Learning objectives
- •
Identify physical exercises that should be incorporated in the management of osteoporosis.
- •
Identify physical exercises that should be avoided in patients with osteoporosis.
- •
Recognize when to refer a patient for physical therapy.
The case study
Reasons for seeking medical help
- •
JC, a 68-year-old Asian woman, was recently diagnosed with osteoporosis as evidenced by a T-score of −2.5 in her upper four lumbar vertebrae. Her VFA does not show any fractures. She is now taking alendronate 70 mg weekly as directed and is not experiencing adverse effects. She would like to exercise, but is unsure which physical exercises are appropriate for her.
- •
She is also concerned that her balance has deteriorated since she stopped doing yoga after her hip surgery for osteoarthritis. She currently lives alone and would like to stay as independent as possible.
Past surgical and medical history
- •
Right hip replacement due to osteoarthritis at age 62 years. Good results except for occasional bouts of unsteadiness, occurring with no definite precipitating factors. She, however, experienced three near-falls during the past 2 weeks. She saw her primary care provider who recommended she continue walking and use a walking aid if necessary. She is reluctant to follow that advice and is seeking help.
- •
Natural menopause at age 52 years, received hormonal replacement therapy for about 6 months then discontinued it because of fear of adverse effects.
Lifestyle
- •
Gardens regularly, weather permitting.
- •
Took yoga classes for about 4 months prior to her hip replacement surgery. She enjoyed these exercises and is happy to continue, but is concerned they may not be appropriate for her, especially since she experienced bouts of unsteadiness.
- •
Walks daily, about 45 min.
- •
No cigarette smoking.
- •
No excessive sodium, caffeine, or alcohol intake.
Medication(s)
- •
Multivitamin daily.
- •
Vitamin D3 1000 units daily.
- •
Calcium 1200 mg daily.
Family history
- •
Negative for osteoporosis.
Clinical examination
- •
Weight 100 lbs., height 62″.
- •
Mild kyphosis.
- •
No significant clinical findings.
Laboratory results
- •
Comprehensive Metabolic Profile (CMP): All results within normal limits.
- •
Serum 25-hydroxy-vitamin D: 42 ng/mL.
Multiple choice questions
- 1.
Exercises to incorporate in a program for osteoporosis include:
- A.
Planks.
- B.
Pelvic bridges.
- C.
Wall angels.
- D.
Reverse sit-ups.
- E.
All of the above.
Correct answer: E
Comment:
Ideally, a physical exercise program should be developed, individualized, and tailored to meet JC’s specific personal needs, capabilities, and circumstances. Ideally this should be done in conjunction with a physical therapist or an occupational therapist experienced with the needs and problems of patients with osteoporosis who have undergone hip replacement surgery.
Trunk flexion exercises such as sit-ups may increase pressure on the vertebral column. Plank exercises are preferable for patients with osteoporosis. Planks strengthen the rectus abdominis. Pelvic bridges strengthen the gluteal muscles and pelvic floor, as well as hip flexors.
Supine poses are a good choice for patients with kyphosis and balance issues because they do not increase the pressure on the thoracic vertebrae and do not increase the risk of falling. They also tend to isolate the hip flexors, which help in stabilization of the core and spine. Wall angels are beneficial to improve posture and strengthen back extensor muscles.
In JC’s case, she has mild kyphosis which can potentially be improved by performing these exercises. In addition, many exercises can be performed from a seated position. This is especially helpful if the patient has difficulty standing and/or walking due to arthritic pain. These exercises include ankle plantar flexion and dorsiflexion, knee flexion and extension, hip flexion, extension, abduction, adduction, shoulder, and elbow flexion. It is also useful to use rubber balls, a small one to exercise the muscles of the hand and a larger one for hips, knees, and ankles. Many of these exercises can be performed while the patient is sitting down.
- A.
- 2.
Balance exercises appropriate for fall prevention in patients with osteoporosis include:
- A.
Tai Chi.
- B.
Sit to standing exercises.
- C.
Yoga.
- D.
Whole body vibration machines.
- E.
A, B, and C.
Correct answer: E
Comment:
Tai Chi performed regularly improves balance, coordination, muscle strength, and helps fall prevention. Tai Chi also improves bone mineral density in the lumbar vertebrae. Sitting to standing exercises target core muscles which aid in balance. Yoga also helps with balance and proprioception. Results of research concerning whole body vibration machines and balance in older individuals are inconclusive at present.
- A.
- 3.
A physical exercise program for osteoporosis should be:
- A.
Individualized.
- B.
Ideally supervised by a licensed health care professional with expertise managing patients with osteoporosis.
- C.
Easily accessible.
- D.
In a gym setting.
- E.
A, B, and C.
Correct answer: E
Comment:
Physical exercise programs should be, at least initially, supervised by a licensed health care professional. Programs should be tailored to the individual needs, regarding cardiovascular health, strength, balance, accessibility, and cognitive functions. It does not need to be in a gym setting. It should be developed for the patient to perform in his or her home, preferably with minimal equipment to keep it cost efficient and more accessible.
- A.
- 4.
Exercises to avoid by patients with a diagnosis of osteoporosis include:
- A.
Sit-ups.
- B.
Deep spinal twists.
- C.
Forward bends.
- D.
Rounding of the back.
- E.
All of the above.
Correct answer: E
Comment:
JC should avoid exercises that involve rounding of the spine, such as sit-ups, cat/cow in yoga, forward bends with a rounded back, and weighted movements at the end range of flexion. These exercises may increase the risk of sustaining a vertebral compression fracture. In addition, deep twisting motions can cause compression fractures. It is also important for JC to remember to use a hip hinge when picking up objects from the floor, as this decreases the pressure on her back and is proper lifting form.
- A.
- 5.
Aerobic exercise benefits other disease processes including:
- A.
Diabetes mellitus.
- B.
Cardiovascular diseases.
- C.
Sarcopenia.
- D.
Neurodegeneration.
- E.
All of the above.
Correct answer: E
Comment:
Physical exercise is an effective method of improving glycemic control in patients with type II diabetes mellitus. Aerobic exercises can help decrease muscle wasting that occurs with sarcopenia. Aerobic exercises help decrease neurodegeneration, increase neuron formation and mitochondrial biogenesis, and modulate amyloid-degrading enzymes.
- A.
- 6.
Peak bone mass occurs in the following groups:
- A.
Teenage years.
- B.
20s–30s.
- C.
40s.
- D.
At the beginning of the menopause.
- E.
After the menopause.
Correct answer: B
Comment:
Peak bone mass is not reached at the same time in all the skeleton. In most bones, however, it is reached in the 20s–30s. Physical activity has the greatest impact on adolescents as they still develop their bone mass to reach the highest genetically determined level.
- A.
- 7.
JC comes back to the office to follow-up on her osteoporosis regarding exercises. She has heard that free weights will help her but has never lifted weights. The following is recommended:
- A.
Buy a light set of free weights for at-home use.
- B.
Work with a personal trainer for an appropriate plan and for guidance on correct form.
- C.
Work with a personal trainer but encourage weight machine use.
- D.
Do not lift free weights.
- E.
Use a mix of free weights and machines at a gym.
Correct answer: B
Comment:
JC has mild kyphosis and no history of lifting weights. Given this, and her eagerness to develop an exercise programs tailored to her own individual needs, a good recommendation is for her to seek help from a personal qualified trainer who would ensure she has correct lifting form and to help create a workout plan individualized to meet her own needs.
As a general rule, a combination of resistive and aerobic exercises will be helpful. It is also important for JC to fully understand that experiencing pain while performing a physical exercise is an important sign that the intensity of that particular exercise at that particular time is being exceeded and is an important warning signal to stop performing this exercise. She may try again a few days later.
- A.
- 8.
In addition, JC would like help for her mild kyphosis. Recommendations include:
- A.
Refer to physical therapy for individualized exercises.
- B.
Advise JC to “stand up straight” and work on standing straight multiple times throughout the day.
- C.
Discuss a few exercises and provide an educational handout.
- D.
Consider kyphoplasty.
- E.
A and C.
Correct answer: E
Comment:
Having a reliable reference to give patients as well as a few basic exercises for them to do is a great first step in improving the patients’ posture and overall wellness. Referring to physical therapy is another option and can help patients with more in-depth care as well as developing an individualized plan. Given the low magnitude of the pain JC is experiencing, there is no need to consider kyphoplasty.
- A.
- 9.
JC returns 6 months later for a follow-up visit. She is feeling well, but is asking whether a whole body vibration machine would speed up her progress. The best response is:
- A.
The results of the research are conflicting.
- B.
It is highly recommended.
- C.
Resistance exercises are a more appropriate option.
- D.
A combination of weight-bearing and resistance exercises are more appropriate options.
- E.
A and D.
Correct answer: E
Comment:
Kyphosis can be improved by exercises that target paravertebral muscles. Research regarding whole body vibration machines is at present inconclusive. Most published studies have a small sample size. There also is little consistency on the minimum amount used to show an improvement in bone density. Both weight-bearing exercise and resistance exercises are recommended to help increase bone density in patients with a diagnosis of osteoporosis.
- A.
- 10.
JC would like to directly target her lumbar vertebrae in her exercise plan. Ways to specifically target lumbar vertebrae include:
- A.
Running.
- B.
Jumping.
- C.
Cyclic.
- D.
Any of the above.
- E.
None of the above.
Correct answer: E
Comment:
While research is limited regarding site-specific increases, a mixture of aerobic and resistance exercises is recommended to help increase bone mineral density.
- A.
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