Osteoporosis

What You Should Know

 What is Osteoporosis?

A condition in which the infrastructure

of bone becomes thin and weakened.

Weakened bone is at higher risk for

fracture to occur from minimal
stresses.

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Normal & Osteoporotic Bone Architecture
Normal Bone Osteoporotic Bone

Reproduced from J Bone Miner Res 1986;1:15-21 with permission of the American Society for
Bone and Mineral Research. © 1986 by Massachusetts Medical Society. All rights reserved.
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 Who Gets Osteoporosis?

ANYONE could be at risk for Osteoporosis

 Most people are identified after age 50

 Some diseases & conditions increase risk

 Even men & children are at risk

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Risk Factors You Can’t Change
•Age
•Gender (4/5 cases are female)

•Postmenopausal status

•Family history, race (Caucasian or Asian),

Vit D genetics
•Small frame (<127 lb = osteoporosis risk)

•Hyperparathyroidism, RSD, cancer, organ

replacement
•Necessary medications (steroids,

antiseizure, anticoagulants, synthroid, many

chemotherapies, some diuretics)
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(National Osteoporosis Foundation, 2002)
 Additional Risk Factors
Diseases that Are Often Treated with
Glucocorticoid Medications*

Asthma Glaucoma
Bursitis Lupus Erythematosus
Crohn’s Disease Multiple Sclerosis
Chronic Active Osteoarthritis
Hepatitis Psoriasis
Dermatitis (Severe) Rheumatoid Arthritis
*Partial List (National Osteoporosis Foundation, 2002)
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 Risk Factors You Can Change
• Diet – inadequate calcium and vitamin D,
too much or too little protein
• Some bone-damaging medications
• Unhealthy lifestyle choices
• Alcohol (more than 2 drinks/day)
• Smoking (any!)
• Too little exercise
• Under-eating (<127 lb = osteoporosis risk)

(National Osteoporosis Foundation, 2002)

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 Bone Development
 Bones build mass beginning at birth and peak by
age 20-30
 Peak bone mass is attained between 25 & 30 y/o
• 50% accrued during teen years
• Declines by 1 – 1.5%/ year after peak
• Declines by 3 – 5%/ year 1st 5 yr/ menopause

Active Slow Rapid Less Rapid

Growth Loss Loss Loss

(National
10 20 30 40 50 60 70 80 90 Osteoporosis
Age in Years Foundation, 2002)
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 Calcium and Bone
 Recommended daily calcium intake
• Children and Young Adults
• 1-10 years 800 mgs
• 11-24 years 1,200 mgs
• Adults 1,000 mgs
• Pregnant and Lactating Women 1,200 mgs
• Postmenopausal Women Not on ERT 1,500 mgs
• Men over the age of 65 1,500 mgs
(National Osteoporosis Foundation, 2002)

 Excess salt displaces calcium

– Is added to almost all canned foods!
 High phosphates leach calcium from bone!
– Soda – the worst culprit
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 Bone Nutrition - Beyond Calcium
 Vitamin D
• At least 800 units daily (Boonen S et al, 2006; Pfeifer M et al, 2002)
• 30 minutes of sun to hands & face daily sufficient in sub-tropical
latitudes but only the “sunny” 6 months in temperate latitudes
 Magnesium
• 400-600/day – allows calcification as a natural calcium
chelator (Barzel US, 1998)
• Depleted by stress, physical exertion
 Protein Intake and Bone - moderation is the key
• Women (35-59 y/o) w/ protein intake >95g/day (5 servings red
meat/wk) vs those <59 g/day had increased risk of forearm fractures
(Feskanich D et al, 1996)
• High amounts of protein intake (~200 g/day) associated with
decreased bone density (Barzel US 1998)
• Low protein diets (<50g/day) associated with decreased bone density
(Chiu JF et al 1997)
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 Drug Options – FDA approved
 Anti-resorptives (slow bone resorption)
• Bisphosphonates (alendronate, risedronate,
ibandronate, pamidronate) (Wasnich RD et al, 2004;
Chestnut III CH et al, 2004, Chan SS et al, 2004)
• Selective estrogen receptor modulators
(raloxifene)
• Calcitonin (Miacalcin)
• Estrogen (Writing Group WHI, 2002; Nerhood RC 2001)
• Risks with long-term use may outweigh benefits,
may be safer with lower doses
• Always needs to be given with progesterone when
uterus present
 Anabolic (bone forming)
• Parathyroid hormone (teraparatide) (Heaney RP,
2003)

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 Why Do Bones Weaken?
 Bones depend on calcium, other
chemicals, and vitamins to keep
them strong.
 Bones grow as a response to physical
stress being put on them.
 The density (hardness) of bones
requires a good diet, some sunlight,
and exercise in order to stay strong
and not break.
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 It’s a Big Problem
 Osteoporosis affects more than 10
million people in the US
8 million women
2 million men (but they are
catching up)
 24 million others have low bone
mass, called osteopenia
 Osteopenia is a precursor to
osteoporosis
(National Osteoporosis Foundation, 2002)
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 Why is It a Problem?
 Osteoporosis, by itself, is not a
problem. It doesn’t cause pain and
you will not know you have it!

 Theproblem is that it makes bones

very brittle and brittle bones can
break easily.

A broken bone is called a FRACTURE.

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 Fracture Numbers
 Every year there are 1.5 million bone fractures in
this country
300,000 hip fractures
700,000 vertebral fractures
250,000 wrist fractures

 Women have a greater lifetime risk of sustaining

a hip fracture than breast, ovarian , and uterine
cancer combined

 Fracture care costs $3 BILLION every year!

(National Osteoporosis Foundation, 2002)

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 Fractures HURT
Fractures cause:
 Pain
 Limited mobility
• Prolonged bedrest causes:
 Lossof strength
 Pneumonia

 Disability
 Death
• 20% of those with hip fractures die within one year
• Increased mortality with each vertebral fracture

(National Osteoporosis Foundation, 2002)

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 Determinants of
Osteoporotic Fracture
 Number of
osteoporosis
risk factors
 Forward
bending
(trunk flexion)
 Poor balance,
or accidents
resulting in
falls
Vertebral Fracture Hip Fracture 17
 Fracture Force Risks During
Bending and Lifting
 Compression loads imposed on
the L3 motion segment (lower
back) by 30º of trunk flexion
– 1800 N with arms at chest
– 2610 N with arms in front, holding 2
kg in each hand (Schultz et al 1982)
 300 to 1200 N enough to fracture
an osteoporotic vertebra (Edmondston et
al 1997)
 Practical Application - bend and
lift in everyday life with the trunk
in relative neutral!
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Exercise and Vertebral Fractures
(for women with a previous fracture)
Type of Exercise New Fractures
 Spinal Extension (Back
 16%
arches/lifts)
 Spinal Flexion  89%
(Crunches)
 Combined Flexion and  53%
Extension
 No exercise  67%

(Sinaki and Mikkelson, 1984)

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 How Do I Know if I Have It?
 There are many types of screening tests
available in the community. Many use a
finger or a foot to estimate possible risk.

 The gold standard (the absolute test) for

determining the amount of bone density
an individual has is a DEXA test. It is like
an X-ray without the radiation.

 You lie on a table and a scanner passes

over you. A computer determines how
much bone you have by the information
read by the scanner.
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 What’s a T-score?
 The amount of bone you have is
determined by how much has been lost
since childhood, assuming you had lots of
calcium and activity at that time
 A T-score is a statistical number which
says whether you are above or below
“normal”
 T-scores are such numbers as -1.4 or -3.0
or even + 1.0 sometimes.

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 T-scores

 Normal T-scores range from +1 to -1

 Osteopenia T-scores
-1.0 to -2.5

 Osteoporosis T-score
less than -2.5 (up to -6.0)
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 What Should I Do First?
There are 3 major things you can do
1. Talk to your doctor about a Bone Density
Test
2. Talk to a physical therapist about your
activity level and an exercise program to
combat osteoporosis
3. Talk to a dietician to make sure your diet
is providing your bones with enough
calcium and is balanced correctly

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What If I Already Have Osteoporosis?
 Talk to your physician and pharmacist
about medications available to help you
 Make sure your diet includes enough
calcium, not too much caffeine or alcohol,
and adequate, but not excessive, protein.
 Spend at least 30 minutes/day in sunlight
and/or eat foods which are fortified with
Vitamin D
 and………………..

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 See a Physical Therapist
 PTs are able to develop an exercise
program for you that will be appropriate
for your condition

 PTs will evaluate your posture, your

strength, your range of motion, your
balance, and your general endurance
status

 PTs will develop a balanced program which

should help keep you fit as well as safe

 PTs can answer your questions or refer

you to others who will 25
 Studies on Exercise
 Appropriateexercise may slow the
rate of bone loss

 Sedentarylifestyles and immobility

lower bone density

 Effects
of exercise are improved
when combined with proper nutrition
and medication
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 Exercise Effect on Bone –
Works only when “Regular”
 Postmenopausal women exercised
3 times per week for 9 months
 Stair-climbing for ~ 30 minutes
each session
 Spinal bone density  4% in
exercisers
 Spinal bone density  to baseline
within 9 months for those who
stopped exercising
(Dalsky 1988) 27
 Resistance Training
Increases Bone Density Best
 Landmark study (Nelson & Fiaterone 1994)
– Sedentary 50-70 y/o postmenopausal women
– Resistance training 2 X/wk on 5 machines for 1
year
– Significant bone density increases in spine, hip,
total body
 Many other studies validate, including:
– Cussler EC 2003
– Kerr D 2001
– Kelley GA 2001
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 Principles of Exercise for
People with Lowered Bone Mass
 Postureis critical in all activities
 Weight bearing is important

Walking, Dancing, Stair climbing

 Resistance exercise is the best way
to strengthen bone & muscle groups
 Balance exercise to decrease fall risk

 Avoid activities or positions that

move the body into bent (flexed)
postures
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 Exercise Intervention Works
 After Vertebral fracture
– 6 months of supervised exercise  back strength
and psychological status (Gold et al: 2004)
 For kyphosis and balance
– 12 weeks of SAFE yoga (no forward bending!!!)
improves balance & posture (Greendale et al, 2002)
 For osteoporosis and back pain
– 10 weeks of combination group and
individual exercise increases height,
improves back posture and strength (Lindsey
et al, 1995)
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 Eclectic Treatment Focus Essential
 Frailty Injury Cooperative Interventions
Trial Analysis revealed that a year after
the intervention:
– Fall rate decreased 10% in those who did
strength exercises only
– Fall rate decreased by 17% in those who
received “balance” exercises only
– Fall rate decreased by 31% in those who did
both plus the Tai Chi.
(Wolfson L et al: Balance and strength training in older adults:
intervention gains and Tai Chi maintenance. 1996)

– Those who increase all balance scores

show a 60% reduction in fall risk.
(Tinetti ME et al: A multifactorial intervention to reduce the risk of
falling among elderly people living in the community. 1994) 31
Prevention of Bone Loss and
Minimizing Fracture Risk
 Healthy lifestyle choices
– Exercise
– Nutrition
 Early treatment
– Screening
– Individualized therapies
 Physical Therapy
– Resistive weight bearing exercise
– Correct body mechanics
– Balance interventions
– Treat mechanical pain & dysfunction
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 See a Physical Therapist
for More Details!

http://www.apta.org
Click the “Find a PT” button
Find Out More About Osteoporosis
Web sites for up to date information:

www.geriatricspt.org/clients/resources.cfm
www.nof.org
www.surgeongeneral/library/bonehealth
www.osteo.org
www.fore.org

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 References
1. Barzel US, Massey LK. Excess dietary protein can adversely affect bone. J
Nutr. Jun 1998;128(6):1051-1053.
2. Boonen S, Vanderschueren D, Haentjens P, Lips P. Calcium and vitamin D
in the prevention and treatment of osteoporosis - a clinical update. J
Intern Med. Jun 2006;259(6):539-552.
3. Chan SS, Nery LM, McElduff A, et al. Intravenous pamidronate in the
treatment and prevention of osteoporosis. Intern Med J. Apr
2004;34(4):162-166.
4. Chesnut III CH, Skag A, Christiansen C, et al. Effects of oral ibandronate
administered daily or intermittently on fracture risk in postmenopausal
osteoporosis. J Bone Miner Res. Aug 2004;19(8):1241-1249.
5. Chiu JF, Lan SJ, Yang CY, et al. Long-term vegetarian diet and bone
mineral density in postmenopausal Taiwanese women. Calcif Tissue Int.
Mar 1997;60(3):245-249.
6. Cussler EC, Lohman TG, Going SB, et al. Weight lifted in strength training
predicts bone change in postmenopausal women. Med Sci Sports Exerc.
Jan 2003;35(1):10-17.
7. Dalsky GP, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ Jr.
Weight-bearing exercise training and lumbar bone mineral content in
postmenopausal women. Ann Intern Med. Jun 1988;108(6):824-828.
8. Edmondston SJ, Singer KP, Day RE, Price RI, Breidahl PD. Ex vivo
estimation of thoracolumbar vertebral body compressive strength: the
relative contributions of bone densitometry and vertebral morphometry.
Osteoporos Int. 1997;7(2):142-148.
9. Feskanich D, Willett WC, Stampfer MJ, Colditz GA. Protein consumption
and bone fractures in women. Am J Epidemiol. Mar 1 1996;143(5):472- 35
479.
 References (Cont)
10.Gold DT, Shipp KM, Pieper CF, Duncan PW, Martinez S, Lyles KW. Group
treatment improves trunk strength and psychological status in older
women with vertebral fractures: results of a randomized, clinical trial. J Am
Geriatr Soc. Sep 2004;52(9):1471-1478.
11.Greendale GA, McDivit A, Carpenter A, Seeger L, Huang MH. Yoga for
women with hyperkyphosis: results of a pilot study. Am J Public Health.
Oct 2002;92(10):1611-1614.
12.Heaney RP. Advances in therapy for osteoporosis. Clin Med Res. Apr
2003;1(2):93-99.
13.Herbold NH, Frates SE. Update of nutrition guidelines for the teen: trends
and concerns. Curr Opin Pediatr. Aug 2000;12(4):303-309.
14.Kelley GA, Kelley KS, Tran ZV. Resistance training and bone mineral
density in women: a meta-analysis of controlled trials. Am J Phys Med
Rehabil. Jan 2001;80(1):65-77.
15.Kelley GA, Kelley KS, Tran ZV. Exercise and lumbar spine bone mineral
density in postmenopausal women: a meta-analysis of individual patient
data. J Gerontol A Biol Sci Med Sci. Sep 2002;57(9):M599-604.
16.Kerr D, Ackland T, Maslen B, Morton A, Prince R. Resistance training over 2
years increases bone mass in calcium-replete postmenopausal women. J
Bone Miner Res. Jan 2001;16(1):175-181.
17.Lindsey C, Reisine S, Fertig J. Evaluation for the effects of exercise on
posture, back strength, pain & mood in postmenopausal women with
osteoporosis & back pain. Paper presented at: WCPT, 1995; Washington,
DC.
18.National_Osteoporosis_Foundation. America's Bone Health: The
State of Osteoporosis and Low Bone Mass in Our Nation.
Washington, DC: National Osteoporosis Foundation; 2002.
36 36
 References (cont)
19.Nelson ME, Fiatarone MA, Morganti CM, Greenberg RA, Evans WJ. Effects of
high-intensity strength training on multiple risk factors for osteoporotic
fractures: a randomized controlled trial. JAMA. Dec 28 1994;272(24):1909-
1914.
20.Schultz AB, Andersson GBJ, Haderspeck K, et. al. Analysis and
measurement of lumbar trunk loads in tasks involving bends and twists. J
Biomechanics. 1982;15(9):669-675.
21.Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the
incidence of vertebral fractures: a prospective 10 year follow-up of
postmenopausal women. Bone. Jun 2002;30(6):836-841.
22.Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion
versus extension exercises. Arch Phys Med Rehabil. Oct 1984;65(10):593-
596.
23.Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to
reduce the risk of falling among elderly people living in the community. N
Engl J Med. Sep 29 1994;331(13):821-827.
24.Wasnich RD, Bagger YZ, Hosking DJ, et al. Changes in bone density and
turnover after alendronate or estrogen withdrawal. Menopause. Nov-Dec
2004;11((6 Pt 1)):622-630.
25.Wolfson L, Whipple R, Derby C, et al. Balance and strength training in older
adults: intervention gains and Tai Chi maintenance. J Am Geriatr Soc. May
1996;44(5):498-506.
26.Writing Group for the Women's Health Initiative Investigators. Risks and
benefits of estrogen plus progestin in healthy postmenopausal women:
principal results From the Women's Health Initiative randomized controlled
trial. JAMA. Jul 17 2002;288(3):321-333. 37