.
• Patients can be advised to spend time lying in prone or prone on elbows to
stimulate thoracic extension.
• Postural taping or bracing may be required to assist with maintenance of
correct posture and for pain relief.
• Advice can be given about correct ways to lift as well as correct posture
during standing, lying, sitting and bending.

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FALLS REDUCTION
• In elderly individuals or where falls risk factors have been
identified, treatment should be directed towards reducing falls and
their consequences.
• Patients who report multiple falls may benefit from referral to a
falls clinic or to medical specialists for further evaluation and
multi-faceted interventions.
• Home hazard modification may be required often in consultation with an
occupational therapist.
• Consideration should be given to prescription of gait aids and
external hip protectors in appropriate patients.
• Lower limb strengthening and balance training

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PAIN RELIEVING TECHNIQUES
• Exercise has been shown to reduce back pain and improve psychological
well-being.
• Hydrotherapy may be beneficial due to the heat and unloading effects
prior to commencing a land-based exercise program.
• Other pain-relieving techniques include ice, hot packs, soft tissue
massage, TENS, interferential therapy and shortwave diathermy.
• Gentle spinal mobilization can be performed well short of end range.
• However, forceful joint manipulation is contraindicated.
• To deal more positively with chronic pain, cognitive and behavioural
strategies or relaxation techniques may be employed by the
physiotherapist.

18. Sreeraj S R
EDUCATION
• A large part of the physiotherapist's role is to provide
osteoporosis education and to empower the individual to take
control of the condition.
• Patients may be anxious and require reassurance and advice about
safe activities.
• Information about life - style behaviours such as diet and
smoking should be provided.
• The physiotherapist may need to liase with other medical and
health professionals for overall patient care.

19. Sreeraj S R
THANK YOU