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  • Deborah Thomas BPT MCSP MAPPI Chartered Physio

Osteoporosis and bone health

Osteoporosis is a silent disease – this means, it does not give or cause any pain, discomfort, or show any other symptoms. People usually do not know they have Osteoporosis unless they have had a bone density scan (DXA scan). Osteoporosis usually develops slowly over several years. It can affect women and men, but women are more at risk. The only ‘symptoms’ are a broken (fractured) bone, and the impact this then has on the body. An easily broken bone, possibly from a light trip over – is usually the first sign, that will lead to further investigations.



Osteoporosis is defined by the Royal Osteoporosis Society (ROS) as ‘a condition where your bones lose strength, making you more likely to break a bone than the average adult’. We all gradually start losing bone from around the age of 35 as a normal part of our lives, however[D1] some people develop osteoporosis and lose bone much faster than normal.


Our lifestyle, genetics, levels of activity all impact on the quality of our bones, and the bone density and strength. There are known risk factors that contribute to Osteoporosis and fractures related to bone density. How much bone tissue our body makes and can repair- affects our ‘bone density’, other risk factors will influence our ‘bone strength’.

Essentially, the aim is to prevent or reduce the risk of anyone breaking a bone due to Osteoporosis, and when looking at risk factors, this is what we are assessing – what is the risk, taking in all the factors involved, that one will break a bone DUE to Osteoporosis.


I’ll explain a little about osteoporosis, and focus mainly on how I, as a physiotherapist & Pilates instructor, can help you maintain movement, strength, and function, to enhance your balance, prevent falls, adjust your exercise regime according to your bone density, and also treat you if you have experienced an Osteoporotic fracture (broken bone).


It’s never too late to change your exercise regime, choices, and HOW you do things, address your diet and lifestyle – all these can still have a positive effect on your bones and help you lead a healthy, comfortable life and prevent fractures associated with Osteoporosis. Bones are a dynamic tissue, changing all the time: it has building cells called ‘Osteoblasts’ and removed cells called ‘Osteoclasts’ – there is a fine balance between the activity of these cells.


Let’s delve into some information about the condition:


There are some risk factors we cannot change:


Our genes, aging, being a woman, Being of Caucasian or Asian origin, or if you have already experienced broken bones.


Some medical conditions are known to affect bone strength and therefore put you at higher risk of osteoporosis: rheumatoid arthritis, hyperthyroidism, parathyroid disease, Crohn’s, coeliac disease as these two affect the absorption of food & nutrients, and any condition that will lead to long periods of immobility; specifically in women: early menopause, having a hysterectomy with removal of ovaries, before the age of 45, anorexia nervosa, Turner’s syndrome, excessive exercise causing an absence of periods for 6 months or more – these all cause a reduction in the Oestrogen hormone levels. In men, these conditions cause a reduction in the hormone testosterone: surgery for some cancers, Klinefelter syndrome, Kallman syndrome, naturally lower testosterone levels and so affect bone structure.


Several medicines are also known to affect bone strength: glucocorticoid (steroids) tablets, if taken for more than three months, long term inhaled steroids, anti-epileptic medications, breast cancer treatments, such as aromatase inhibitors and some prostate cancer medications. There is ongoing research on other medications that may cause a reduction in bone strength: medications to reduce inflammation of the stomach and oesophagus (proton pump inhibitors (PPIs)), diabetic medications in the glitazone group, including pioglitazone, injectable progestogen contraceptives, such as Depo Provera, and some medicines used for mental health conditions. For further info on this look at: https://theros.org.uk/information-and-support/understanding-osteoporosis/causes-of-osteoporosis-and-broken-bones/

However, there are some risk factors that we can change – let us look at these:


Low Body Weight

When we have a low body weight – we are more likely to have lower bone density. In addition, we’ll probably have less fat tissue cushioning out hips – so if one falls – there is more likely to be an impact on the hip causing a fracture.


Smoking

Smoking causes the ‘Osteoblasts’ cells to slow their activity – these are the bone-building cells. Smoking can also lead to an earlier menopause in women – and menopausal women do have a higher chance of being osteoporotic and breaking a bone.


Drinking too much alcohol

Alcohol affects both the cells that build and break down bone. It of course can affect our balance and enhance chances of falling.


Balance issues, falls, tripping over

Our ability to prevent and recover from small slips and trips depends on a very dynamic balance ability. Our balance is influenced by many factors – amongst them – Foot & Ankle free movement and stability, Knee & Hip joint health, and whole leg muscle strength & coordination.

The most common investigations & tests, to establish your risk of breaking a bone due to osteoporosis are:


DXA scan (often pronounced DEXA) – this is used to measure your bone density and informs of how much bone tissue you have. These results are best combined with:


A fracture risk assessment this is a tool used to calculate your risk of breaking a bone in the next 10 years and may be referred to as a FRAX test.

If a fracture (broken bone) is suspected, then an Xray, MRI or CT may be used to diagnose it.


Does Osteoporosis cause pain?

As explained above, the change in bone density itself does not cause any symptoms or pain. If a bone is broken, most commonly a wrist or hip bone following a fall – this can lead to pain. Occasionally spinal fractures occur – usually NOT following trauma or a fall - and these may lead to back pain, this type of fracture is usually when the bones in the spine squash down on themselves rather than break apart. A spinal fracture may not cause pain, but can lead to height loss, a more curved spine, or muscle spasm.

A study in 2010 found that ‘In post-menopausal women with back pain, the presence of lateral waist pain, may identify women at higher risk of prevalent VF (vertebral fractures = spinal fractures).


Interestingly, osteoporosis does not affect your healing from a broken bone – and so you can expect these fractures to heal.


If you have experienced any of these fractures, this will generate further assessment to see if they are due to osteoporosis. Your physiotherapist may communicate with your GP to recommend these investigations and can refer you for a private DXA scan.


This is an excellent booklet full of information for those who have broken a bone: https://www.rcplondon.ac.uk/file/9915/download


As a physiotherapist, my aims are to:

· Help you maintain a healthy lifestyle and improve quality of life

· To include a variety of physical activities and exercises, that challenge your balance, flexibility, and strength. Exercises that use resistance training to promote your bones and muscles and help them develop further density and strength.

· I use a variety of manual therapy and soft tissue techniques to address muscle spasm, reduce joint and muscle tenderness, increase range of movement.

· I treat using Acupuncture as an option to address pain if present.

· To educate you about this condition, alleviate fears, reassure, and address functions of daily living such as housework, hobbies, and sports.


There is ongoing research on what type, how much and how often physiotherapy input is helpful – depending on if treatment is to prevent or as a result of a fracture: a large study found That ‘A treatment that may help people is physiotherapy. There is evidence that several different types of physiotherapy, such as exercise or manual (hands-on) therapy, may help’


As a Pilates instructor, I have undergone special training in modifying exercises to suit specific bone density conditions and adjusting exercises in case you have experienced an osteoporotic fracture. Research has shown that ‘Pilates exercises increase BMD (Bone mass density), improve quality of life and walking distances, and relieve pain, and can thus be offered to patients with OP.’ Paolucci T 2016


So, we are looking to prevent bone density deterioration as much as we can, maintain and improve balance to prevent falls, and treat any problems that occur when a bone has broken.

The ROS recognise that ‘Without this information, people significantly reduce activity levels, limiting both function and enjoyment’.


While attending the ROS conference in 2018 (then called NOS) I learned that the variety of bone loading is key to bone strength: bone tissue stops responding to a regular load. Bone is a dynamic organ, or tissue and so the variety is key to challenging it and demanding more from it.


The research and advice regarding how much do we load / how intense should the exercise regime be, once we’ve experienced a fracture – is mixed.

I take great reassurance from the LIFTMOR trial: ‘High-intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial’ 2018: the researchers used high-intensity resistance and impact training for postmenopausal women with low bone mass – so a population at risk. They showed the program ‘notably improved bone mass in postmenopausal women with osteopenia and osteoporosis’, it also improved their spinal posture and ‘was not associated with an increased risk of vertebral fracture’. The exercises they used were deadlift, squat, and overhead press with weights. Traditionally – these are avoided in this population. In fact – the control group, who performed exercises perceived to be gentler and bone protective, had a greater number of new or deteriorating vertebral deformities during the trial.


In addition: Helen Senderovich et al (2018) concluded that: ‘exercise is primarily shown to reduce the loss of BMD and increase bone stiffness, demonstrating its ability to act as a barrier to the development of OP (osteoporosis). Specifically, high-impact loading was found to increase femoral neck BMD. High-intensity progressive resistance training may improve vertebral height as well as lumbar spine and femoral neck BMD’

So, have we been treating over – conservatively?

The ROS have produced a Consensus Statement called: Strong, Steady & Straight: NOS Exercise and Osteoporosis, to download:


Emphasising these significant elements:

· ‘Physical activity and exercise have an important role in the management of osteoporosis, promoting bone strength, reducing falls risk, and the management of vertebral fracture symptoms.’

· ‘People with osteoporosis should be encouraged to do more rather than less. This requires professionals to adopt a positive and encouraging approach, focusing on ‘how to’ messages rather than ‘don’t do’.

· ‘Physical activity and exercise is not associated with significant harm, including vertebral fracture’

· ‘People with painful vertebral fractures need clear and prompt guidance’

· ‘Professionals should avoid restricting physical activity and exercise unnecessarily according to BMD’

NOGG 2017: clinical guideline for the prevention and treatment of osteoporosis recommends: ‘Physiotherapy is an important component of rehabilitation after fracture. Muscle strengthening and balance training exercise interventions may reduce falls by improving confidence and coordination as well as maintaining bone mass’

And this is what I do!

So if you think you are at risk of osteoporosis, or have been told you are, and if you’ve experienced a fracture and are unsure about where to go from here / how to exercise safely or things hurt – come and see me!

Written by Deborah Thomas – Chartered Physiotherapist – 25.6.2020

References:

1. ROS: Royal Osteoporosis Society: https://theros.org.uk/

3. Royal College of Physicians https://www.rcplondon.ac.uk/

4. Management of chronic pain in osteoporosis: challenges and solutions: Teresa Paolucci et al: Journal of Pain Research 2016:9 177–186

5. Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT: Karen L Barker et al 2019: NIHR Health Technology Assessment Volume 23 • Issue 44 • August 2019

6. High-intensity exercise did not cause vertebral fractures and improves thoracic kyphosis in postmenopausal women with low to very low bone mass: the LIFTMOR trial 2018: S. L. Watson et al Osteoporosis International https://doi.org/10.1007/s00198-018-04829-z

7. An Insight into the Effect of Exercises on the Prevention of Osteoporosis and Associated Fractures in High-risk Individuals Rambam Maimonides Med J www.rmmj.org.il 1 January 2018 Volume 9 Issue 1 e0005

8. NOGG 2017: clinical guideline for the prevention and treatment of osteoporosis

9. Lateral back pain identifies prevalent vertebral fractures in postmenopausal women: cross-sectional analysis of a primary care-based cohort: Emma M. Clark: Rheumatology (Oxford). 2010 March; 49(3): 505–512. doi:10.1093/rheumatology/kep414

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