Osteoporosis

Osteoporosis is “… a [silent] skeletal disorder characterized by compromised bone strength predisposing to increased risk of fracture.” (1)(p.7) Estimates suggest 200 million women worldwide and 10 million Americans have osteoporosis. (1-4) Bone strength reflects the integration of two main features: bone mineral density (BMD) and bone quality. Body regions with high trabecular bone content are the most affected by osteoporosis, with fractures of the spine, proximal femur (hip), distal forearm, proximal humerus, and pelvis being the most common. (2, 4) Men comprise 20% to 25% of patients with hip-fracture as a result of osteoporosis. (4)

Risk Factors for Primary and Secondary Osteoporosis

For many years, the term primary osteoporosis has been used to describe osteoporosis tied to age-related changes associated with menopause. Major risk factors for primary osteoporosis include: (1, 2)

• Female gender

• Aged 65 years or older

• Vertebral compression fracture

• Fracture with minimal or no causative trauma after age 40

• Family history of osteoporotic fracture (especially parental hip fracture)

• Low vitamin D levels and low dietary calcium (5)

• Excessive alcohol consumption

• Smoking

• Post-menopausal body weight that is less than 60 kg (132 lbs), and/or present body weight that is more than 10% below body weight at age 25 years.

A number of other conditions and medications can also influence BMD and bone fragility; these cases are considered to be secondary osteoporosis. (1, 2, 6, 7) Some causes of secondary osteoporosis include: (1, 2, 6, 7)

• Primary hyperparathyroidism

• Hypogonadism (low testosterone in men; early menopause in women (ie, before age 45)

• Use of medications that may cause bone loss (eg, dilantin, heparin, aromatase inhibitors, excess thyroid hormone, prednisone, etc.)

• A medical condition that can cause osteoporosis (eg, rheumatoid arthritis)

• A medical condition that can affect the absorption of nutrients (eg, Crohn’s disease, celiac disease, and inflammatory bowel disease)

• Type 1 Diabetes

• Cancer and chemotherapy

• Chronic liver and chronic kidney diseases

Physical therapy treatment is indicated for improving bone health. Specifically, preventive goals of physical therapy should include:

• Bone preservation

• Fall prevention

• Fracture prevention

• Tertiary prevention (post-fracture management)

Bone Preservation

Specific exercise programs can preserve BMD in pre and postmenopausal women. (1, 2, 14) Programs including mixed or varied loading can be beneficial for the preservation of bone density. (27) Examples of effective mixed loading include: (a) jogging with other low-impact activity such as stair climbing or walking; and (b) impact activity with high-magnitude exercise (such as resistance training). Of note, walking alone has not been found to be effective for preserving bone in postmenopausal women. (28)

Fall Prevention

Addressing issues placing individuals with osteoporosis at risk for falls is imperative. Individual factors such as poor footwear, polypharmacy, or use of medications or other substances that cause dizziness are important to consider. Comorbidities like urinary incontinence or those that limit mobility, such as arthritis, can also increase fall risk. (29-31)

To reduce fall rates, programs should include both muscle strengthening (aimed at increasing muscle mass) and balance exercises. (32, 33) It is important to note that one study has found that fall-prevention programs alone did not increase femoral neck BMD. (34)

Environmental factors, such as unsafe stairs, lack of handrails for support, slippery floor surfaces, and tripping hazards also are important to address as they can lead to falls. (2)

Please refer to the clinical summary on “Fall Risk in Community-Dwelling Elders” for further information on interventions.

Fracture Prevention

Physical therapists can help individuals prevent fractures in a number of ways, by:

1. Helping improve posture with education and postural retraining, as thoracic posture influences spine loads. (35)

2. Providing guidance on proper bending and lifting ergonomics, to help individuals avoid vertebral compression fractures caused by excessive loads being applied to the spine. Physical therapists should advise those with severe osteoporosis to use caution with spinal flexion, rotation, and side-bending. (1, 2)

3. Prescribing assistive devices to help with balance, and protective equipment such as hip protectors. (2, 36) Compliant flooring can help reduce the force applied to the body when a fall occurs, reducing the risk of fracture. (37)

4. Reducing any mobility impairments caused by osteoporotic fractures or other common medical conditions that increase the risk for falls, such as arthritis and neurological conditions. Interventions can include therapeutic exercises for strengthening, stretching, and manual therapy. (38, 39)

5. Improving motor control and muscle strength to optimize joint loads, reduce thoracic kyphosis, and improve motor function. (40)

Tertiary Prevention: Post-Fracture Management

Many individuals require physical therapy intervention after having sustained an osteoporotic fracture. Pain, physical impairment, functional impairment, and reduced quality of life are commonly reported. (40) The physical therapist aims to enable the individual to return to safe mobilization, with the highest level of independence that can safely be achieved. Appropriate walking aids should be employed as needed to safely meet each individual’s mobility goals. Post-fracture care for individuals with osteoporosis requires a unique approach, due to this group’s high risk of refracture. (15-18) The Fragile Fracture Care Management Program has proved to be a helpful treatment guide. (41) (Source, American Physical Therapy Association)