Key words: Exercise, Osteoporosis, Prevention

Introduction

The aim of this blog piece is to give an overview of the disease process of Osteoporosis and the importance of exercise prescription in the management of this condition. This can make patients feel more comfortable discussing exercise and alleviate  concerns of sustaining fractures from being active.

Osteoporosis

Osteoporosis is a condition of reduced bone mineral density that has an estimated prevalence of 10% in those over 50 years old and rising with age [1]. It is more common and occurs earlier in females due to reduced oestrogen circulating after the menopause [2]. The condition does not infrequently go undiagnosed until a low impact fragility fracture occurs. Common locations for these include the hip, spine and humerus [3]. These fractures can have a significant impact on morbidity and mortality – 16-36% 1 year mortality rate in hip fractures [4]. Additional complications range from chronic pain to mental health disorders with an impact on quality of life [5]. 

The diagnosis may  stem from an initial fracture, which can occur from activity and abnormal loading activity, including low impact trauma.  A DEXA scan may be requested where a T-score is calculated which measures bone density [5].

Given the mechanism of injury, patients may lose confidence and be concerned to exercise due to fear of further injury leading to further morbidity due to inactivity [3].  However, evidence points to controlled and safe activity for these patients promotes bone health through increasing turnover, developing strength and balance to help protect bones as well as reducing falls [6].

How to Exercise

• One of the key takeaways for patients and practitioners is that bones need to be both stimulated to strengthen, but also protected. This comes from safe weight bearing activity as well as strengthening exercise [1].
• Impact exercise is safe, with higher impact being better for bones. This may be something patients can build towards from initially starting with hydrotherapy, progressing walking/running/jumping. It is important to consider relevant risk factors including any previous spinal fractures, other injuries or medical co-morbidities that impact exercise tolerance [8]. 
• Muscle strengthening exercise stimulates bone regrowth but also gives the bones more protection. There are multiple ways to do this, including body weight exercises, resistance bands or moving to free weight training. This can also be built up slowly with exponential benefit to patients [8].  
• In line with chief medical officer guidelines, adults should aim for 150 minutes of moderate intensity exercise per week. It is recommended to incorporate strength and balance training 2 to 3 days per week. Each session should last 30 minutes, aiming for lower weights with higher repetitions for the most physiological benefit. Avoiding prolonged sedentary periods is recommended [7].
• It is recommended for patients looking to initiate activity, do so with the guidance of a trained practitioner/trainer [9]. This would be following a holistic clinician review by optimising chronic health conditions, sensory impairment and medication review.
• Read part 2 of our blog in January for an example     

Benefits to patients 

• Improved balance thus reducing falls and subsequent injury [10] 
• Improvement in overall quality of life by finding enjoyment in new activities and improving social support
• Improved confidence
• Reduction in severity and progression of overall frailty in the context of a comprehensive geriatric assessment [1]  
• Improvement in management/prevention of co-morbidities e.g. diabetes
• Improvements in posture and subsequent improvements in pain control[7]

Conclusions

1. Being physically active brings a huge range of benefits to the health of those with osteoporosis
2. Bone health and turnover significantly improves with safe and appropriate prescription of exercise
3. Taking a holistic approach to reviewing patients in relation to the cause of their falls is paramount. Optimising chronic health conditions, nutrition and medications is crucial alongside exercise prescription.

Authors:

Dr Callum Innes MBChB, MFSEM (UK) – University of Bath

Dr Andrew Shafik – Professional Development Advisor, University of Bath

Dr Malin Farnsworth – Frailty Consultant, Epsom and St Helier University Hospitals NHS Trust

References

1. Sabri, S.A., et al., Osteoporosis: An Update on Screening, Diagnosis, Evaluation, and Treatment. Orthopedics, 2023. 46(1): p. e20-e26.
2. Cosman, F., et al., Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporosis Int, 2014. 25(10): p. 2359-81.
3. Brooke-Wavell, K., et al., Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine, 2022. 56(15): p. 837-846.
4. Morri, M., et al., One-year mortality after hip fracture surgery and prognostic factors: a prospective cohort study. Scientific Reports, 2019. 9(1): p. 18718.

5. Clynes, M.A., et al., The epidemiology of osteoporosis. Br Med Bull, 2020. 133(1): p. 105-117.
6. Suzuki, N., O. Ogikubo, and T. Hansson, The course of the acute vertebral body fragility fracture: its effect on pain, disability and quality of life during 12 months. Eur Spine J, 2008. 17(10): p. 1380-90.
7. Foundation, I.O. Exercise for Bone Health and Osteoporosis. 2020  16/08/24]; Available from: https://www.osteoporosis.foundation/sites/iofbonehealth/files/2022-10/exercisebrochure_web_1.pdf.
8. Society, R.O. Exercise and Physical Activity for Osteoporosis and Bone Health. 2024  15/08/24]; Available from: https://theros.org.uk/information-and-support/osteoporosis/living-with-osteoporosis/exercise-and-physical-activity-for-osteoporosis/.
9. O’Halloran, P.a.B., Gurjit, Exercise Prescription in Health and Disease. 2012. p. 98.
10. Medicine, M. Evidence Finder: Falls and Frailty. 2024  16/08/24]; Available from: https://scotland.movingmedicine.ac.uk/why-movement-matters/evidence-finder/.