1 Physical therapy for Osteoporosis By Dr. Rajal Sukhiyaji

2Contents :- Definition / Description Prevalence Sign and symptoms Causes Risk factors Physical examination Diagnosis Pharmacological option in osteoporosis Physical therapy Alternative / holistic management Exercise safety References

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What is osteoporosis? Osteon is bone and porosis is hole

in Greek. Osteoporosis is a “ Systemic

skeletal disorder “ characterized by “ Low bone mass “ , microarchitectural deterioration of bone tissue leading to bone fragility , and consequent increase in fracture risk .

It leads to abnormally porous bone that is compressible , like a sponge.

The spine , hips and wrists are common areas of bone fractures from osteoporosis.

4 Prevalence :-Osteoporosis is the most prevalent bone disease in the world.

According to the International Osteoporosis Foundation, 1 in 3 women over 50 will experienced osteoporotic fractures, as will 1 in 5 men .

Female to male ratio 1 : 6 .

5Types of bone cells :- Two types :-

1) Osteoclasts

2) Osteoblasts

Bone Remodeling :-

Five phases –

1) Activation

2) Resorption

3) Reversal

4) Formation

5) Quiescence (Resting phase)

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7 Types of osteoporosis :-

2 types :-

a) Primary osteoporosis

I. Type-1 : Postmenopausal osteoporosis

II. Type-2 : Age – associated osteoporosis

b) Secondary osteoporosis

Loss of bone is caused by an identifiable agent or disease process such as inflammatory disorder , bone marrow cellularity disorder and corticosteroid use.

8Clinical signs and symptoms :- Fractures caused by osteoporosis are often painful. Osteoporosis is often

called the ‘Silent disease’ or ‘Silent thief’ as many people don’t recognize they have it until a fracture occurs.

Back pain: Episodic, acute , low thoracic/high lumbar pain

Compression fracture of the spine 

Bone fractures

Decrease in height 

Kyphosis

Dowager’s hump

Decreased activity tolerance

Early satiety

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Causes :- Hereditary , congenital :-

Osteogenesis imperfecta

Neurologic disturbances

Gonadal dysgenesis

10 Acquired ( Primary & secondary )

Generalized :

Localized Inflammatory arthritis Fractures and immobilization in cast

Primary Idiopathic Postmenopausal Age related

Secondary Nutrition Sedentary lifestyle , immobility , smoking Gastrointestinal diseases Malignancy Drugs Endocrine disorder

11Risk factors :-[ National Osteoporosis Foundation Physician guidelines for risk factors for osteoporotic fracture. ] Current cigarette smoking Low body weight (<127 pounds) Alcoholism Estrogen deficiency Prolonged amenorrhea (>1 year) Early menopause (<45 year) or bilateral ovariectomy Lifelong low calcium intake Recurrent falls Poor health / fragility Inadequate physical activity Family history of osteoporosis

12 Physical examination :-

Osteoporosis• Height loss• Body weight• Kyphosis• Humped back• Tooth loss• Skinfold thickness• Grip strength

Vertebral fracture• Arm span-height

difference• Wall- occiput

distance• Rib-pelvis

distance

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No single maneuver is sufficient to rule in or rule out osteoporosis or vertebral fracture without further testing.

14 Diagnosis :- Bone Mineral Density (BMD) test :-

The most common test.

Results are reported using T-scores.

T-scores are relative to how much higher or lower your bone density is compared to that of a healthy adult.

T-score :- It is the number of standard deviation (SD) above or below a reference value.

15 Category T-score

Normal -1.0 or Above

Osteopenia(Low bone mass)

-1.0 to -2.5

Osteoporosis -2.5 or Less

Severe osteoporosis -2.5 or Less with one or more fragility

fracture

16 Laboratory Tests :-• Blood Calcium levels

• 24-hour urine calcium measurement

• Thyroid function tests

• Parathyroid hormone levels

• Testosterone levels in men

• 25-hydroxyvitamin D test to determine whether the body has enough vitamin D

• Biochemical marker tests

17Pharmacological option in osteoporosis :-

Antiresorption :-

Act on osteoclasts and stabilize bone

Calcium Estrogen Calcitonin Bisphosphonates Selective estrogen receptor

modulators Thiazide diuretics

Formation :- Act on osteoblasts and

increase bone formation Vitamin D Anabolic steroids Parathyroid hormone Growth factors (investigation) Fluoride (investigation)

18Clinical picture of osteoporosis :-

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Goals :-1) To educate proper posture.2) Teach safe ways of moving and lifting.3) To prevent a decline in bone mass and prevent fractures.4) To increase the strength in bones.5) To maintain or improve balance.6) To improve flexibility.7) To help decrease the stress placed on the bones by tight muscles. 8) To improve overall mobility. 9) To control pain and gradually returning back to regular activities.

Physical therapy :-

25 If patient has fracture related to osteoporosis, treatment will start with focus on decreasing pain.

For that modalities like,

I. Ice

II. Heat

III. Ultrasound

IV. Electric current

After that , start with more advanced exercises involving strengthening ,balance, weight bearing and flexibility exercises.

26 Exercise :- 1) Extension exercises2) Chin tucks3) Scapular retractions4) Thoracic extensions5) Hip extension

These all exercises will improve posture , balance and strength also.

Note :- Flexion exercises are CONTRAINDICATED. Anterior compressive forces to the vertebra can contribute to compression fractures.

27 Vertebroplasty (kyphoplasty):-

It is recently been used for the management of

vertebral fractures. This procedure involves the

injection of Acrylic cement (such as

Polymethylmethacrylate) into a partially collapsed

vertebral body.

63% of osteoporotic patient decrease their use of

opiates and analgesics for pain control.

7% increase their use

30% remain the same.

28 Orthoses is also used in osteoporotic spine It promote extension of spine.

Hip protectors :- Hip protectors are an external hip protection

system that aims to reduce the hip facture.

29Non-strenuous exercises for patient with severe osteoporosis :- Upper back and shoulder extension exercises perform with spine supported.

30 Back extension exercise in sitting position. This position avoids or minimizes pain in patient with severe osteoporosis.

31 Physical therapy :-

Physical therapy intervention for individuals with osteoporosis, or even osteopenia, should include:

Maintain posture

Strengthening exercise

Weight bearing exercise

Balance exercise

Flexibility exercise

32Maintain Posture :- Stooped upper spine posture- called

kyphosis – common

Losing height as a result of these fractures is a common occurrence in osteoporosis.

Goal :- To get body lined up from head to toe, with weight going through hips.

Physical therapist role :- Give instruction that all times to try to “ BE TALL “.

33 Different posture :-

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Correct posture during lifting any object…….

35Correct sleeping posture

36 Strengthening exercise :- Gentle weighted exercises , using either elastics or weights for

upper and lower extremities. These exercises help to improve the individuals overall physical

function and postural control.

37Extension exercises in prone position with a pillow under the abdomen to avoid hyperextension.

To increase the effect of back extension strengthening, weight is added.

38 Exercise for improving strength in lumbar extensors and gluteus maximus muscles.

39 Home based arm loading

exercises :- The following exercises increase bone

mineral density in the wrist and load the forearm in various directions. It should be done three times a week and repeated 10–15 times on each occasion.

Arm press :- Stand facing a wall, about 50cm away from

it, with your feet slightly apart, arms bent at the elbows and hands at shoulder height.

Lean your body forwards towards the wall by bending your elbows in a controlled movement.

Push your body back to the starting position.

40 Wrist curl :-

This is an easy exercise that will work for forearm muscles. It can do with a light weight or water bottle, and progress further by increasing the weight – (the safe limit is 5kg (11lbs) in each hand.

Tip :- Keep your elbows in contact with your thighs, parallel to wrists. This will make the exercise more effective.

Turn your forearm over and repeat using an overhand grip.

41 Weight bearing exercises :- Walking outdoors or on a treadmill

Gentle non-pounding forms of dance

Stair climbing

These all are useful activities to put weight through the bones and encourage an upright posture while also improving cardiovascular health.

High impact activities such as running, jumping, and pounding forms of dance should be strictly avoided.

42Balance :-

Poor balance can lead to a fall which can easily fracture an osteoporotic bone. Exercises to improve your balance ,

Standing with feet close together Standing on one foot, or standing with one foot

in front of the other. Closing eyes can make any of these activities

even more difficult. By challenging balance, reaction time to

unexpected situations such as tripping will improve and likelihood of falling will decrease.

Safe environment is most important. As balance gets better, more challenging

exercises will be provided.

43 Flexibility exercise :- By improving and maintaining flexibility,

the stress put on bones by tight muscles will decrease and the ability to practice good posture and body mechanics will be improved.

Good flexibility also improves your mobility, which in turn improves you balance and decreases your risk of falls.

Stretching for upper back and chest will be prescribed to decrease the developing a stooped posture.

Stretches for hips, calves, and neck are also important.

44 Pectoral stretching exercise performed in standing position. This is used to reduced kyphotic posture.

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Other flexibility exercises

46Alternative/Holistic Management (current best evidence)

Alternative management of osteoporosis includes diet, vitamin supplementation, and herbal supplementation.

Diet has a direct correlation to bone growth and as we age we may not be absorbing the adequate amount of calcium.

By using calcium-rich foods, such as milk, cheese, almonds, broccoli, and cauliflower , we can get the enough amount of calcium.

47 leafy green vegetables are a great addition to the diet with

osteoporosis it has been shown that oxalate acid that is found in spinach prevents absorption of calcium in the stomach.

Vitamin supplements may also be necessary when managing osteoporosis.

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According to the University of Maryland Medical Center (UMMC), 1,500 milligrams of calcium, taken in 3 doses of 500 milligrams per day, is an effective supplement to strengthen the bones and prevent further bone loss.

Other vitamins that are recommended to retain bone strength are vitamins D and K.

Herbal supplements are another form of management. The University of Maryland Medical Center reports that several herbs, such as black cohosh, oat straw, and kelp can help with management of osteoporosis.

49 Yoga :-

Yoga can stimulate the bones to retain calcium, provided the body gets enough calcium. ( According to yoga expert, Mary Schatz, M.D )

50 Exercise safety :- There are some important dos and don’ts should be aware of, to enable to

take up a more active lifestyle in a safe and effective way.

It is important not to rush into unaccustomed exercise too quickly.

Exercise must be taken regularly to have any benefit.

Avoid combining flexion and rotation of the trunk to reduce stress on vertebra.

Think carefully about undertaking activities that may increase the chance of a fall.

Always maintain an upright posture.

51References :-

1. National Osteoporosis Foundation. Having a Bone Density Test.http://www.nof.org/articles/743 (Accessed 28 March 2013).

2. Mayo Clinic. Osteoporosis treatment: Medication can help.http://www.mayoclinic.com/health/osteoporosis-treatment/WO00127 (Accessed 28 March 2013).

3. Goodman. Fuller. Boissonnault. Pathology; Implications for the Physical Therapist. 2nd. Philadelphia: Saunders, 2003.

4. Jensen ME, Evans AJ, Mathias JM, et al. Percutaneous polymethylmethacrylate vertebroplasty in treatment of osteoporotic vertebral body compression fracture.

5. S. Brent Brotzman, Kevin E. Wilk, Clinical Orthopaedic Rehabilitation6. Randall L. Braddom, Physical Medicine & Rehabilitation7. Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercise

52 Thank you