osteoporosis and exercise: what’s the evidence?€¦ · –combined aerobics (calisthenics) &...

Hudson Valley District NYPTA December 7, 2011

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Marie A. Kardys Kelly PT DHS 1

Osteoporosis and Exercise:

What’s the Evidence?December 7, 2011

Marie A. Kardys Kelly PT DHS OCS FAAOMPT

Unit Coordinator Outpatient Orthopedic Physical Therapy

Helen Hayes Hospital, West Haverstraw, NY

Osteoporosis Course Objectives • Identify risks of osteoporosis

• Identify patient education information

• Identify effect of postural exercise

• Identify effect of resistance exercise

• Identify effect of weightbearing exercise

• Identify exercise program to decrease risk of osteoporosis and fracture

Osteoporosis

• Signs & symptoms… the silent disease

– Loss of ht of 1 ½”

• Diagnosis: Bone Mineral Density

NYSOPEP

Risks• Non- modifiable

– Female, age, genetics, Caucasian, Asian,

menopause, diseases

• Modifiable

– Low Ca/Vit D diet, fiber/antacid interference with Ca

absorp, low activity, low BMI, low sex hormones,

smoking, high alcohol , meds, but not high

salt/protein/caffeine/ phosphorus if Ca intact ok,

Cummings, Cooper, NOF, NYSOPEP

Patient Education

• Calcium 1200 mg if > 50 yo…8 oz milk 300 mg

Ca & 100 IU Vit D

• Vit D 600 IU (age 1-70), 800 IU (71+)

• Caffeine ≤ 300mg; avg… 8 oz coffee 130 mg,

8 oz tea 50 mg, 12 oz coke 50 mg

• Alcohol < 3 drinks (8-10 g alcohol) Papaioannou

• Sodium, Protein, Phosphorous

• Vit A, K, C Cummings, Cooper, NOF, NYSOPEP , ods.od.nih.gov/factsheets/calcium

Patient Education

• Ask MD about

– Loss of more than 1-1/2

inches of heightCummings, Cooper, NOF, NYSOPEP

• Falls Risks

– Lower body weakness..exercise

– ↓ vision…enough lighting

– gait/balance problems…..clear

spaces to walk

– Impaired hearing…aid

– 4+ medications.. Ck for side effects

– Slippery high heeled shoes..flat non-

skid

– Long loose pant legs..hem

– History of falls


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Medications

• alendronate - available as a generic medication (Brand name:

Fosamax, Fosamax D)

• calcitonin (brand name: Miacalcin or Fortical)

• denosumab (brand name: Prolia)

• estrogen therapy / hormone therapy (ET/HT)

• ibandronate (brand name: Boniva)

• raloxifene (brand name: Evista)

• risedronate(brand name: Actonel or Actonel with Calcium)

• teriparatide or Parathyroid Hormone (brand name: Forteo)

• zoledronic acid (brand name:Reclast) NYSOPEP

National Osteoporosis Foundation

• Founded 1984

• Voluntary health organization

• Promotes programs of public and clinician

awareness, education, advocacy and research.

Patient Education

• 1997 Osteoporosis

Education

• New York State

Osteoporosis Prevention

Education Program

(NYSOPEP) within the

NYS DOH.

• All NYers learn

prevention, diagnosis,

and treatment of

osteoporosis.

• Coor center: HHH

• Regional centers

– Cental : SUNY Upstate Med Univ

– Hudson Valley: HHH

– Long Island Winthrop University

Hosp

– Metro Hosp Special Surgery

– Northeastern: Glens Falls Hosp

– Western: Sisters of Charity

Hosp

2010 Practice Guidelines Canada

• Assess 50+ w fragility fx

– For ↓BMD, BMI, meds,

alcohol, smoking, falls, fx,

↓ ht

• Calculate 10 yr fx risk http://www.shef.ac.uk/FRAX/

• Treatment

– Exercise

– Fall prevention

• Home assess, vision, hip

protectors

– Calcium & Vit D

– Drugs Review Papaioannaou

• 10 yr fx risk

– Low < 10 %

– Medium 10-20%

– High > 20% or ho fragility fx

Osteoporosis Prevention and Management

Management Provider

Testing for cause of bone loss Physician

Exercise prescription Physical therapist

Management of pain and mobility

limitations

Physical therapist

Dietary Nutritionist

Ergonomic advice Physical or occupational therapist

Pharmacotherapy Physician

Protective equipment Physical or occupational therapist

Fall risk assessment Physical therapist

Environmental modification Physical or occupational therapist

Summary Sran


Therapy Goal Intervention

Promote bone formation/prevent

loss

Indiv ex program

Fall prevention Indiv ex, mobility aids, ergonomic

advice, environmental mod,

education.

Fracture prevention Ergonomic advice, protective

equipment, education

Post fx rehab Manual therapy, indiv ex, mobility

aids, ergonomic advice,

environmental mod, education

Treatment other relevant m-skel

cond that limit mobility or incr

fall/fx

Manual therapy, indiv ex, mobility

aids, ergonomic advice, education

Sran 5005


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• Postural ex

• Flexibility ex

• Strengthening ex

• Weight-bearing ex

• Balance ex

• Pain modalities & Manual therapy

• Ergonomic & Environmental advice Sran

Ex for Osteoporosis PTJ 1987

Extn & Isometric abdom ex

Contraindicated ex

Summary paper Aisenbrey

HHH Handout 1989

Ingrid Baruch

Osteoporosis & Posture

• Effect of hyper-kyphosis on falls risk

– Decr str

– Incr sway

– Gait unsteadiness

– Incr falls risk

Descriptive Sinaki 2005

Osteoporosis & Posture

• Effect of hyper-kyphosis on fracture risk

• 1.5-2.6 Incr risk new fx as hyper kyphosis incr

cohort study Huang

Assessment of Posture• Occiput to wall distance

– Pain/↓ spine mobility without osteoporosis

– Vert fx & ↓ BMD without ↓ clinical or func status

– Severe forward head asso with

• ↓ str spine extn, ankle df & pf

• ↓ bal & gait

• Gait ↑ base of support ↓ velocity

• ↓ func scores

• Not related to BMD or fxs

Balzini L 2003


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Assessment of Posture• Rib Pelvis distance

– Examiner inserts fingers betwn ribs and

pelvis at midaxillary line

– Likelihood ratio of fx 4 fingers 0.1 (min)

– Likelihood ratio 0 distance 11.5 (conclusive)

– ≤ 2 fingerbreaths sensitivity for fx 87% &

specificity 47%

– If neg x ray → PT for str/flexibilitySiminoski 2003

Posture & Exercise

• Improved C & T curves

Descriptive study Ball

Postural Exercise

• Exercisers

– improve (↓) kyphosis

– ↑ body height

• Non-exercisers

– worsened (↑) kyphosis

– ↓ body height

Ball 2008

Postural Exercises Routine #1

Descriptive Ball 2008

Postural Exercise Routine #2

• Warm up standing

– AROM shl, chest, upper

back

• Strength

– Prone trunk lift to neutral

– Quadruped arm leg lift

– Shl flex on roller

– Sidelie thoracic rot

• Stretching

– chest stretch on roller

– Prone rectus stretch with

hip extn

– Supine SLR

– Quadruped Thoracic extn

and chest stretch

• Postural correction

• Cool-down

– wall pushup

– off the wall

– calf stretch

• Home postural correction Single group pretest-

post test Katzman 2007Katzman 2007

Postural Routine #2


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Other Posture Exercises

Rib Lift Chin Tuck

Mobilization & Osteoporosis

Thoracic Spine PA Loading

• In vitro mechanical failure load 200-728 N,

avg 479 N +162 w fxs T6 SP x 11 T7 SP x 1

• In vivo loads PA mobs to humans force 106-

223 N, avg 145 + 38 N

• High invivo are similar to low invitro forces

• Whole cadaver PT max load 135N; unable to

fx.Descriptive Sran 2004

Pain Mgt w Ex & Manual PT• Pop: osteoporotic fx,

n=20, Female =17

• Treatment grp n=11

– 10 wks

– In clinic 3x/wk posture

taping & awareness,

STM, PA T spine, ed,

back care, str & trunk

contrl

– HEP daily posture & rom

• Outcomes measures

– Numeric rating scale pain &

restriction daily activities,

generic & disease specific

QoL, TUG, Kyphosis, Timed

loaded Standing Test

(TLST)for arm/trunk

endurance

• Results treatment grp

– ↓ pain @ rest & w moWon

– ↑QoL phys func

– ↑ TLST RCT Bennell

Osteoporosis & Exercise

Effect on Bone Density Resistance & Weightbearing

• Incr BMD

– Aerobic ex (calisthenics)

– Resistance ex

– Walking

– Combined aerobics (calisthenics) & WB ex

Cochrane Database Meta-analysis Bonaiuti


Effect on Bone Density

• For positive effect

– Intensity for JRF 8RM

– Intensity for GRF 85% HR max Review Boer

• Equal positive BMD effects when

– Low intensity or 40% 1RM at 2x/wk

– High intensity of 80% 1RM at 3x/wk RCT Bemben



• Site specific effects weight training

– Fem troch: JRF

– Fem troch & intertroch: JRF

– Fem troch, neck, Ward’s triangle, total hip: JRF

– Fem neck, L2-4: GRF

Review Zehnacker


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• 4 types of effective ex

– Weighted squats, hack squats, leg press, hip extn, hip add, hip abd, knee extn, ham curls.

– Stair-climbing,/step boxes with weighted vest, jumping ex, beverage boxes.

– Military press, lat pull down, seated rows, rotatory torso.

– Back extn with weighted backpacks, leg press, bench press, trunk extn, elbow flex, wrist curl, reverse wrist curl, tricpes extn, forearm pro and supReview Zehnacker

Exercise Machines Used in Research Studies

Zehnacker

Free Weight Exercises Used in Research Studies

Zehnacker

Radius

matched ex & contrl Ayalon



• Incr BMD lumbar & positive change hip

– Resistance ex at 60-70% 1RM

– 8-12 reps, 1 or more sets

– 2-3 days/wk

– Treatment effect with HRT & calcium intakeMeta-analysis Martyn-St James


• Line dancing, +squats, & +stamping

• Line dance 1x/wk x 1 yr

• Dance & squats 8 x 2 5x/wk

• Dance & squat & stamp x4 2x/dy 5x/wk

• BMD incr but not signif

• Balance incr all grps

• TUG decr all grps

• # squats inc stamp>squat> dance RCT Young


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Long Term Effects of Ex vs Control

• At 7 yr f/u signif benefit to Ex grp vs contrl for

– Less hip fx

– Lower death rate

– Less postural sway

– Faster walking speed

– Improved Frenchay Activities Index Score

RCT Korpelainen 2010

Osteoporosis & ExerciseFlexion vs Extension Exercise

0

10

20

30

40

50

60

70

80

90

100

new fx

Extn n= 25

Flex n= 9

E &F n= 19

No ex n= 6

Prospective non-randomized Sinaki 1984

Flexion vs Extension Exercise

Sinaki 1984

Trunk Strength & BMD

• Correlation Strength with BMD

– Trunk extn > flex Halle

– Ecc extn torque correlates w BMD Iki

– 4 yr study: OR of maintain BMD 10 x > in top vs

bottom tertile Iki

Vibration Ex & Osteoporosis

• Vibration exercise vs walking

• Reciprocation platform

• 3x/wk x 8 mos

• Incr BMD fem neck vib grp

• Incr balance vib grp

• Cost $495 RCT Gusi

• Hi vs Lo intensity vibration vs contrl

• No between grp diff RCT Beck

Vibration Ex & Osteoporosis

• 108 women RCT

– Rotational vibrating device

– Vertical vibrating device

– Contrl sham relax ex

• Ex routine

– 15 min 3x/wk

– Dynamic leg ex on platform

• Results

– ↑BMD lumbar spine in Rot

Vib grp

– No change BMD fem neck in

Vib grps

– ↑ max isometric leg str in

both vib grps

– No change power in jump in

vib grps

• Conclusions

– ↓fx risk by ↑ BMD & m str– RCT Stengle


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Healthy Men & Ex & Vit D • RCT 4 grps

– Ex & fortified milk

– Ex alone

– Fortified milk alone

– Control

• Results

– Milk grps sigf more CA w

Vit D intake

– Milk no change BMD

– Ex ↑ BMD

• Conclusions for 50-79

yo healthy men w

normal Ca & Vit D

– Ca & Vit D above nl

without incr BMD

– Ex is safe & effective to

↑ BMD fem neck &

lumbar spine RCT Kukulian

Exercise Other Effects

• Falls in community

– Decr risk RCT Liu-Ambrose

– Decr #

– Decr serious injury RCT Campbell

• Pain in with low bone density

– Decr RCT Teresa

• Quality of life in with low bone density

– Improved RCT Teresa RCT Hongo

• Quality of Life women with osteoporosis

– Trunk extn x 10, 5x/wk vs no ex

– Signif incr str ex grp vs contrl

– Signif incr QofL only ex grpRCT Hongo

Osteoporosis & Exercise How Do You Work on Balance?

Exercise to Challenge Systems:

• Somatosensory

– Decrease base of support: 1 leg

– Move in space: • Sway to limits of balance

• toss/throw/kick ball

• Step over/around

– Perturbation: push

text Spiriduso

• Vestibular

– Head turns

– Change body position

• Visual

– Dark room

– Patterned tiles

“Best Ex for Osteoporosis”

• Postural ex

• Avoid flexion ex, torsion ex, military press

• Progressive resistive ex 40-80% 1RM 2-3x/wk

for hip

• Aerobic WB ex at 85% max HR for fem neck

and lumbar spine

• WB multi load for wrist

• Balance ex

Conclusions

• Exercise improves posture

– Decrease fall risk

– Decrease fracture risk

• Exercise increases bone density, prevents loss

• Exercise type is site specific for BMD

• Wrist ex must be multi load type

• Exercise, Ex & manual therapy can ↓ pain

• Exercise can improve Q of L


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Thank You

References Osteoporosis• Aisenbrey J. Exercise in the prevention and management of osteoporosis. Phys

Ther. 1987,67:1100-1104.

• Ball JM, Cagle P, Johnson BE, Lucasey C, Lukert BP. Spinal extension exercises

prevent natural progression of kyphosis. Osteoporosis Int. 2008; DOI

10.1007/s00198-008-0690-3 (epub ahead of print)

• Balzini L, Vannucchi L, Benvenuti F, Benucci M, Monni M, Cappozzo , Stanhope SJ:

Clinical Characteristics of Flexed Posture in Elderly Women. JAGS 2003, 51(10):1-

8.

• Beck B, Norling T. The effect of 8 mos of twice-weekly low- or higher intensity

whole body vibration on risk factors for postmenopausal hip fracture. Am J Phys

Med Rehabil 2010;89:997–1009.

• Bemben D, Bemben M. Dose–response effect of 40 weeks of resistance training

on bone mineral density in older adults. Osteoporos Int (2011) 22:179–186

• Bennell KL, Matthews B, Greig A, Briggs A, Kelly A, Sherburn M, Larsen J, Wark J.

Effects of an exercise and manual therapy program on physical impairments,

function and quality-of-life in people with osteoporotic vertebral fracture: a

randomised, single-blind controlled pilot trial. BMC Musculoskeletal Disorders,

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• Bottomley JM, Lewis CB. Geriatric Rehabilitation A Clinical Approach. 2nd ed.

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women. Sports Medicine.2005;35:779-830

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Tugwell P, Cranney A. Exercise for preventing and treating osteoporosis in

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risk of bone fracture more than walking: a randomized controlled trial. BMC

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• Katzman WB, Sellemeyer DE, Stewart AL, Wanek L, Hamel KA. Changes in flexed

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• Korpelainen R, Keinanen-Kiukaanniemi S, Nieminen P, Heikkinen J, Vaananen K,

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• Kukuljan S, Nowson CA, Sanders KM, Nicholson GC, Seibel MJ, Salmon J, Daly

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Bone Structure and Strength in Older Men: An 18-Month Factorial Design

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• Liu-Ambraose T, Khan KM, Eng JJ, Janssen PA, Lord SR, McKay HA. Resistance and

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References Osteoporosis• Sran M. Failure characteristics of the thoracic spine with a posteroanterior load:

Investigating the safety of spinal mobilization. Spine. 2004; 29(21):2382-2388.

• Sran MM, Khan KM. The role of the physical therapist in the prevention and

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vibration on bone mineral density and falls: results of the randomized control

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resistance and agility raining reduce back pain ad improve health-related quality

of life in older women with low bone mass. Osteopros Intl. 2005;16:1321-1329.

• URL http://ods.od.nih.gov/factsheets/calcium

• URL http://www.nof.org/osteoporosis/diseasefacts.htm

• URL http://www.nysopep.org.shtm

• URL http://www.shef.ac.uk/FRAX/

References Osteoporosis

• Young CM, Weeks BK, Beck BR. Simple, novel physical activity maintains proximal

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osteoporosis and exercise: what’s the evidence?€¦ · –combined aerobics (calisthenics) &...

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