Evidence-based Therapeutic Interventions for Individuals with Osteoporosis

Nancy Cullinane PT, MHS, WCS is today's guest blogger. Nancy has been practicing pelvic rehabilitation since 1994 and she is eager to share her knowledge with the medical community at large. Thank you, Nancy, for contributing this excellent article!

Clinically valid research on the efficacy and safety of therapeutic exercise and activities for individuals with osteoporosis or vertebral fractures is scarce, posing barriers for health care providers and patients seeking to utilize exercise as a means to improve function or reduce fracture risk^1,2. However, what evidence does exist strongly supports the use of exercise for the treatment of low Bone Mineral Density (BMD), thoracic kyphosis, and fall risk reduction, three themes that connect repeatedly in the body of literature addressing osteoporosis intervention.

Sinaki et al³ reported that osteoporotic women who participated in a prone back extensor strength exercise routine for 2 years experienced vertebral compression fracture at a 1% rate, while a control group experienced fracture rates of 4%. Back strength was significantly higher in the exercise group and at 10 years, the exercise group had lost 16% of their baseline strength, while the control group had lost 27%. In another study, Hongo correlated decreased back muscle strength with an increased thoracic kyphosis, which is associated with more fractures and less quality of life. Greater spine strength correlated to greater BMD⁴. Likewise, Mika reported that kyphosis deformity was more related to muscle weakness than to reduced BMD⁵. While strength is clearly a priority in choosing therapeutic exercise for this population, fall and fracture prevention is a critical component of treatment for them as well. Liu-Ambrose identified quadricep muscle weakness and balance deficit statistically more likely in an osteoporotic group versus non osteoporotics⁶. In a different study, Liu-Ambrose demonstrated exercise-induced reductions in fall risk that were maintained in older women following three different types of exercise over a six month timeframe. Fall risk was 43% lower in a resistance-exercise training group; 40% lower in a balance training exercise group, and 37% less in a general stretching exercise group⁷.

These studies allow us to unequivocally conclude that spinal extensor strengthening and therapeutic activities aimed at improving balance and decreasing fall risk are tantamount as therapeutic interventions for osteoporosis. But postural education/modification and weight bearing activities aimed at stimulating osteoblast production intended to improve BMD are a reasonable component of an osteoporosis treatment plan, despite the lack of concrete evidence for them. Nutrition and mineral supplementation with calcium and vitamin D have been shown to reduce morbidities, and hence we should incorporate this education into our treatment plans as well^{8, 9}. Studies on the efficacy of vibration platforms hold promise, but thus far, have not been substantiated as an evidence-based intervention to improve BMD.

Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures^1,2 is a multiple-part publication in the journal Osteoporosis International, based upon an international consensus process by expert researchers and clinicians in the osteoporosis field. These publications include exercise and physical activity recommendations for individuals with osteoporosis based upon a separation of patients into to three groups: osteoporosis based on BMD without fracture; osteoporosis with one vertebral fracture; and osteoporosis with multiple spine fractures, hyperkyphosis and pain. This group of experts emphasize the importance of teaching safe performance of ADLs with respect to bodymechanics as a priority to accompany strength, balance, fall & fracture prevention, nutrition and pharmacotherapy management. They promote establishment of an individualized program for each patient with adaptable variations of these concepts, with the most accommodation allotted for individuals with multiple vertebral compression fractures. An example of such an adaptation is altering prone back extensions such as those documented in the studies by Sinaki and Hongo, into supine shoulder presses, thus strengthening the back extensors in a less gravitationally demanding posture. Osteoporosis Canada has adapted the main concepts from these publications into a patient-friendly, instructional website with reproducible handouts at http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/

A firm conclusion from the Too Fit to Fracture project is that higher quality outcomes studies are desperately needed to assist all healthcare providers in managing osteoporosis more effectively and comprehensively, and to do so prior to the onset of debilitating fractures that tend to produce serious comorbidities.

1. Giangregorio et al. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International. 2014; 25(3): 821-835
2. Giangregorio et al. Too Fit to Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fracture. Osteoporosis International. 2015; 26(3):891-910
3. Sinaki et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002; 30: 836-841 4. Hongo et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis; a randomized controlled trial.Osteoporosis International. 2007; 10: 1389-1395
5. Mika et al. Differences in thoracic kyphosis and in back muscle strength in women with bone loss due to osteoporosis. Spine. 2005; 30(2): 241-246
6. Liu-Ambrose et al. Older women with osteoporosis have increased postural sway and weaker quadriceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontology, Series A Biolog Sci Med Sci. 2003; 58(9): M862-866
7. Liu-Ambrose et al. The beneficial effects of group-based exercise on fall risk profile and physical activity persist 1 year post intervention in older women with low bone mass: follow-up after withdrawal of exercise. J Am Geriat Soc. 2005; 53 (10): 1767-1773
8. Ensrud et al. Weight change and fractures in older women: study of osteoporotic fractures research group. Archives Int Med. 1997; 157 (8): 857-863
9. Kemmler et al. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results. Med and Sci in Sports Ex. 2002; 34 (12): 2115-2123