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Hudson Valley District NYPTA December 7, 2011
Property of
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
Hudson Valley District NYPTA December 7, 2011
Property of
Marie A. Kardys Kelly PT DHS 2
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
Osteoporosis Prevention and Management
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
Hudson Valley District NYPTA December 7, 2011
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Marie A. Kardys Kelly PT DHS 3
Osteoporosis Prevention and Management
• 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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Marie A. Kardys Kelly PT DHS 4
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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Marie A. Kardys Kelly PT DHS 5
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
Osteoporosis & Exercise
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
Osteoporosis & Exercise
Effect on Bone Density
• 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
Hudson Valley District NYPTA December 7, 2011
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Marie A. Kardys Kelly PT DHS 6
Osteoporosis & Exercise
Effect on Bone Density
• 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
Osteoporosis & Exercise
Effect on Bone Density
• 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
Osteoporosis & Exercise
• 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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Property of
Marie A. Kardys Kelly PT DHS 7
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
Hudson Valley District NYPTA December 7, 2011
Property of
Marie A. Kardys Kelly PT DHS 8
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
Hudson Valley District NYPTA December 7, 2011
Property of
Marie A. Kardys Kelly PT DHS 9
Thank You
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Hudson Valley District NYPTA December 7, 2011
Property of
Marie A. Kardys Kelly PT DHS 10
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• Sran MM, Khan KM. The role of the physical therapist in the prevention and
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• 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
femur bone mineral density, and improves muscle strength and balance in
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