Effects of Exercise on Osteoporosis in Postmepausal Women
Julia de Castro Grant SDPT
Physical Therapy Program Department of Orthopedics & Rehabilitation, University of New Mexico, Albuquerque, NM
Abstract
Background & Purpose
Is it possible to slow, halt, or even reverse osteoporosis with exercise?
Osteoporosis is a silent disease that has been estimated to affect 10 million
individuals in the US. Every year there are millions of cases of osteoporotic
fractures. Furthermore, it has been estimated that one in every two Caucasian
women will experience an osteoporotic fracture in their lifetime.[C] These fractures
represent multiple health complications with impaired quality of life, as well as an
economical burden for society.[10] Reviewed research highlights effects of exercise
on the progression of osteoporosis on postmenopausal women.
Case Description
This case study considers a 57-year-old postmenopausal female who was
prescribed physical therapy for treatment of chronic sciatica and neck pain.
Radiographs revealed acute cervical degenerative disease. Past medical history
was remarkable for chronic idiopathic osteoporosis. Due to prescription and time
limitations, therapy for her osteoporosis was restricted to patient education and a
home exercise program.
Outcomes
Due to time limitations for the intervention proposed to this patient, there were no
measurable changes on bone mineral density. However, the clinical question has
been answered, and research reviewed in this study provided valuable information
on future optimal exercise prescription for patients with similar characteristics.
Bottom-line
High impact activities, combined with resistive training exercise, sustained for a 12
month minimum produce measurable improvements to bone mineral densities in
postmenopausal women.
Methods
Background
The aim of this study is to examine the effects of exercise on osteoporosis in
postmenopausal women. Osteoporosis is a chronic metabolic bone disease
where the body’s breakdown of bone is greater than the formation rate,
causing low bone mineral density and increased bone fragility. The progression
of osteoporosis is not painful and generally lacks symptoms, making it difficult
to diagnose. Some call it a silent disease which makes itself known by a
fracture — usually too late in its progression.[12]
The clinical question for this case study shall include three parts:
What are the effects of exercise on osteoporosis?
Can exercise slow down the progression of the disease?
Can exercise stop, or even reverse, the progression of the disease?
While a strong body of evidence currently supports exercise slowing down the
progression of osteoporosis, it is not clear whether it is possible to reverse or
curb it altogether. Hence research presented in this study attempts to
establish the specific effects of exercise on osteoporosis and identify which
type of exercise intervention is most efficient and conducive to long-term
management of the disease.
Findings
Optimal Exercise Prescription
.
Based on the reviewed evidence, and further specified by Marin et
al. [15] and Engelke et al. [6], recommended intervention for
patients similar to the subject would consist of the following inclinic supervised sessions:
•15 minute warm up on stationary bike or elliptical machine
maintaining heart rate between 70-80% of HRmax; maximum
heart rate formula used to calculate patient’s HRmax would be =
206 − (0.88 × Age). [B]
•Functional activity exercises including step ups, balance
exercises, squats, jumping, heel rises, modified planks, modified
push-ups, hip abduction with ankle weights, single leg stance on
foam, mini squats on balance board (in medial/lateral and
anterior/posterior direction), weighted lunge walk.
•Resistive exercises on machines with greater intensity and less
volume of repetitions, performed at 75% of 1 RM, 6 repetitions for
two sets, for both upper and lower body
In order to provide sufficient variety, patient would alternate one
week of resistive exercises with one-week of functional activity
exercises.
Both exercise series would include the same warm-up and would
be followed by simple stretches to major muscle groups; both
exercise programs would be 40 minutes in length.
While high impact exercises such as jumping have been shown to
provide benefits in increasing bone mineral density [6, 23], these
may not be applicable to most patients in this particular 50-70 year
old age group. Reduced fitness and activity levels in this
population likely limit high compliance to a plyometric exercise
regimen. Moreover, jumping would increase risk for falls where
exercises were unsupervised for affordability and simplicity.
Ultimately, exercise regimens must be tailored for each patient
and integrated into their lifestyle; therapists would furthermore
review patients’ exercises every three months for appropriate
adjustments.
Discussion
Given risks associated with the use of drugs for the treatment of
osteoporosis, continued research of the benefits of exercise as an
alternative therapy is of paramount importance. Conclusively, the positive
effects of exercise on osteoporosis are firmly documented, and research
reviewed in this study indicates that exercise can slow and even halt the
progression of osteoporosis. Whether exercise may reverse bone loss
experienced by postmenopausal women remains inconclusive and further
research is needed.
The Engelke longitudinal study published in 2005 was most helpful in
defining a specific set of exercises combining high impact exercises and
resistance training. The study took place in Erlangen with
postmenopausal women and lasted three years. The results
demonstrated significant maintenance of bone density in the intervention
group on lumbar spine, hip and calcaneus (except at the forearm) when
compared to the control group. [5] The study concluded that a lowvolume/ high-intensity exercise program can effectively arrest the
decrease in BMD.
As previously reviewed, the most appropriate prescription focuses on
.
higher impact activities combined with resistive training. Walks and Tai
Chi are further beneficial provided these are not the sole activities. In
order to achieve measurable changes in BMD, patients need to maintain
interventions for significant periods such as twelve months or more.
Intervention duration is an important aspect of patient education since
expectations need to include a realistic time frame in order for patients to
reap the benefits from sustained efforts required to complete an exercise
prescription.
Other factors affecting BMD include:
• Lean Mass, Exercise, & BMD As previously mentioned, the type of
exercise intervention is a factor in obtaining significant changes in bone
mineral density. However there are other elements such as lean mass
and fat mass, which have been shown to strongly and positively relate to
bone mineral density as well. The mechanism behind muscle contraction
affecting bone mass has been well established, whereby a muscle’s
exertion on bone increases bone health through mechanical load.
According to a cross sectional study by Marin et al. [15] in Sāo Paulo, lean
mass was found to be the most important element of body composition
significantly related to BMD of femoral neck, lumbar spine and total body.
Lastly, fat mass was strongly correlated to only femoral neck BMD.
Subjects were postmenopausal women and the intervention included
balance, aerobic and strength exercises of moderate intensity. [15]
• Body Weight & BMD Moreover a further element that cannot be
overlooked is body weight in relation to osteoporosis. Contrary to popular
belief in the general public, the Global Longitudinal Study of Osteoporosis
in Women (GLOW) lists obesity as a risk factor for ankle and upper leg
fractures. Nearly 1 in 4 postmenopausal women with clinical fractures are
obese. While effects of adipose tissue on bone health are beyond the
scope of this case study, research has linked fat mass with increased
BMD. [15] The distinction however is in the distribution of fat since
peripheral and visceral fat affect the body in opposite ways. Peripheral,
subcutaneous fat is the sole source of endogenous estrogen in
postmenopausal women, a key agent for increasing bone mineral density
or slowing down bone loss. [2] On the other hand, higher overall BMI is
inversely related to Vitamin D, contributes to insulin resistance, and the
associated visceral fat has higher levels of pro inflammatory cytokines, all
of which lead to bone loss, amongst other detrimental effects. [5]
To conclude, this discussion further clarifies the multitude of factors
that need to be taken into consideration for their respective impact
on bone health. Osteoporosis is a disease affected by multiple
elements, and treatment should strive to target all modifiable risk
factors such as diet, lifestyle, BMI, smoking, and alcohol
consumption. Future in-depth studies that compare long term
outcomes of pharmacological treatment against a combined
intervention of exercise and diet would improve our understanding of
optimal interventions. Additionally, systematic reviews indicate
doubts whether benefits of medication outweigh long term risks of
pharmacotherapy. Future research would also benefit from greater
consistency in exercise prescriptions for ease of applicability,
reproducibility and generalization of results.
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