# Exercise as it relates to Disease/The role of exercise in reducing the need for joint replacement for people suffering osteoporosis
## What is Osteoporosis and how is it related to Joint Replacements?
### Osteoporosis

Osteoporosis is the most common metabolic bone disease affecting an estimated 200 million people worldwide. In the United States there is over 12 million people suffering osteoporosis with over 9 million of that cohort being women. Dolbow and Gorgey (2013) defined osteoporosis as, “a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Bone strength reflects the integration of two main features: bone density and bone quality.”

### Relation to Joint Replacements

Joint replacements are on the rise due to an increasingly ageing population and there was an estimated 1 million joint replacements in 2013 in the United States alone. Approximately 90% of the reason for needing a joint replacement is due to osteoarthritis. Labuda et al. (2008) concluded saying one in four people receiving joint replacements are osteoporotic. Ishikaawa et al. (2013) found that, “one in two women and one in four men aged fifty years or older will experience an osteoporotic related fracture in their lifetime.“

### Three key Elements of Osteoporosis

Due to a wide research scope on osteoporosis there can be varying definitions depending on the author but what is crucial to understand is that osteoporosis will always consist of these three elements
* Decreased bone mass
* Decreased bone quality and,
** Dolbow and Gorgey (2013) defined bone quality as the health of the material properties of the bone.
* Increased risk of bone fracture

## How do you find out if you are Osteoporotic?

A dual-energy x-ray absorptiometry scan or commonly known as a DXA scan measures your bone mineral density (BMD). The World Health Organisation scientific group defines the gradient of risk as; per standard deviation decrease in BMD, a 1.5 time increase is seen in your chances of a fracture. This being said, the femoral neck has the highest gradient of risk with every standard deviation decrease in BMD the chances increase 2.6 times. For more information about a DXA scan visit this webpage.

### BMD scores from a DXA scan - Females (Same system for males)

* Normal
** Hip BMD <1.0 SD below the young adult female reference mean (T score above 21.0)
* Osteopenia
** Hip BMD between 1.0 and 2.5 SDs below the young adult female reference mean (T score between 21.0 and 22.5)
* Osteoporosis
** Hip BMD = or .2.5 SDs below the young adult female reference mean (T score at or below 22.5)
* Severe Osteoporosis
** Hip BMD = or .2.5 SDs below the young adult female reference mean in the presence of 1 or more fragility fractures
For more information about understanding your DXA scan results visit this insightful webpage

### Fragility Fractures

Fragility fractures are fractures that develop from no perceived injury. Something as simple as a cough, sneeze or sudden movement can cause a fracture and Fletcher (2013) reported that 80% of all fractures in women aged over 50 can be accounted by fragility fractures. Dolbow and Gorgey (2013) reported 550,000 vertebral fractures occurred over the past year in the United States as a direct result of fragility fractures.

## The Issue
### In Terms of Treatment

Due to there being no single treatment for osteoporosis there needs to be an understanding that the ultimate goal is fracture prevention. In the United States there was a reported 400,000 hip fractures due to patients falling and having osteoporosis. If we decrease our fall rate, the less likely the patient is likely to have a fracture and, the less likely the patient will need a joint replacement. While increasing BMD is a main goal with people suffering osteoporosis, what also needs to be given adequate attention include; fall prevention, assuage pain, increasing the ease of practical every day chores which will all in turn increase independence and enhance quality of life.

### Multi-facted Fracture Prevention Program

With this understanding of a multi-faceted fracture prevention program, this fact sheet will discuss some key areas. It is strongly encouraged to see the attached links at the end of the sheet to further better your knowledge. In saying that, we will look at exercises to increase BMD, diet and lifestyle choices which all counteract the negative adverse affects of osteoporosis.

## Recommendations
### Exercise

The theory behind exercise in the treatment of osteoporosis is that when muscle contracts stresses are put on the bone due to the tendons that connect the muscle to the bone. For the bone to be able to support this new stress it starts to increases in BMD. With this knowledge any weight bearing activities such as walking, jogging and dancing will increase BMD. High intensity exercise hasn’t shown significant results in increasing BMD along with all the implications that can occur due to the brittleness of the bones. Osteoporotic patients will welcome the recommendations of endurance moderate-intensity exercise lasting approximately 30–60 minutes three to five times a week is very beneficial. Fletcher (2013) prescribes strength training three days per week, which could include leg press, leg extension, leg curl, squats and arm exercises. Dolbow and Gorgey (2013) advises that patients over sixty years of age enroll in fall prevention programs which should include strengthening of the legs, trunk and balance activities.
This great research article talks about the exercise guidelines that people of all ages should adhere to to limit the effects of osteoporosis. (Scroll down and click on the ‘Canadian Academy of Sport and Exercise Medicine Position Statement: Osteoporosis and Exercise’)

### Diet

Dolbow and Gorgey (2013) defines a healthy diet is one that is high in calcium and vitamin D which can be found in milk or any other dairy products. Green leafy vegetables with also a healthy serve of fish (salmon and sardines) accompanied by sunlight each day which helps stimulate vitamin D production in our bodies which in turn build our BMD.
For more information about diet feel free to visit Nutrition Australia's website.

### Lifestyle Changes

Dolbow and Golgey (2013) strongly advises that if the patient suffering osteoporosis is smoking and drinks excessively that this should cease immediately.
Another part of a lifestyle change is fall prevention hazards with the home environment. To best suit your needs it is advised that any hazards that could make you trip should be removed and handrails are a great addition to any stairs to keep the patient safe and fall free.

## Further Research

* Osteoporosis Australia is a great resource for any of your queries
* Cochrane Reviews are more for if you want to delve deep into the understanding of osteoporosis and the current research that is out.
* The greatest information center is the International Osteoporosis Foundation website. Here you can find anything about both men and women suffering osteoporosis.

## Reference List

* Ishikawa, S, Kim, Y, Kang, M, & Morgan, D 2013, 'Effects of Weight-Bearing Exercise on Bone Health in Girls: A Meta-Analysis', Sports Medicine, 43, 9, pp. 875–892, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* Labuda, A, Papaioannou, A, Pritchard, J, Kennedy, C, DeBeer, J, & Adachi, J 2008, 'Prevalence of Osteoporosis in Osteoarthritic Patients Undergoing Total Hip or Total Knee Arthroplasty', Archives Of Physical Medicine & Rehabilitation, 89, 12, pp. 2373–2374, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* Matos, O, Bassana, J, Orsso, C, Gabriela, F, Sprenger, S, & Ribeiro, W 2013, 'Study of relationship between osteoarthritis, postural changes and osteoporosis in postmenopausal women. / Estudios de la relación entre osteoartritis, las alteraciones posturales y osteoporosis en mujeres posmenopáusicas', Revista Andaluza De Medicina Del Deporte, 6, 1, pp. 9–11, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014
* Peeters, G, Brown, W, & Burton, N 2014, 'Physical Activity Context Preferences in People With Arthritis and Osteoporosis', Journal Of Physical Activity & Health, 11, 3, pp. 536–542, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.

## References

* 1 2 3 4 Küçükçakır, N, Altan, L, & Korkmaz, N 2013, 'Effects of Pilates exercises on pain, functional status and quality of life in women with postmenopausal osteoporosis', Journal Of Bodywork & Movement Therapies, 17, 2, pp. 204-211, SPORTDiscus with Full Text, EBSCOhost, viewed 30 September 2014.
* ↑ Palombaro, K, Black, J, Buchbinder, R, & Jette, D 2013, 'Exercise for Managing Osteoporosis in Women Postmenopause', Physical Therapy, 93, 8, pp. 1021-1025, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* 1 2 3 4 5 Dolbow, D, & Gorgey, A 2013, 'Non-Pharmacological Management of Osteoporosis', Clinical Kinesiology (Online Edition), 67, 2, pp. 5-9, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* ↑ Ashraf, A, Shooshtari, S, Homayouni, K, Roshanzamir, S, Zafarghasempoor, M, Ajhdarnia, N, Satari, S, & Rezaianzadeh, A 2011, 'ASYMMETRY OF BONE MINERAL DENSITY OF THE HIPS IN PATIENTS WITH UNILATERAL KNEE OSTEOARTHRITIS:: A CROSS-SECTIONAL STUDY', Journal Of Musculoskeletal Research, 14, 1, pp. 1-6, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* 1 2 3 4 Fletcher, JA 2013, 'Canadian Academy of Sport and Exercise Medicine Position Statement: Osteoporosis and Exercise', Clinical Journal Of Sport Medicine, 23, 5, pp. 333-338, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.
* ↑ Ishikawa, S, Kim, Y, Kang, M, & Morgan, D 2013, 'Effects of Weight-Bearing Exercise on Bone Health in Girls: A Meta-Analysis', Sports Medicine, 43, 9, pp. 875-892, SPORTDiscus with Full Text, EBSCOhost, viewed 28 September 2014.