Exercise for Bone Health Part 1: What You Need to Know
Have you been diagnosed with Osteoporosis or Osteopenia (OP)?
Not knowing the in’s and out’s of how these low bone density conditions are best managed may seem a bit daunting, especially with all the scary information out there.
Yes, small knocks or falls can result in a fracture and yes precautions need to be taken when engaging in certain forms of exercise.
Unfortunately this information can instill more fear, making you more reluctant to move, which will only hinder you more.
With the following information our goal is to educate you on Osteoporosis and empower you to exercise with confidence.
Before you read ahead, I am going to give you the key take-away message - you are unique and the following information needs to be applied to your current situation, with consideration to your health history, movement history and OP risk factors.
Not everything below applies to YOU. If you have any questions or queries about how this information applies to you please reach out. You can contact me here.
Osteoporosis and Osteopenia affects 2 in 3 Australians over the age of 50, and with an ageing and increasingly sedentary population it is something we are going to see more of.
This is why it is so important that we educate ourselves and those we care about, on all the little things (and big things) we can do minimise and prevent the occurrence or progression of this disease.
So what is Osteoporosis exactly?
It is a condition in which bones become fragile, leading to a higher risk of fractures (or breaks) than in normal bone.
Osteoporosis happens when your body gets rid of more bone than it is creating. When bones lose minerals, such as calcium, more quickly than the body can replace them, leading to a loss of bone thickness (bone mass or density).
As bones become thinner and less dense even a minor bump or fall can result in a fracture. Common fracture sites include: lumbar spine, hip, wrist (but can affect any bone).
What is Osteopenia? What is the difference?
Osteopenia is also known as low bone density. This is the range of bone density between normal and diagnosed osteoporosis, which means you need to take action to support your bone health.
If it happens at all, it usually occurs after age 50. The exact age depends how strong your bones are when you're young. If they're hardy, you may never get osteopenia. If your bones aren't naturally dense, you may get it earlier. Your bones are usually at their densest around the age of 30.
Does a diagnosis of Osteopenia mean you will get Osteoporosis?
Having low bone density or osteopenia does not mean you will get osteoporosis. It means you have a greater chance of developing osteoporosis if you lose bone in the future.
Key Numbers for Osteoporosis in Australia
2.2 million Australians are affected by osteoporosis
11% of men and 27% of women aged 60 years or more are osteoporotic
42% of men and 51% of women are osteopenic
Lifetime risk of osteoporotic fracture after 50 years of age: 42% in women, 27% in men.
20,000 hip fractures per year in Australia (increasing by 40% each decade).
Total costs relating to osteoporosis are $7.4 billion per year of which $1.9 billion are direct costs.
Osteoporosis and Hip Fractures
Hip fractures are a common injury resulting from falls in the ageing population. Those who sustain a hip fracture are more than 3.5 times more likely to die within 12 months compared to their non-injured counterparts. The excess mortality risk at 12 months was higher in males than in females.
This is a scary statistic!
What can we do about this? Stop the Fracture Cascade!
The risk of future fractures rises with each new fracture - the “cascade effect”. Research has shown that women who have suffered a fracture in their spine are over 4 times more likely to have another fracture within the next year.
Early diagnosis is essential to prevent further fractures!
What causes Low Bone Density?
There are many causes, which can be grouped into four categories.
Family history is a key risk factor (non-modifiable)
Many lifestyle factors
Associated with certain diseases/conditions and medications
Physical Factors include:
Low physical activity or immobility
Low body weight
Low muscle mass and strength
Protein or calcium undernutrition
Lifestyle factors include:
Alcohol > 2 standard drinks/day
Vitamin D insufficiency
Diseases or Conditions with Increased Risk include:
Chronic kidney disease
Coeliac disease or malabsorption
Myeloma or MGUS
Medications that Increase Risk include:
Excess thyroid hormone replacement
Anti-epileptic medications (e.g. Gabapentin)
How is Osteoporosis or Osteopenia diagnosed?
One must have a bone scan, known as a DEXA Scan (Dual-energy X-ray absorptiometry), which estimates the thickness of your bones, specifically your hip and lumbar spine (and sometimes your wrist). This will provide a T-score which will then determine where you are on the spectrum of normal bone density to osteoporosis.
Normal = -1.0 or above (e.g. 0.9, 0, -0.9)
Osteopenia = Between -1.0 and -2.5 (e.g. -1.1, -1.6, -2.4)
Osteoporosis = -2.5 or below (e.g. -2.6, -2.9, -3.4)
Who should have a bone scan?
The National Osteoporosis Foundation (NOF) recommends that you have a DEXA scan if you are:
A women age 65 or older
A man age 70 or older
You break a bone after age 50
A woman of menopausal age with risk factors
A postmenopausal women under age 65 with risk factors
A man age 50-69 with risk factors
This is the only test to diagnose osteoporosis and tells you if you have normal bone density, low bone density (osteopenia) or osteoporosis.
Having a bone density scan will identify if you have weak bones before you have a break and predict your chance of breaking a bone in the future. It will also tell you if you have Osteoporosis after having a fracture.
Ongoing scans will also identify if your medications are working - therefore assessing any change in bone density.
You should also consider having a bone density scan if you have:
An X-ray of spine showing a break or bone loss
Back pain with a possible break in your spine
Height loss of ½ inch or more within one year
Total height loss of 1 ½ inches from your original height
So you have been diagnosed with Osteoporosis and/or Osteopenia. What are you treatment options?
The most important thing is that osteoporosis is detected as early as possible to ensure bone health is managed to prevent future fractures.
Getting adequate calcium and vitamin D and exercise are essential to improve and maintain good bone health. Lifestyle changes may also be recommended - e.g. to stop smoking and avoiding excessive alcohol intake.
Your doctor will be best placed for a medical review of any risk factors and any other diseases and medications which may impact bone health. Your bone health will need to be monitored closely with regular bone scans every 1-2 years when taking medication. Based on your T-scores and risk factors, you and your doctor will decide if and when you need to take medication. There are a range of medications available in Australia.
When should you commence treatment?
As mentioned above, early detection is the most important factor in managing this condition. Based on your risk factors and lifestyle factors, you can get started on those first - change may be hard, but it will be worth it!
Based on the results of your bone density scan your doctor will make a recommendation if you should be taking medication.
They will also consider risk factors for osteoporosis, your likelihood of breaking a bone in the future, your medical history and current health.
Knowing your risk fracture risk for risk of fracture in the next 10 years is also important, as it helps to identify people who have a greater chance of breaking a bone and those that may benefit from taking medication. There is an online fracture risk assessment tool FRAX®.
FRAX® is a great tool that can help identify those individuals who have a greater chance of fracture and those that may benefit from taking medication.
Treatment Guidelines Postmenopausal Women 50 years and Older (set by the National Osteoporosis Foundation)
T-score -1.0 and above = no medication
T-score between -1.0 and -2.5 (low bone density or osteopenia) with certain risk factors should consider taking medication
T-scores of -2.5 and below (osteoporosis) should consider taking medication
Falls and Bone Health
Preventing falls is a big part of managing bone health as even minor falls can result in a broken bone for those living with OP. Falls most often happen at or around the home and 6% of these result in a broken bone.
Why do falls happen?
Reduced strength and balance, declining vision, low blood pressure, medications and tripping hazards around the home.
To minimise falls we would recommend:
Exercise. Seeing a Physiotherapist or Exercise Physiologist is essential. They can assist with a falls prevention program and recommend any community-based programs. Exercise programs should include: resistance training and balance exercises
Schedule a Medical Review. This is important. Your doctor can assess for any conditions or medications that may contribute to increased dizziness or poor balance. They may recommend you see an Optometrist to correct vision, a Podiatrist for proper footwear or a Dietician to ensure adequate Calcium and Vitamin D intake.
Home assessment. An occupational therapist may make recommendations for handrails, non-slip strips for the bathroom and stairs and ensure all rooms are well lit and trip hazards are removed.
Exercise for Bone Health Part 2: Optimising Bone Density Through Exercise
Giaongregorio, L. M., Papioannou, A., MacIntyre, N. J., Ashe, M. C., Heinonen, A., Shipp, K., Wark., J., McGill, S., Keller., H., Jain, R., Laprade, J., Cheung, A. M. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int. (2014). March 2014; 25(3): 821-835.
Giaongregorio, L. M., McGill, S., Wark., J.,Laprade, J., Heinonen, A., Ashe, M. C., MacIntyre, N. J., Cheung, A. M., Shipp, K., Keller., H., Jain, R., Papioannou, A. (2014). Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporos Int. (2015). March 2014; 26(3): 891-910