Role of Exercise in Preventing and Treating Osteoporosis - Literature review Example

Role of Exercise in Preventing/ Treating Osteoporosis" Word count: 3659 Table of Contents Introduction 2. Recommendations 3. Conclusion 4. References Introduction Osteoporosis is categorized as a skeletal disorder, arise owing to reduced bone mass and disturbed micro-architect of bone. It greatly affects elderly females. It is observed that in case of osteoporosis, reduction occurs only in bone mass and not in bone mineralization. Any disturbance in regular structural design of bone or any loss of trabecular prerequisites or a decline in skeletal connections or cortical covering is considered as osteoporosis. Thus, osteoporosis is responsible for loss of bone strength thereby enhancing the possibility of bone breakage or fracture. Recent research recommends that regular exercise at all stages play an imperative role in preventing osteoporosis. Various features serve as a contributing aspects in the development of osteoporosis. A reduction in the level of estrogen, calcium and reduced physical activities pave the way for the augmentation of depletion in bone mass (Chesnut, 1984). Sufficient levels of calcium is required to suppress bone resorption (Korcok, 1982), moreover, bone mineralization or calcification strengthens the bone (Williams, 1984). Physiotherapy plays a pivotal role in treating patients who are at the potential risk or those who are afflicted with this condition. It is essential that physiotherapist must possess sound awareness and knowledge regarding the condition and management of osteoporosis. The present article provides an overview about osteoporosis along with the information regarding features for the development of osteoporosis. It is highly recommended that postural guidance accompanied by weight-bearing workouts play key role in managing patients with indicative osteoporosis (Kanis, 1994). Recent study conducted by Bergland et al (2010) concludes that exercise improved mobility, balance and HRQOL (Health Related Quality of Life) in osteoporosis with a history of vertebral fractures. Similar recommendations are given by Nikander et al (2010), stated that exercise has a great implication on bone strength in children but could not gather enough data to prove the implication of exercise on adults. Another approach was made by Lirani-Galvão and Lazaretti-Castro (2010) emphasising that osteoporosis and its consequential fractures are emerging as major health issues amongst the elderly population. They emphasized that impact exercises, specific strength training, balance and co-ordination training enable one to sustain or enhance the density of spine and hip bones and diminish the incidence of falls amongst the elderly group. It is also suggested that treatment regimen for osteoporosis patient must include conventional treatment along with the non-pharmacological execution to enhance life excellence. Considering the cost of pharmacological means, emphasis is being laid on the augmentation of bone mineral density (BMD) by non-pharmacological means. These means encompass rehabilitation and physical work outs. According to the studies being performed on osteoporosis, World Health Organization (WHO) has defined it as “a Bone Mineral Density (BMD) level of more than 2.5 SDs below the mean BMD for young, white, adult women”(Kanis, 1994). Based on this, around 30% of postmenopausal women are suffering with osteoporosis (Shea, 2004). Symptoms related with osteoporosis comprise back pain, restrictions on physical performance, and psychosocial mutilation and thereby quality of life is affected (Nevitt, 1998). Bone formation occurs if the minimal threshold of physical workouts is obtained, providing strength, regularity, amplitude and extent of spur; interrupted resting periods plays an essential role for the bone health. Borer (2005) defined exercises for osteoporotic patients to be energetic, not inert; surpass the threshold strength; alternating rest, and workouts, weight inflicting exercise patterns along with appropriate nutrient balance. The diet must be supplemented with subsequent amount of calcium and cholecalciferol for vitamin D. Reduction of weight as an upshot of physical deeds must be evaded and sufficient intake of diet encompassing appropriate amount of protein, vitamins and minerals be given. Thus, physical activity is an add-on to nutrition or other therapies (Prior, 1996). Recommendation to physical outputs is not a recent issue, the past two decades have been emphasizing upon customary, reasonable physical activities especially to those with osteoporosis and who are at potential risk (Prior, 1996). Community or group exercise is favourable amongst elderly population (Prior, 1996). It is recommended that exercise conserves and perk up bone mass, muscular vigour, endurance and cardiovascular strength, as the rationale of exercise is to prevent the bone loss and thereby dropping the risk of falls and fractures. (Prior, 1996). It is established that bone is a dynamic tissue and has tremendous potential to adapt itself to various kinds of stress being induced and this input becomes determinant factor to fix on the bone strength. Bone displays hypertrophy when muscular and weight bearing activities are being performed (Jacobson, 1984). The result was supported by Aloia et al (1976), who assessed that total bone mass of male marathon runners was superior than their sedentary counterparts. The results were analogous to the findings of Talmage and Anderson (1984) displaying the fact that bone density of female university scholars is directly proportional to their physical labour being performed during their childhood or adolescent age. According to Nilsson and Westlin (1971) the mineral content of the bone is directly related to the amount of stress that was generated in sports. Physical activities has positive implications on the bone and therefore it can serve as an affix to other hormonal as well as non-hormonal remedies (Prior, 1996). Bergland et al (2010), proposed a hypothesis for a duration of 3-months exercises schedule followed by a lesson plan of 3 hrs, suggesting the methodology to manage osteoporosis. The results show an extensive affirmative impact on mobility, equilibrium, along with the enhanced quality of life after the completion of the course and when continued for a year. The whole motive was to encourage female population to be physically energetic and perform physical workouts as a routine for healthy living. The study was further supported by Madureira et al (2007), where a year course on balance guidance enhances mobility tests. The results were analogous with the study conducted by Papaioannou (2003), displaying the importance of physical exercise to combat osteoporosis, with a foundation of home-based exercise program exhibiting diminished pain from standing, bending and walking in fragile osteoporotic patients with augmented vertebral fractures, followed by a year of follow-up, the study corresponds with the Berglands results. Although Berglands findings were confined to the shorter duration and it is really difficult to say if the improvements were in real sense or they had "placebo effect" but their results corresponds with the improved health quality of life of osteoporotic individuals (Bergland, 2010). Mechanical weight bearing exercise enhance the bone matrix thereby diminishing the apoptosis of osteocytes and promoting the differentiation of osteoblasts. This is directly correlated with calcium signalling pathways, voltage-activated channels and Wnt/ β-catenin, prostaglandin and other associated pathways (Bonewald, 2008; Turner, 2004). It is also known that osteogenic reaction to mechanical pressure weakens with age (Kohrt, 2004), but with physical workouts this can result in effective bone formation and maintenance (Turner, 2005). Stretching, balance and other related exercises along with/ without the hormone therapy are key to enhance BMD as compared to those who are dependent on the hormonal therapy only (Going, 2003). It is also established that soft exercises, inducing minimal wear and tear of the tissues are better than high impact exercises for elderly population (Prior 1996). Muscular exercise enhance bone strength and piezoelectric effect shows augmentation in BMD, as these actions create compression, tension or torsion thereby exciting the cells to deposit minerals on stress induced areas. Thus, muscular stress induce bone formation (Menkes, 1993). According to the studies reported by Lirani-Galvão and Lazaretti-Castro (2010) BMD rise emerges to be highly specific to site and demands guidance from 70% to 90% of 1 repetition maximum (1 RM), in 8 to 12 repetitions, 2 to 3 sessions per week, in a period of 1 year. It is also imperative to have a strength training as it is crucial for enhancing bone mass. Running is an established osteogenic enhancer. The most reliable constructive transformation on BMD after an exercise were at the lumbar spine followed by high intensity resistance training (Lirani-Galvão, 2010). According to Lirani-Galvão and Lazaretti-Castro (2010) a schedule has to be formulated to implement the exercise program for the cases of osteoporosis. These patients not only have low BMD but also they are at potential risk for falls and fractures. Sensory discrepancy, living unaccompanied, age, musculoskeletal weakness, reduced reflexes and lack of coordination, affiliated medicines, allied ailments may give a predisposition for falls in elderly group. Those who experience falls lose their confidence and are at greater risk of danger (Kessenich, 2007). It is essential that balance must be maintained between the activities in terms of exercise and the cardiovascular condition of the elderly population as these are imperative factors for having a healthy life style. It is recommended that aerobic exercise can also safeguard from osteoporosis and better life style. According to Gunendi et al (2008) aerobics performed for half an hour in a treadmill provided considerable enhancement in maintaining static and dynamic balance. Abductors, adductors and quadriceps are also supportive exercises for osteoporosis cases. These provide flexibility and balance. Recent studies also suggest that Tai Chi enhances balance and thereby preventing falls (Chan, 2004), although these studies are contradicted by Lee et al (2008) for osteoporosis, but later it gained support as it helps to increase the balance of the patient and thereby generating confidence in walk and to carryout day-to-day pursuits. The workouts must be provided in a controlled environment and under controlled set of conditions so as to avoid muscular pain especially along with spine flexion, rotation and lateral flexion and therefore exercise must be performed with utmost care and precautions. Moreover, as reported by Sinaki and Mikkelsen (1984) greater frequency of compression vertebral fractures were observed in trunk flexion while performing training. Exercises with swift and sluggish swap actions, force exercises, aerobic exercises enhancing 70% cardiac frequency and those that are responsible for providing strength to the muscles must be performed in a controlled manner and in the presence of physiotherapist to prevent fall and to reduce loss of bone mass. Care is required for patients suffering from osteoporosis, introduction of exercise programs can be complicated in such critical cases. Patients undergone vertebral compression fracture repeatedly complain about brutal pain due to paraspinal muscle spasms. Characteristically, such fractures occur in the lower thoracic or upper lumbar vertebrae at the time of performing routine activities. In certain acute cases the patient is confined to bed with the application of local analgesics or ice bags. In some cases massaging is performed so as to relax the muscles. It is advised to minimize the immobilization due to enhanced bone resorption therefore patient is required to maintain appropriate stance, unable to do so results in Kyphotic postures, which may be a cause of wedging deformities resulting in compression fractures ((Lukert, 1982; Goodman, 1985)). It becomes important for physiotherapist to guide the patient to keep straight while sitting, walking or standing. Rehabilitation encompass back care doctrine as gently sloping to the side prior to sitting up in bed and bend on knees instead of bending on waist. In acute cases patients are not advised to lift any weight. Flexion exercise are not recommended to patients with fragile vertebrae and more emphasis must be given on extension exercise (Sinaki, 1984). Patient must be prevented from further skeletal deformities by means of utmost care and precision. This is the most crucial parameter for rehabilitation program. Studies suggest that the proximal femur, proximal humerus, and distal radius are the most prevailing fringe sites for osteoporotic fractures (Kaplan, 1986). The literature suggest that weight bearing exercise enhance skeletal mass and augments BMD. Stress is generated in bone through these weights, that aids in increase in bone mass. Exercise increase bone mass in skeleton so stress over the skeleton is highly recommended. Weight bearing exercise must be performed on a gradual basis, once endurance is achieved then with time weight can be enhanced for further strength. This generates tremendous confidence in the patient. According to an estimation, about more than 25 million adults in United States alone are suffering or are at potential risk of developing osteoporosis. The condition is most often allied with an insufficient calcium intake and vitamin D is essential for bone health. As osteoporosis characterize diminution in mass of bone, also diminish microarchitectural framework of bone, thereby deteriorate the tissues of bone and amplify the fracture risk. The occurrence of osteoporosis and fractures is on a rise and an individual becomes prone when decline in bone mass is associated with age. It is therefore, osteoporosis has come into sight as a key health issue in developed nations. It is a condition that portrays recurrent fractures, and is expected to persuade more of females than males. With the progression of age, bones become tender resulting in osteoporosis in older adults, post menopausal women, non ambulatory individuals and individuals on chronic steroid therapy. It is therefore bone remodelling becomes critical and this is achieved through physical workouts along with incorporation of calcium and vitamins in the diet (Goldman, 2004). It is now established that vitamin D plays a vital role in structuring and nourishing bones by escalating assimilation of calcium from intestine and deposit calcium in bones to preserve optimal BMD (Bone Mineral Density). Surveillance indicates that reduced incorporation of calcium is related to vitamin D; causing loss of bone mass thereby increase the chances of osteoporosis (a condition representing low BMD). Osteoporosis is a condition of fragile bones creating the condition of vulnerability to fractures (Cranney et al, 2007). Conclusion Osteoporosis is a grave ailment that impinge on the elderly population, chiefly women. Huge financial, communal, and physical expenses upshot from this trouble. With the enhanced longevity there is a rise on elderly population, therefore efforts are desired to prevent falls and fractures through appropriate and needed measurements, by preventing osteoporosis. It is essential for the elderly population as well as sensitive females to keep a constant co-ordination with the physiotherapist for the alteration of exercise depending upon the time and management or work schedule and implementation of innovative ones in the routine to have a sound bone health and to prevent the onset and intensification of osteoporosis. Table 1 (Appendix) indicates the kind of exercises that are being recommended in various research studies to thwart osteoporosis. Based on various evidence and research being performed at various corners of the world it is established that that physical workouts directly affects the skeletal resistance because of the capability of bone tissue to change mechanical weight into electrical force that is being transmitted to the bone cell like an impulse and hence alters the metabolism of bone cells or osteocytes (Lirani, 2005). On the contrary, abandonment of physical workout may result in loss of bone mass. It is therefore imperative to understand the role of physical workouts in combating osteoporosis. With time understanding towards bone tissues has shown a remarkable progress and ascertained the fact of piezoelectricity of bone cells. This enables the application of physical methods like vibrations, ultrasound or electrical field to excite the configuration of bone, and these methods pave the way for the prevention of osteoporosis. On the other hand, primarily it was contemplated that vitamin D is necessary only for preventing rickets in children or osteomalacia in adults but it is essential to prevent the condition of bone deformities in all ages as well as to preserve bone mass density or condition of osteoporosis in elderly group. To maintain perfect bone health physical workouts must be accompanied with balanced nutrients supplemented with calcium and at least normal level of vitamin D of 75-125nmol/L. References 1. Aloia, JF., Cohn, SH., Babu, T., 1978. Skeletal mass and body composition in marathon runners. Metabolism, 27, 1793-1796. 2. Bennell, KL., Matthews, B.,Greig, A., Briggs, A., Kelly, A., Sherburn, M., Larsen, J., Wark, J., 2010. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial, BMC Musculoskeletal Disorder, 11, 36, 1-11. 3. Bergland, A., Thorsen, H., Karesen, R., 2010. Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial. Osteoporos Int DOI 10.1007/s00198-010-1435-7. 4. Bonewald, LF., Johnson, ML., 2008. Osteocytes, mechanosensing and Wnt signaling. Bone, 42(4), 606-15. 5. Borer KT., 2005. Physical activity in the prevention and amelioration of osteoporosis in women: interaction of mechanical, hormonal and dietary factors. Sports Med, 35 (9), 779-830. 6. Chan, K., Qin, L., Lau, M., Woo, J., Au, S., Choy, W., 2004. A randomized, prospective study of the effects of Tai Chi Chun exercise on bone mineral density in postmenopausal women. Arch Phys Med Rehabil, 85(5), 717-22. 7. Cranney A, Horsley T, ODonnell S, Weiler H, Puil L, Ooi D, Atkinson S, Ward L, Moher D, Hanley D, Fang M, Yazdi F, Garritty C, Sampson M, Barrowman N, Tsertsvadze A, Mamaladze V., 2007. Effectiveness and safety of vitamin D in realtion to bone health, Evid Rep Technol Assess, 158, 1-235. 8. Chesnut CH., Treatment of postmenopausal osteoporosis. Compr Ther, 10, 41-47. 9. Going, S., Lohman, T., Houtkooper, L., Metcalfe, L., Flint-Wagner, H., Blew, R., 2003. Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy. Osteoporos Int, 14, 637-43. 10. Goldman, A., 2004. Cecil Textbook of Medicine, 22nd edition. Volume 2. Saunders: An Imprint of Elsvier. 11. Goodman, CE., 1985. Osteoporosis: Protective measures of nutrition and exercise. Geriatrics, 40, 59-70. 12. Gunendi, Z., Ozyemisci-Taskiran, O., Demirsoy, N., 2008. The effect of 4-week aerobic exercise program on postural balance in postmenopausal women with osteoporosis. Rheumatol Int, 28(12), 1217-22. 13. Jacobson, PC., Beaver W., Grubb SA., et al., 1984. Bone density in women: College athletes and older athletic women. J Orthop Res 2, 328-332. 14. Kanis, J., 1994. The WHO study group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int, 4, 368–381. 15. Kaplan, FS., 1986. Osteoporosis: An update. Hosp Med 22, 173-197. 16. Kessenich, CR., 2007. Nonpharmacological prevention of osteoporotic fractures. Clin Interv Aging, 2(2), 263-6. 17. Korcok, M., 1982. Add exercise to calcium in osteoporosis prevention. JAMA, 247, 1106-1107. 18. Kohrt, WM., Bloomfield, SA., Little, KD., Nelson, ME., Yingling, VR., 2004. American College of Sports Medicine Position Stand: physical activity and bone health. Med Sci Sports Exerc, 36(11), 1985-96. 19. Lee, MS., Pittler, MH., Shin, BC., Ernst, E., 2008. Tai chi for osteoporosis: a systematic review. Osteoporos Int, 19(2), 139-46. 20. Lukert, BP., 1982. Osteoporosis: A review and update. Arch Phys Med Rehabil, 63, 480-487. 21. Lirani, AP., Lazaretti-Castro M., 2005. Evidences of physical agents action on bone metabolism and their potential clinical use. Arq Bras Endocrinol Metabol, 49 (6), 891-6. 22. Lirani-Galvão, APR., Lazaretti-Castro, M., 2010. Physical approach for prevention and treatment of osteoporosis. Arq Bras Endocrinol Metab, 54(2), 171-8. 23. Madureira, MM., Takayama, L., Gallinaro, AL., Caparbo, VF., Costa, RA., Pereira, RMR., 2007. Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporosis Int, 18, 419–425. 24. Menkes, A., Mazel, S., Redmond, RA., Koffler, K., Libanati, CR., Gundberg, CM., 1993. Strength training increases regional bone mineral density and bone remodeling in middle-aged and older men. J Appl Physiol. 74(5), 2478-84. 25. Nevitt, MC., Ettinger, B., Black, DM., Stone, K., Jamal, SA., Ensrud, K., Segal, M., Genant, HK., Cummings, SR., 1998. The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med, 128, 793–800. 26. Niksnder, R., Sievanenn, H., Heinonen, A., Daly, RM., Uusi-Rasi, K., Kannus, P., 2010. Targeted exercise against osteoporosis: A systematic review and meta-analysis for optimising bone strength throughout life. BMC Medicine, 8, 47. 27. Nilsson, BE., Westlin, NE., 1971. Bone density in athletes. Clin Orthop, 77, 179-182. 28. Papaioannou, A., Adachi, J., Winegard, K., Ferko, N., Parkinson, W., Cook, R., Webber, C., McCartney, N., 2003. Efficacy of home-based exercise for improving quality of life among elderly women with symptomatic osteoporosis-related vertebral fractures. Osteoporosis Int, 14, 677–682. 29. Prince, RL., Smith, M., Dick, IM., 1991. Prevention of postmenopausal osteoporosis. A comparative study of exercise, calcium supplementation, and hormone-replacement therapy. N Engl J7 Med , 3 2 5, 1189-95. 30. Shea, BM., Bonaiuti, D., Iovine, R., Negrini, S., Robinson, V., Kemper, HC., Wells, G., Tugwell, P., Cranney, A., 2004. Cochrane review on Osteoporos Int exercise for preventing and treating osteoporosis in postmenopausal women. Eur Medicophys, 40, 199–209. 31. Sinaki, M., Mikkelsen, BA., 1984. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil, 65(10), 593-6. 32. Talmage, RV., Anderson, JJB., 1984. Bone density loss in women: Effects of childhood activity, exercise, calcium intake, and estrogen therapy. Abstract. Calcif Tissue Int, 36. 33. Turner, CH., Robling, AG., 2004. Exercise as an anabolic stimulus for bone. Curr Pharm Des, 10(21), 2629-41. 34. Turner, CH., Robling, AG., 2005. Mechanisms by which exercise improves bone strength. J Bone Miner Metab, 23 Suppl, 16-22. 35. Williams, ER., Caliendo, MA., 1984 Nutrition Principles, Issues, and Applications. New York, NY, McGraw-Hill Book Co, 354. Appendix Table 1: Effect of Physical Exercise on Bone in Postmenopausal Women Physical Exercise Program Effect on Bone along with other effects Stretching + Balance + Resistance exercise + impact exercise + hormone therapy Enhance femoral neck BMD Strength training for hip flexors, adductors, abductors, elbow flexors and extensors, back extensors, abdominal muscles Maintenance of lumbar spine and femoral neck BMD Strength training (extensor lumber muscles) Maintenance of lumbar spine BMD Decreased incidence of vertebral fractures Upper and lower body resistance exercise along with jump training Enhanced hip and spine BMD Pool-based exercise Enhanced hormonal markers (insulin-like growth factor-1, growth hormone and calcitonin) Increased calcaneous ultrasound measurements High impact exercise along with strength training (trunk and proximal femur muscles) Enhanced lumbar spine and hip BMD Decrease in back pain (Lirani-Galvão, 2010) Read More