Osteoporosis and WB Ex

Osteoporosis & Weight Bearing Exercises for Older Adults PT 7428 Therapeutic Interventions Shannon Herrin, PT, DPT, EdD Fall 2025

Objectives

  • Explain the pathology of osteoporosis.

  • Clarify the implications associated with osteoporosis that affect physical therapist practice.

  • Discuss risk factors for osteoporosis.

  • Interpret DEXA bone density test results.

  • Determine the elements of physical therapy examination and evaluation for individuals with osteoporosis.

  • Compare and contrast interventions for individuals with osteoporosis.

Osteoporosis (OP)

  • Definition: A chronic, progressive disease characterized by:

    • Low bone mass

    • Impaired bone quality

    • Decreased bone strength

    • Increased risk of fractures

  • Types of Osteoporosis:

    • Primary Osteoporosis: Most common type affecting individuals; typically linked to aging.

    • Females: Often follows menopause, typically occurring between ages 40-60.

    • Males: Usually occurs later in life, around ages 65 and older.

    • Secondary Osteoporosis: Linked to medications or other conditions/diseases, including:

    • Corticosteroids

    • Immobilization

    • Inflammatory bowel disease

    • Autoimmune disorders

    • Endocrine disorders

    • Renal disease

    • Diabetes

    • Cancer

Osteoporosis Etiology

  • Primary Osteoporosis:

    • Not fully understood; it is a complex multifactorial genetic disorder influenced by:

    • Environmental factors like low calcium intake

    • Genetic factors (Mondockova et al, 2018)

    • Characterized by:

    • Rate of bone resorption exceeding the rate of bone formation

    • Increased osteoclastic activity compared to osteoblastic activity

  • Contributing Factors:

    • Prolonged negative calcium balance

    • Decreased gonadal and adrenal function

    • Progressive estrogen deficiency

    • Sedentary lifestyle

Implications for Physical Therapy Practice

  • Significant impact on the older adult population:

    • Prevalence Statistics (2017-2018):

    • Overall prevalence of osteoporosis at the femur neck, lumbar spine, or both among adults aged 50+: 12.6%

    • Females: 19.6%

    • Males: 4.4%
      (NCHD Data Brief, 2021, www.cdc.gov/nchs/data/databriefs/db405-H.pdf)

Diagnosis of Osteopenia & Osteoporosis

  • Methods:

    • Medical history

    • Physical examination

    • Laboratory testing

    • Imaging:

    • Most commonly used diagnostic tool is the dual-energy X-ray (DEXA) scan of spine and hip

    • DEXA compares individuals' bone mineral density (BMD) to that of young normal adults of the same sex

  • T-score Interpretation:

    • T-score of -1.0 or greater = Normal

    • T-score between -1.0 and -2.5 = Osteopenia (below-normal BMD)

    • T-score of -2.5 or lower = Osteoporosis (higher fracture risk)

    • T-score below -2.5 with >1 fragility fractures = Severe osteoporosis

Screening Recommendations

  • Females:

    • The U.S. Preventive Services Task Force (USPSTF) recommends screening for women aged 65+ regardless of risk factors, and for younger women with fracture risk similar to older women.

  • Males:

    • The National Osteoporosis Foundation recommends BMD testing for men aged 70+ regardless of risk factors, and for men aged 50-70 with risk factors for fracture.

Risk Factors

  • Categories of Risk Factors Include:

    • Age: Peak bone mass occurs between 25-35 years.

    • Body build: Fragile, older females tend to have decreased cortical bone density.

    • Family history

    • Medications such as corticosteroids and anti-seizure drugs (e.g., Dilantin).

    • Gender: Higher risk in females.

    • Ethnicity: Higher risk in individuals of Northern European descent and Asians.

    • Inactivity: Reduced mechanical stresses on bones.

    • Tobacco and alcohol use.

    • Depression.

    • Diet and nutrition impacts.

    • Psychological stress: Can have overlapping pathways leading to both mental health disorders and osteoporosis.

Clinical Manifestations of Osteoporosis

  • Common Symptoms:

    • Decreased height

    • Postural changes like kyphosis with vertebral compression fractures

    • Back pain resulting from vertebral compression fractures

    • Fractures, most commonly occurring in:

    • Vertebral bodies

    • Hip

    • Radius

    • Pelvis

Vertebral Compression Fractures

  • Associated Issues:

    • Decreased quality of life and increased pain

    • Increased thoracic kyphosis

    • Compounding digestive and respiratory problems

    • Increased psychological concerns (anxiety, depression)

    • Increased mortality risk

    • Higher risk of subsequent fractures within one year

Pharmaceutical Management

  • Common Medications for Treatment Includes:

    • Bisphosphonates: First-line treatment choices that decrease bone resorption, which include:

    • Alendronate (Brand: Binosto, Fosamax) - taken weekly

    • Risedronate (Brand: Actonel, Atelvia) - can be taken weekly or monthly

    • Ibandronate - taken monthly or as quarterly IV infusion

    • Zoledronic acid (Brand: Reclast, Zometa) - annual IV infusion

    • Denosumab (Prolia): Injection every 6 months that decreases bone resorption.

    • Hormone-related therapy:

    • Estrogen therapy decreases bone resorption and increases osteoclast activity but has been less utilized due to increased cancer risk, especially breast cancer.

    • Raloxifene (Brand: Evista): Mimics estrogen effects on bone density in postmenopausal women.

    • Bone-building medications: For severe osteoporosis or if other treatments are ineffective:

    • Teriparatide (Brand: Bonsity, Forteo): Daily injections, similar to parathyroid hormone.

    • Abaloparatide (Brand: Tymlos): Daily injections, also a parathyroid hormone analogue.

    • Romosozumab (Brand: Evenity): Monthly injections, associated with significant potential side effects.

Physical Therapy Intervention Evidence

  • Review Findings:

    • Aerobic Exercise: Can prevent loss of bone density and may increase bone density; however, simple walking does not increase BMD but can prevent progressive bone loss.

    • Weight-Bearing Aerobic Exercise: At higher intensities (e.g., speed walking, jogging) can improve BMD.

    • Strength Training:

    • Increases BMD only at sites of loading.

    • Moderate intensity; high-load, low repetitions needed.

    • Progressive resistance exercise for lower limbs noted as most effective for BMD at femoral neck.

    • Multicomponent Training:

    • Combination of exercises including weight-bearing activities, balance training, high-magnitude exercises, muscle strength, and functional tasks can maintain or possibly even increase BMD, particularly in spine.

    • The combination of exercises should be tailored to the patient’s clinical presentation.

    • Consensus on Protocols:

    • No agreement exists on optimal duration, frequency, and combination of exercise types.

    • Training with Vibrating Platforms:

    • Controversial findings regarding improvement in BMD across different sites - the Osteoboost device is FDA approved for osteopenia.

Physical Therapy Examination & Evaluation

  • Assessment Components:

    • Medical history including falls, fractures, medications, and calcium/vitamin D intake.

    • Posture assessment.

    • Range of motion and flexibility testing.

    • Strength evaluation.

    • Endurance checks.

    • Balance evaluation.

    • Gait analysis.

    • Cardiorespiratory fitness measurement.

Physical Therapy Interventions

  • Recommended Specific Exercises Include:

    • Postural extension exercises to promote posture improvement.

    • Strength training targeting trunk and abdominal muscles, specifically in non-flexed positions.

    • Resistance exercises directed to the involved areas, potentially utilizing weighted vests/belts for added load.

    • Weight-bearing endurance activities such as marching, walking, low-impact aerobics, stair climbing, and dancing with appropriate equipment.

    • Balance exercises to improve stability.

    • Patient education focusing on:

    • Good body mechanics

    • Proper posture and alignment during exercises and daily activities

    • Fall prevention strategies encompassing

    • Proper shoe wear

    • Adequate lighting

    • Eliminating hazards at home

    • Use of assistive devices as necessary

    • Ensuring adequate vision.

Physical Therapy Intervention Dosing & Limitations

  • General Dosing Recommendations:

    • Focus on moderate-intensity strengthening/resistance with load, emphasizing correct alignment, at least 3 times/week.

    • Weight-bearing, endurance activities should occur 3-5 times/week (e.g., intense walking, stair climbing).

    • Expect the greatest gains in areas with the lowest bone mass and weakest muscles.

    • Recognize that as the physiological ceiling for exercise-induced improvements is approached, more effort will be required for smaller gains.

    • Consistent engagement in regular physical activity, aerobic exercise, and site-specific training is vital for maintaining strength and density improvements and preventing bone loss.

Knowledge Check

  • TRUE OR FALSE: Osteoporosis resulting from immobilization should be considered secondary osteoporosis. (A. True B. False)

  • Clinical Case Study: A patient presents with a DEXA bone scan T-score of -2.0 and no history of fractures. Document the findings in the chart. (A. Normal B. Osteopenia C. Osteoporosis D. Severe osteoporosis)

  • Risk Factors Consideration: Which of the following factors should be considered a risk factor for osteoporosis? (A. Psychological stress B. Black racial background C. Overweight or obese BMI category D. Regular marijuana use)

  • Common Fractures: Which of the following bones is the most commonly fractured in individuals with osteoporosis? (A. Wrist B. Hip C. Spine D. Pelvis)

  • Medication Usage: TRUE OR FALSE: Bone-building medications like Forteo are typically utilized first in the treatment of osteoporosis. (A. True B. False)

  • Exercise Frequency: TRUE OR FALSE: Walking slowly on level surfaces does not increase bone density but can prevent progressive bone loss. (A. True B. False)

  • Exercise Guidelines: At a minimum, how often should a person with osteoporosis perform moderate-intensity strengthening exercises to improve bone mineral density? (A. 1 time/week B. 2 times/week C. 3 times/week D. 4 times/week)