Bone Health and Exercise

What is Osteopenia and Osteoporosis?

• Osteoporosis is a condition that affects the inside of your bones, causing them to lose their strength and making them easier to break. 

• Bone is a living tissue that constantly changes, older worn-out bone tissue gets broken down by cells called Osteoclasts and rebuilt by bone building cells called Osteoblasts. This is known as bone remodelling. 
• Peak bone density occurs typically in our 20s, it tends to plateau in our 30s and by 35/40 reabsorption of bone occurs.
• This is a normal ageing process.
• However sometimes we lose bone faster than we remodel bone which results in Osteopenia and then Osteoporosis. 

• Osteopenia is the early stage of bone loss which if not treated may result in Osteoporosis. 
• Research shows that most broken bones occur in the moderate to marked Osteopenia range.¹ 
• The most common fracture sites are wrists, hips and spinal bones. 
• If left untreated the effects can be devastating so early identification and prevention is hugely important.

Osteoporosis is a silent disease because there are often no signs and symptoms prior to fracturing (breaking) a bone.

Are Osteoporosis and Osteopenia treatable?

• Yes both are preventable and treatable 
• It is very uncommon where a person cannot improve their bone health

UK statistics:

• Osteoporosis affects over 3.5 million people in the UK in 2015
• This figure is set to rise as we have an ageing population 
• 1 in 2 women and 1 in 5 men over the age of 50 will break a bone as a result of poor bone health ² 
• Osteoporosis causes over half a million fractures yearly ³ 
• Only 25% of adults are familiar with the term Osteoporosis ⁴ 
• 1/5 of women who have broken a bone break three or more before even being diagnosed ⁵ 
• 64% of women and 43% of men living with Osteoporosis are not getting the NHS treatment that they need ²

Cost:

• As of 2013 Fragility fractures are estimated to cost the UK around £4.4 billion each year. ⁷ 
• Hip fractures alone account for 69,000 emergency admissions into English hospitals, adding up to 1.3 million bed days and a cost of £1.5 billion each year. ^{8, 9}

Important to know:

• Osteoporosis or Osteopenia can affect you at any age – it is not an elderly person’s condition
• It often has no signs or symptoms – ie you will often not know that you have it
• Men can also be affected by Osteopenia and Osteoporosis

Risk Factors:

How do you get diagnosed?

• It is diagnosed by having an assessment and a DEXA scan which you are usually referred to by your GP/specialist. 
• DEXA scans are very safe – they use a much lower level of radiation than a standard X-ray. ⁶
• At Physio On The Green we work closely with Consultants and GPs who you can be referred on to if needed
• It is very important that the cause of your bone loss is investigated and addressed, to identify or help slow or reduce your risk of developing Osteoporosis.

How can Physio/Exercise help?

• Studies have shown that impact exercise alone maintains or improves Bone Mineral Density (BMD) in the hip ¹⁰ 
• High-intensity muscle strengthening exercise in combination with impact exercise maintains or improves spine BMD ¹¹,¹⁴ 
• Improving the strength of back muscles may maintain or improve BMD in the spine and reduce the risk of vertebral fracture ¹⁵
• There is moderate quality evidence that resistance training with high or low force has a small to medium effect on bone mass in the forearm ^{16, 17}

High-intensity muscle strengthening exercise alone may maintain or improve BMD at the hip ¹¹ and spine ^12,13

Physio On The Green Bone Health Program – what does it involve?

• At Physio On The Green we will provide an evidence-based exercise programme designed specifically to prevent osteoporotic fracture and improve bone density by stimulating bone development and preventing falls in at-risk individuals.
• The program will be led by our physiotherapist Jenni Dowley who has previously worked with people who have Osteoporosis and Osteopenia and run a Bone Health Program.
• Each individualised program is based on the Royal Osteoporosis and other exercise guidelines. 
• The initial appointment will be a detailed assessment including; a full history, balance/strength/functional assessment, neck and back assessment
• Once you have been assessed a program will be designed for you where you will take part in a physio led program that focuses on three main areas: Strong, Steady, Straight 
• Strong: to increase muscle strength, reduce falls risk and impact to stimulate new bone formation 
• Steady: to decrease falls
• Straight: Strengthen postural muscles alongside education to to reduce pain and reduce risk of vertebral fractures
• The program can be tailored to all levels

Is exercising safe?

• In studies that the Royal Osteoporosis Society looked at to develop their exercise guidelines there was no evidence of symptomatic vertebral fracture in association with impact exercise or moderate to high intensity muscle strengthening exercise. ^18,19 There were, however, modest improvements in quality of life, balance, pain and fear of falling.²⁰
• In a recent study of high-impact and high- intensity muscle-resistance exercise for people with significantly low BMD, there were no reports of fractures, although the sessions were supervised by an instructor for technique and overall safety (including falls risk).²¹ 
• In a further study, adverse events (both falls and fractures) did not differ significantly between the control and the intervention groups but were more common in those undertaking unsupervised exercise (strength, balance and daily moderate to vigorous physical activity), although still relatively rare.²²

Further Resources:

• The Royal Osteoporosis Society 
• Irish Osteoporosis Society

References:

1. Irish Osteoporosis Society
2. International Osteoporosis Foundation. ‘Broken Bones, Broken Lives: A Roadmap to Solve the Fragility Fracture Crisis in the United Kingdom’, 2018 
3. British Orthopaedic Association. The Care of Patients with Fragility Fracture, 2007 
4. Echo – Global Research. Protecting Brands and Reputation. Brand Awareness & Audience Insights Study [Internal report commissioned by Royal Osteoporosis Society (formerly National Osteoporosis Society)], 2013 
5. Royal Osteoporosis Society (formerly National Osteoporosis Society). Stop at One Survey, 2013
6. NHS – Osteoporosis
7. Calculated using mid 2013 population data [i] and osteoporosis incidence from [ii].[i] Office of National Statistics, 2014. Annual Mid-year Population Estimates, 2013. [ii] Kanis J, Johnell O, Oden A, Jonsson B, Laet C and Dawson A, 2000. Risk of hip fracture according to the World Health Organisation criteria for osteopenia and osteoporosis. Bone 27, pp.585-590.
8. Health and Social Care Information Centre, 2013. Hospital Episode Statistics, Admitted Patient Care, England 2012-13. 
9. Calculated using hip fracture costings from [i] updated using the Health Service Cost Index [ii] and Finished Consultant Episodes for hip fracture [iii] [i] Lawrence T, White C, Wenn R and Moran C, 2005. The current hospital costs of treating hip fractures. Injury 36, pp.88-91. [ii] Department of Health, 2013. Health Service Cost Index. Available at: http://www.info.doh.gov.uk/doh/finman.nsf/Newsletters [March 2013, March 2005 and March 2001].[iii] Health and Social Care Information Centre, 2013. Hospital Episode Statistics, Admitted Patient Care, England 2012-13. Primary Diagnosis (4 character detail, FCEs)
10. Zhao R, Zhao M, Zhang L. Efficiency of Jumping Exercise in Improving Bone Mineral Density Among Premenopausal Women: A Meta-Analysis. Sport Med. 2014;44(10):1393- 1402. 
11. Howe T, Shea B, Dawson L, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011;(7):CD000333.
12. Kelley GA, Kelley KS, Kohrt WM. Effects of ground and joint reaction force exercise on lumbar spine and femoral neck bone mineral density in postmenopausal women: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2012;13(1):177
13. Martyn St.James M, Carroll S. Progressive high- intensity resistance training and bone mineral density changes among premenopausal women: Evidence of discordant site-specific skeletal effects. Sport Med. 2006;36(8):683-704. 
14. Zhao R, Zhao M, Xu Z. The effects of differing resistance training modes on the preservation of bone mineral density in postmenopausal women: a meta-analysis. Osteoporos Int. 2015;26(5):1605-1618. 
15.  Sinaki M, Itoi E, Wahner HW, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002;30(6):836-841
16. Babatunde OO, Evans AL, Hind K, Paskins Z, Forsyth J. Exercise interventions for preventing and treating low bone density in the forearm: a systematic review and meta-analysis (in submission).
17. Guadalupe-Grau A, Fuentes T, Guerra B, Calbet JAL. Exercise and bone mass in adults. Sport Med. 2009;39(6):439-468.
18.  Knutsnor S; Leyland S; Skelton D; James L; Cox M; Gibbons N; Clark E. Adverse events and safety issues associated with physical activity and exercise for adults with osteoporosis and osteopenia: A systematic review of observational studies and an updated review of interventional studies. J Frailty, Sarcopenia Falls. 2018. 3(4) (In Press)
19.  Cox M. Exercise for Preventing and Treating Osteoporosis in Postmenopausal Women. London; 2017.
20. Gibbons N. Exercise for Improving Outcomes after Osteoporotic Vertebral Fracture. MSc Thesis (Physiotherapy). 2017.
21. Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res. 2017;33(2):211-220. 
22. Giangregorio LM, Gibbs JC, Templeton JA, et al. Build better bones with exercise (B3E pilot trial): results of a feasibility study of a multicenter randomized controlled trial of 12 months of home exercise in older women with vertebral fracture.