Osteoporosis and Exercise Jennifer Clark What is Osteoporosis: Osteoporosis is a chronic skeletal disorder that occurs when there is a micro- architectural loss of bone tissue and a decrease in bone mineral density (BMD), causing bones to be easily susceptible to fractures (Downy & Siegel 2006). Fractures can be caused by the simplest of movements such as daily living activities and occurs most commonly in the proximal femur (hip), vertebrae (spine), and the distal end of radius and ulna (wrist) (Hardman & Stensel 2003). It is estimated that 30-50% of women and 15-30% of men will experience at least one osteoporotic fracture during their lifetime (Nikander, et al. 2010). In the UK alone, approximately 1 in every 2 women over the age of 50 will experience an osteoporotic fracture, along with 1 in every 5 men (International Osteoporosis Foundation 2009). There are two types of osteoporosis: primary and secondary. Primary osteoporosis is a deterioration of BMD caused by biological factors such as age, sex, race, genetics, and weight. On average, each person‟s BMD peaks around 18-25 years of age and slowly decreases as they age. Therefore, a person‟s risk of developing osteoporosis increase as they gets old. Women are also more likely to develop osteoporosis. This is because women‟s BMD tend to peak at a younger age in comparison to men and decreases more rapidly due to menopause which decreases levels of estrogen in the bodies and increases bone absorption (Vondracek 2010). Studies have also shown that Caucasians and Asians have a higher risk of developing the disorder as well as people with pervious family history of osteoporosis. It is estimated that 60-80% of BMD is determined by a person‟s genetic background (Nieman 1998). Lastly, people that are below normal weight tend to have weaker bones, making them more susceptible to developing osteoporosis because of the reduced starting amount of BMD (Hardman & Stensel 2003). Secondary osteoporosis occurs from chronic conditions that prevent osteoblastic activity such as certain medications, excessive alcohol intake, smoking, and poor nutrition. Patients that are prescribed medications that include low to moderate amounts of glucocorticoids have been found to have a higher risk of fractures (National Osteoporosis Society 2006). Consuming more than 2 glasses of alcohol per day also increases the risk of osteoporosis. People that currently smoke or were pervious smokers have a higher risk of experiencing a fracture. Also, calcium, vitamin D, and protein are essential for bone development, especially during the period when bone growth is most intensive, such as in infancy, puberty, and early twenty‟s. (Stránsky & Ryšavá 2009). Thus, people with deficiencies of any of these nutrients are more at risk of developing osteoporosis. Osteoporosis is most commonly diagnosed using a Dual Energy X-ray Absorptiometry (DXA) test. The DXA is the safest and most reliable method of measuring the grams of bone mineral per unit of bone area, which is derived from the measurements of the person‟s BMD and bone mineral content (BMC) (Otis & Goldingay 2000). Once taken, these measurements are then compared to the standard measurements for the person‟s age. This measurement is called a T-score (Morgan & Kitchin 2008). If the T-score is -1 standard deviation from the mean, then the BMD is normal. If the T-score is -1.1 to -2.4 standard deviations from the mean, then the person is diagnosed with osteopenia and is at risk of developing osteoporosis. If the T-score is - 2.5 standard deviations from the mean, then the person has osteoporosis. Exercise Benefits and Potential: According to Prior, et al. (1996), many patients with osteoporosis become fearful of exercise because of their perceived risk of falling. However, many studies have shown that participating in exercise is more beneficial to bone health in comparison with immobility. Nieman (1998) found that healthy individuals that go on complete bed rest for 4-36 weeks can experience a decrease in BMD of an average of 1% per week. Also, Cumming, et al. (1995) found that women who were mobile for less than 4 hours per day had twice the risk of experiencing a fracture compared to women who were mobile longer. Exercise maintains bone strength due to the piezoelectric effect in the bones that is triggered during exercise. When a muscle contracts from the stress loads of exercise, it causes the bone to slightly bend. The bend creates electrical signals that move along the crystalline material of the bone and activate the metabolism of the osteobytes. (Downy & Siegel 2006 and Lirani-Galvão & Lazaretti-Castro 2010). This stimulates bone formation which helps maintain or increase a person‟s BMD, making the bones less susceptible to fracture. Therefore, it is essential that people diagnosed with osteoporosis exercise regularly and avoid immobility. However, to prevent fearfulness of falling, people with osteoporosis should be educated about which exercises are safe to preform and which types they should avoid. However, research on exercise and osteoporosis have mixed results when it comes to which types of exercise prevent BMD loss the most. Most research has shown that each type of exercise is area-specific, meaning that certain exercises tend to be beneficial for BMD in only one or two areas of the body. By integrating many different types of exercise, a person with osteoporosis has a greater chance of retaining their BMD throughout their entire body. This includes regular practice of aerobic, strength, and balance exercises (Nelson, et al. 2007). Aerobic and Weight-bearing Exercises Although many people with osteoporosis are especially fearful when it comes to weight-bearing and aerobic exercises, research has shown that these types of exercises are extremely important in maintaining BMD because they stimulate the piezoelectric effect (Lirani-Galvão & Lazaretti-Castro 2010). These types of exercises include fast-paced walking, stair-climbing, and low-impact aerobics such as tennis, dancing, and modified gymnastics. Berström, Brinck, and Sääf (2008) conducted a 1- year experiment that observed the BMD contents of osteoporotic women who fast- paced walked for 30-minute intervals 3 times a week, along with an 1 hour professional training session per week consisting of aerobic and strength exercises. Their findings showed an average increase of 3.5% BMD in the spine and 0.9% in the femoral neck. This experiment suggests that light weight-bearing exercises such as fast-paced walking, combine with strength training, can prevent BMD loss. Aerobic exercises such as slow-paced walking and swimming are encouraged for people with osteoporosis to maintain cardiovascular health and limit immobility, but not to strengthen bones or prevent BMD loss. Nonetheless, these exercises are safe for people with osteoporosis to preform, but should not be considered for treatment. Strength and Resistance Training Exercises Strength and resistance training exercises are also highly recommended for osteoporotic patients. Similar to aerobic training, strength training causes muscle contractions which stimulate the piezoelectric effect and increases bone formation (Lirani-Galvão & Lazaretti-Castro 2010). Strength and resistance training have been found to improve spine and hip BMD in osteoporotic and osteopenic women more than any other areas. Studies have shown that weight training exercises involving intensities between 50-90% of 1 resistance maximum (1 RM), for 8-12 repetitions of 2 to 3 sets, over a duration of 1 year, are needed to increase the BMD in osteoporotic women (Zehnacker & Dougherty 2007 and Lirani-Galvão & Lazaretti-Castro 2010). However, strength training is area-specific as well. Therefore, integrating strength and resistance exercises that activate different areas of the body should be considered when designing an exercise routine. Back exercise are also important for people with osteoporosis because they tend to have significantly lower back extensor strength than people without the disorder. Hongo, et al. (2006) found that osteoporotic women who preformed brief low-intensity back exercises 5 times a week over a 4-month period improved in back extensor strength. Also, back exercises have been shown to prevent women from developing kyphosis, a curvature of the spine, as well as help maintain proper posture (Prior, et al. 1996). Back exercises includes isometric abdominal strengthening, pelvic tilt, and gentle back extensions, and should be incorporated in osteoporotic patient‟s exercise routines. Balance and Flexibility Exercises Osteoporotic fractures are the highest causes of disability and mortality in postmenopausal women (Lirani-Galvão & Lazaretti-Castro 2010). Therefore, exercises that promote balance, flexibility, and postural improvements are highly recommended for people with osteoporosis. Balance exercises, especially, have been shown to reduce the amount of falls in osteoporotic women. Madureira, et al. (2007) conducted a study that looked at the benefits of balance exercises on the prevalence of falls in osteoporotic women over a 12-month period. They found that women who participated in an 1 hour balance training program guided by a trainer, along with 3 independently guided sessions of 30-minute balance exercises per week, had significant improvements in balance, mobility, and preventing falls compared to women who only received training for preventing falls. Also, yoga has been shown to improve both balance and BMD. Fishman (2009) conducted an experiment involving 18 osteoporosis patients, of which 11 were instructed to preform 8-10 minutes of specified yoga poses each day for 2 years. The patients that preformed the yoga had increased their spine BMD an average of 0.563 units on the T-scale and their hip BMD an average of 0.867 units. However, since osteoporosis increases bone fragility, yoga poses should be modified to avoid putting too large of loads on bones or causing too much strain from twisting too far ( Krucoff, et al. 2010). Nevertheless, yoga has been found to improve balance, flexibility, and posture in osteoporotic patients and can be used as a technique to prevent falls. A safer approach to improving balance and posture can be by participating in tai chi. Tai chi uses breathing and balance techniques to strengthen bones and perfect posture. Although, research has not shown that tai chi can improve BMD, it has been shown to improve balance and posture in osteoporotic women (Lee, et al. 2008 and Lirani-Galvão & Lazaretti-Castro 2010). Therefore, tai chi can be an option for osteoporotic patients in addition to strength and aerobic exercises. Contraindication: Because of the high risk of fractures associated with osteoporosis, people with the disorder must take certain precautions when exercising. First, it is important for people with osteoporosis to avoid any type of high-impact aerobic exercises (National Osteoporosis Society 2006). High-impact exercises, such as running, skipping, or jumping, put high amounts of loads on the bones, causing the strain to be too excessive. Second, patients with low body weight should be cautious of the amount of calories they burn from exercise and should adjust their diets to compensate for the calories lost. It is suggested that people with low body weight should focus on strength and balance exercises rather than aerobic exercises that promote weight loss. Third, patients should avoid exercises that involve excessive back bending, twisting at the spine, sit-ups, and abdominal crunches (Krucoff, et al. 2010). All of these movements increase the risk of fracture. Nonetheless, osteoporotic people should always consult with a professional fitness advisor to verify beforehand which exercises are safe for them to preform. Other Research: Author Exercise Sex Body Finding Gunendi, et Sub-maximal Post- Balance 4-weeks of sub-maximal al. (2008) aerobic menopausal throughout aerobic exercises exercises osteoporotic the whole improved static and women body dynamic balances. Karinkanta, Resistance 149 women Distal tibia, 1-year training of et al. (2007) training and aged 70-78 tibial shaft, resistance and balance- balance- years-old and femoral jumping training prevented jumping neck functional decline and had training positive effects in the structure of the tibia. Going, et al. Aerobic, 320 post- Femoral 12-months training with (2003) weight-bearing menopausal neck, aerobic, weight-bearing exercises and women trochanteric exercises and weight lifting weightlifting and lumbar exercises increased BMD spine in all areas by 1-2%. Sinaki, et al. Back- 50 post- Back and After 10-year long study, (2002) strengthening menopausal spine women who preformed exercises women, aged back strengthening 58-75 years- exercises had a decrease old in vertebral fracture risk. Voukelatos, Tai chi 702 men and Reduction of 16 weeks (1 session per et al. (2007) women over 60 Falls week) of tai chi reduced years old the frequency of falls in elderly people. Case Study: Angela, a 58 year old Caucasian women, visited her general practitioner after suffering from severe back pain while doing everyday activities such as getting in and out of bed, bending over, and sitting down. She has no family history of osteoporosis, though, like her mother, she has always been “thinned-boned” and nearly underweight (height of 5‟4 and a BMI of 19). She has never smoked a cigarette, drinks a couple of glasses of wine occasionally, tries to maintain a healthy and balanced diet, and is taking no medication. She has worked as a receptionist for the past 15 years and does not participate in any exercise activity other than her daily 30-minute walk with her dog. After a DXA scan of her spine showed a T-score of -2.6, Angela‟s practitioner diagnosed her with osteoporosis and prescriber her an estrogen replacement medication. The practitioner told her to take calcium and vitamin D supplements along with her medication and registered her with a professional trainer to facilitate and organize her exercise routine. Exercise Recommendations: Because Angela has a T-score of -2.6 but has not yet fractured a bone, it is recommended that she begin a low-intensity exercise program, consisting of 2-3 sessions per week of aerobic and strength exercises and 1-2 sessions of balance exercises. As she gets more comfortable with the exercises the intensity may slightly increase, but they should never reach a high-intensity level because of the increase risk of fracture. For the aerobic exercises, slow-paced to fast-paced walking on the treadmill is encouraged as well as 3-5 minutes on a stairclimber. Strength exercises that strengthen the back muscles are highly encouraged for Angela, along with exercises for the hip and legs. However, with the back exercises, the intensity and the amount of reps should start low and gradually increase overtime to prevent fractures. For balance exercises, attending a yoga or tai chi class twice a week is recommended to improve her balance and flexibility. Also, it is encouraged that Angela practices simple balancing exercise at home such as walking in a straight line with one foot directly in front of the other, walking sideways, or switching between standing on one leg. 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