Strength Training with Osteoporosis

**Topic in Geriatrics:** Benefits of Strength Training for Individuals with Osteoporosis

Osteoporosis is common disease that affects the geriatric population. Evidence shows that strength training can maintain, if not improve, bone density in individuals with osteoporosis. Reducing the fall risk and improving strength are important aspects of treatment for individuals with osteoporosis.

**Objectives:**

1.      What is osteoporosis?

2.      How is osteoporosis diagnosed?

3.      What are the benefits of weight-bearing exercises and strength training?

4.      What types of resistance exercises are beneficial?

5.      What are concerns to look out for with regards to osteoporosis?

**Defining Osteoporosis and Diagnosis:**

Osteoporosis is a disease that causes a decrease in bone mass or density. Your bones become more brittle because your body is not producing enough bone or it is losing too much bone.5,6 This puts you at an increased risk for fracture. Osteoporosis or osteopenia (low bone mass, can develop into osteoporosis) affects over 54 million Americans and you have an increased risk of developing osteoporosis if you are over the age of 50.5

Osteoporosis is often diagnosed using a bone density test. Other laboratory tests that can also help with diagnosis are blood Calcium levels, thyroid function tests, parathyroid hormone levels, Vitamin D levels, and testosterone levels in men.6  Your physical therapist or primary doctor may also use the Fracture Risk Assessment Tool (FRAX) to help determine your risk for fracture.

**Evidence for Strength Training:**

Much of the research for interventions varies as far as specific guidelines for individuals with osteoporosis.  This is partly due to some of the research being done on premenopausal women or individuals who do not yet have osteoporosis.  However, based on research so far, exercise has been shown to be beneficial for osteoporosis when compared to no intervention at all.3 As research continues to grow in this area there will be more direct answers for the best non-pharmacological intervention for osteoporosis. Here is what some of the recent research has found about strength training and osteoporosis:

* Strength training, in addition to balance training, can reduce risk for falls in individuals with osteoporosis1

* Weight-bearing aerobic exercise (i.e. fast walking) may not be adequate when it comes to stimulating bone growth7
* Impact exercises and resistance training have been shown to stimulate bone metabolism and reduce fracture risk2
* Dynamic, weight-bearing high force exercises showed improvement in bone mineral density at the hip joint, whereas low force weight-bearing exercises (i.e. Tai Chi) showed improvement in bone mineral density for the spine1
* Multicomponent exercise programs showed improvement in the spine and hip for bone mineral density1
* Resistance training improved physical function and ADLs in older adults with osteoporosis or osteopenia2,3

**Resistance Exercises:**

* Recommendations for resistance training:1,2,3
	+ 2-4x/week
	+ Power training – resistance and velocity
	+ Moderate to high intensity loads – 70-90% of 1 RM (as tolerated)
	+ 6-10 repetitions
	+ Focus on larger muscle groups
	+ Exercises can use resistance bands, free weights, body-weight, etc.

* Strengthening back extensor muscles decreases likelihood of developing vertebral fractures in postmenopausal women and individuals who have undergone vertebroplasty surgery2

* Much of the research recommends combining multiple types of exercise, so broaden your workouts to include resistance training, balance, impact loading, and postural training, and flexibility1,2,7
	+ Don’t just focus on aerobic training

* Consistency and long-term compliance with exercises is important to see benefits3

**Caution signs:**

* Many people do not have signs or symptoms of osteoporosis, if you are above the age of 50, it is always a good idea to talk to your primary doctor about getting checked

* Always check with your physical therapist or primary doctor before doing high-impact exercises (i.e. running, tennis, dancing)
	+ High intensity and high impact exercise can cause a fracture if osteoporosis is severe enough6

* If you have a fracture or history of fractures, always consult with a physical therapist prior to engaging in training program

**Additional Resources:**

1. National Osteoporosis Foundation: https://www.nof.org/patients/fracturesfall-prevention/exercisesafe-movement/osteoporosis-exercise-for-strong-bones/

 2. “Too Fit to Fracture” Facebook page: https://www.facebook.com/toofit.tofracture/

3. YouTube series on individuals with Osteoporosis and exercises they perform: https://osteoporosis.ca/health-care-professionals/clinical-practice-guidelines/exercise-recommendations/video-series-on-exercise-and-osteoporosis/

4. Osteoporosis Canada booklet for “Too Fit to
Fracture” exercises: http://www.osteoporosis.ca/wp-content/uploads/OC-Too-Fit-To-Fracture-Osteo-Exercise-Book.pdf

5. FRAX Score Interpretation: https://melioguide.com/frax/#fr-efbb

6. Physio-pedia on Osteoporosis: https://www.physio-pedia.com/Osteoporosis

**References:**

1. Giangregorio, L. M., Papaioannou, A., MacIntyre, N. J., Ashe,M. C., Heinonen, A., Shipp, K., … Cheung, A. M. (2014). Too Fit To Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. *Osteoporosis International : A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA*, *25*(3), 821–835. http://doi.org/10.1007/s00198-013-2523-2

2.Moreira,Linda Denise Fernandes, Oliveira, Mônica Longo de, Lirani-Galvão, Ana Paula, Marin-Mio, Rosângela Villa, Santos, Rodrigo Nolasco dos, & Lazaretti-Castro, Marise. (2014). Physical exercise and osteoporosis: effects of different types of exercises on bone and physical function of postmenopausal women. *Arquivos Brasileiros de Endocrinologia & Metabologia*, *58*(5), 514-522. https://dx.doi.org/10.1590/0004-2730000003374

3. Wilhelm, M., Roskovensky, G., Emery, K., Manno, C., Valek, K., & Cook, C. (2012). Effect of Resistance Exercises on Function in Older Adults with Osteoporosis or Osteopenia: A Systematic Review. *Physiotherapy Canada*, *64*(4), 386–394. http://doi.org/10.3138/ptc.2011-31BH

4. Kerr, C., Bottomley, C., Shingler, S., Giangregorio, L., de Freitas, H. M., Patel, C., … Gold, D. T. (2017). The importance of physical function to people with osteoporosis. *Osteoporosis International*, *28*(5), 1597–1607. http://doi.org/10.1007/s00198-017-3911-9

5. (2018). *National Osteoporosis Foundation*. Retrieved July 5, 2018 from https://www.nof.org/

6. Osteoporosis. (2018, March 22). *Physiopedia*. Retrieved July 5, 2018 from https://www.physio-pedia.com/Osteoporosis

7. Harding, A. T., & Beck, B. R. (2017). Exercise, Osteoporosis, and Bone Geometry. *Sports*, *5*(2), 29. http://doi.org/10.3390/sports5020029