Physical Therapy’s Role in Osteoporosis Management
Osteoporosis is a bone disease that causes decreased bone mineral density and changes in bone structure, leading to bones that are thin, porous, and brittle, and more susceptible to fractures. Osteoporosis is often a silent disease, in which the most common symptom is breaking a bone after a small fall or minor accident that wouldn’t normally cause a fracture. Factors, such as hormonal changes, nutritional deficiencies, a sedentary lifestyle, family history, and certain medications and diseases, can contribute to the development of osteoporosis. Physical therapy plays a critical role in managing osteoporosis, helping those with osteoporosis maintain and build bone density through a customized exercise program.
What is Osteoporosis?
Osteoporosis affects nearly 10 million people in the United States, ages 50 and older. Osteoporosis is a bone disease that causes decreased bone mineral density and changes in bone structure, resulting in bones that are thin, porous, brittle, and more susceptible to fractures.
Your bones are dynamic tissues that are constantly rebuilding and remodeling, responding to changes in mechanical loads and altering bone mass, structure, and strength to withstand future loads to prevent a bone fracture. Up until your mid-thirties, your body naturally builds more bone than you lose during remodeling. However, after age 35, bone breakdown happens faster than your body can replace it, which causes a gradual loss of bone mass. This loss of bone mass is accelerated in those who have osteoporosis.
Osteoporosis is often a silent disease, in which the most common symptom is breaking a bone after a small fall or minor accident that wouldn’t normally cause a fracture. These types of breaks are known as fragility fractures, bone fractures that occur from low-trauma forces that wouldn’t normally result in injury, such as breaking your wrist or hip during an everyday situation. Other subtle symptoms of osteoporosis can include back pain, loss of height, or a stooped posture (kyphosis).
Factors that increase the risk of osteoporosis include:
Hormonal changes: Women are at a higher risk of developing osteoporosis, particularly after menopause. This is because after menopause, estrogen levels which protect bone cells naturally decline. Women who have irregular periods can also be vulnerable to the condition as well as men with low levels of testosterone.
Nutritional deficiencies: If you have a diet low in calcium and vitamin D, this can increase your risk of osteoporosis. Excessive dieting and low protein intake can also heighten osteoporosis risk. At least 1000 mg of calcium should be consumed daily and increases to 1200mg in post-menopausal women. Vitamin D daily intake should be 800 IU for post-menopausal women and those over 70 and 600 IU for pre-menopausal women and younger men.
Sedentary lifestyle and lifestyle choices: The more regularly you exercise, the lower your risk of osteoporosis as exercise effectively loads your bones and makes them stronger. An inactive lifestyle and poor lifestyle choices like smoking or excessive alcohol use can increase your risk of developing osteoporosis.
Certain diseases and medications: Diseases such as celiac disease, rheumatoid arthritis, IBS, and certain cancers can increase your risk of osteoporosis. Certain medications can also contribute to the condition, such as glucocorticoid medications like prednisone used to treat RA, antiseizure medications used to treat epilepsy, aromatase inhibitors used to treat breast cancer, and proton pump inhibitors used to lower stomach acid levels.
Family history: If you have parents or siblings with osteoporosis, your risk of developing the condition increases. Those with smaller frames and low body mass are also risk factors for the condition.
Physical Therapy’s Role in Osteoporosis Management
Physical therapy plays a critical role in managing osteoporosis, helping those with osteoporosis maintain and build bone density through a customized exercise program. The physical therapist will tailor the patient’s exercise program (its type, intensity, and amount) depending on the patient’s stage of osteoporosis, age, prior injuries, and current abilities.
Bone cells become thicker and stronger in response to the beneficial stress of exercise. This bone strengthening response is stimulated by both joint reaction forces (forces from contracting muscles that pull on the bones they attach to like doing resistance training) and ground reaction forces (forces through the bone from contact with the ground when standing or walking such as when doing aerobic exercise).
Exercise also builds up the strength of the muscles surrounding weak joints and helps increase a patient’s flexibility, mobility, posture, proprioception, and balance to reduce the risk of falls and fractures.
A physical therapy osteoporosis exercise program can include:
Weight-bearing aerobic exercise: Weight-bearing aerobic exercise, like walking, stair climbing, squatting, lunging, or doing step-ups, can slow bone loss and improve bone mineral density. Aerobic exercise strengthens muscles to stabilize and support weak osteoporosis-affected joints.
Resistance training: Resistance training targets specific muscle groups, using pushing, pulling, or lifting of weights to place stress on the musculoskeletal system and build muscle. Exercises can involve free weights, resistance bands, or weight machines to build muscle strength and stronger bones.
Flexibility training: Flexibility training involves moving joints through their full range of motion to help keep muscles working well and engaging in targeted stretching of muscle groups such as the hip flexors, hamstrings, quadriceps, and calf muscles.
Balance training: Static and dynamic balance training is essential to reduce the risk of a fall or fracture in those with osteoporosis. Balance training helps muscles work together to maintain stability even on uneven surfaces and enhances the patient’s proprioception, or awareness of their body in space. Balance training can include standing on one leg, side-stepping, backward walking, forward and lateral step-ups, and weight-shifting in different directions.
Posture and body mechanic instruction: Physical therapists provide instruction on proper posture and body mechanics during daily activities to minimize stress on vulnerable joints, reduce fall risk, and support overall joint health by decreasing the stress on joints and bones from poor posture.
It is recommended that patients with osteoporosis avoid repetitive bending and twisting like sit-ups or crunches or lifting with a bent spine, which increase pressure and friction on the spine and can contribute to a fragility fracture. Unless cleared by your doctor or physical therapist, osteoporosis patients should also avoid high-impact exercises like tennis or golf, which require forceful twisting motions.
Research has shown that aerobic and resistance exercise effectively stimulate bone osteogenesis in osteoporosis patients, improving bone density and reducing fall risk. A 2022 review found that regular weight-bearing aerobic and resistance exercise improved bone strength in those with osteoporosis and also reduced the risk of falls by 26%. One study found that moderate to vigorous aerobic exercise performed 3-4 times per week was associated with a considerably lower incidence of fragility fractures in men and women. Research has found that a resistance program involving moderate to high intensity loads (2-3 sets of 8-12 reps at 70-85% max muscle strength) that increased progressively over time and targeted large muscles in the hip and spine improved BMD in older women.
A year-long study of 162 older adults found that a multi-component exercise program including traditional and high velocity progressive resistance training combined with multi-direction, weight-bearing aerobic exercises and balance training three times a week was effective in improving hip and lumbar spine BMD, muscle strength, functional muscle power, and dynamic balance when compared to the usual care control group.
If you have osteoporosis or are concerned that you may be at risk for the condition, work with a physical therapist who will guide you through a safe, effective exercise program to restore healthy movement and function and rebuild bone strength.
