O R I G I N A L A R T I C L E
U. Lange ÆJ. Teichmann ÆC. Uhlemann
Current knowledge about physiotherapeutic strategies in osteoporosis prevention and treatment
Received: 21 January 2004 / Accepted: 23 August 2004 / Published online: 27 November 2004 ÓSpringer-Verlag 2004
AbstractIn treating patients with osteoporosis, one op- tion in physiotherapy is to comply with given physical norms by using physical stimuli to influence biological functions and structures (bone, muscle) for adaptation, stimulation, and regeneration. Serial physical stimuli can also be used for interventions and actions to minimise pain perception by means of biopsychosocial influence.
In osteoporosis, physiotherapy has to be rated on a par with pharmacotherapy with respect to prevention, cure, and rehabilitation. Generally, two different aims can be defined: (1) those which can be achieved with physical therapy alone, such as structural improvement of the existing and pharmacologically increased bone tissue, slowing down of round-back formation, and fall pro- phylaxis and (2) those which can be achieved with physiotherapy and pharmacotherapy, such as effective pain relief and increased bone density. Regulation and normalisation of physical capacities with an aim towards maintenance and economisation of functions and improvement in abilities call for a skillful and case-spe- cific use of physiotherapy.
Keywords Physical exerciseÆPhysiotherapyÆ Osteoporosis
Introduction
This article cites several studies on exercise and physiotherapy in preventing and treating osteoporosis.
Physiotherapy for this disorder is essentially diagnos- tically oriented, stimulative, preventative, curative, and/or rehabilitative, whereby the choice and dosage depend upon the desired results. The implemen- tation of physiotherapeutic strategies is necessary and of great importance in the treatment of osteo- porosis.
Physical activity, exercise, and bone
Exercise plays an important role in the prevention and treatment of osteoporosis. The aims and objectives of physiotherapy and sport therapy are increased bone substance, pain alleviation, and fall prophylaxis. There has never been and never will be a randomized, dou- ble-blind, placebo-controlled study demonstrating that physical activity/exercise in youth, adulthood, or old age reduces fragility or osteoporosis-related fractures in old age. The most easily demonstrated interaction between physical activity and bone mass is the sub- stantial bone loss that follows complete immobilisation such as that attending spinal cord injury. Immobilised patients may lose 40% of their original bone mass in 1 year, whereas studies on bed rest indicate that standing upright for as little as 30 min each day pre- vents bone loss [1].
Role of exercise in fracture prevention
It is widely believed that physical activity is beneficial to the skeleton. Therefore, exercise has been promoted as a means of preserving skeletal health and preventing age- related fractures [2]. Physical exercise is associated with improved muscle strength, coordination, and balance, and there is compelling evidence that it modifies risk factors for falls.
It is unnecessary to describe in detail the innumer- able extraskeletal effects of physical exercise, particu- larly with respect to the improvements in circulation,
U. Lange (&)
Department of Rheumatology, Kerckhoff Clinic and Foundation,
Sprudelhof 11, 61231 Bad Nauheim, Germany E-mail: U.Lange@kerckhoff-klinik.de J. Teichmann
Medical Clinic C, City Hospital, Ludwigshafen, Germany C. Uhlemann
Institute of Physiotherapy, Jena University, Jena, Germany DOI 10.1007/s00296-004-0528-z
coordination, general well-being, sleep, social contact, and even prevention of infectious disease [3]. These all contribute to better quality of life and may also indi- rectly reduce the risk of falls and fractures [4].
Assuming that a large proportion of osteoporosis fractures are a consequence of traumatic falls and not spontaneous, preventive measures against osseous weakness are best directed toward counteracting mus- cular weakness, improving agility, and correcting visual impairment.
There are several mechanisms by which exercise may reduce the incidence of age-related fractures. There is no doubt that fitness programs begun in childhood have a positive effect on bone geometry, mass, and mineral density. The beneficial effect of exercise on bone mineral density can best be seen during growth.
Higher bone mineral density is the result of surface- specific, periosteal modeling, increasing bone size and endosteal (endocortical, trabecular, intracortical) sur- face modeling and remodeling, producing thicker cor- tices [5]. Whether the cortices are made less porous (due to few or smaller Haversian canals) is uncertain. The exact mechanical stimuli and corresponding transduc- tion to cellular activity that trigger bone remodeling are not known. Therefore, we do not yet know what type, duration, and intensity of loading will produce the greatest osteogenic stimulus. To examine the influence of physical activity on bone mass, however, it is important to understand how physical activity con- tributes to the mechanical loading of specific skeletal tissues.
In young adults, exercise may increase peak bone mass, thereby lowering the risk of fractures later in life.
Secondly, in early menopausal women, exercise may attenuate the rapid bone loss associated with estrogen deficiency. Finally, exercise in older adults may retard age-related decreases in bone mass, reduce the incidence of falling, and decrease the severity of falls.
The belief that exercise reduces fractures is derived from lower levels of evidence, namely retrospective and prospective observation cohort studies and case-control studies. They are all subject to many systematic biases and should be interpreted with extreme skepticism, and the counterclaim (null hypothesis) that exercise has no effect on fracture risk can not be rejected.
Fractures and exercise in women
Several studies show that individuals with lower preva- lence of past or current physical activity are at increased risk of hip fracture [6, 7] and that daily standing, stair climbing, and walking are associated with lower risk [8, 9]. A longitudinal study of osteoporotic fractures [6] and some prospective studies [10, 11, 12, 13, 14] demon- strated that physical activity was protective. The longi- tudinal European Vertebral Osteoporosis Study reported a prospective effect of current exercise in warding off vertebral fractures [15].
Fractures and exercise in men
A protective effect of vigorous physical activity/exercise in warding off hip fractures was demonstrated in the Leisure World Study [11], a longitudinal study, and in three other prospective studies [12,13,14].
Physiotherapeutic strategies in osteoporosis
Physiotherapy for the osteoporosis syndrome per se does not exist. However, physiotherapeutic strategies in the prevention and therapy of manifest osteoporosis have to be considered not as an alternative but as equivalent, supplementary, and necessary treatment. Patients who do not receive physiotherapy are denied effective treat- ment.
For methodic as well as ethical reasons, there are no results available from random clinical studies on the effect of differential vs indicative physical therapy for osteoporosis patients. It must be noted in this respect that there is considerably less evidence in particular for methods in physical medicine than for many medica- tions. Controlled or placebo-controlled studies are much more difficult to carry out. For centuries, there has been a certain amount of empirical data supporting the effectiveness of physical therapeutic interventions and, to date, the beneficial effect of these methods has not been disproved.
Physiotherapy offers the possibility of influencing local phenomena (i.e. pain, malfunction), functional regulating systems, and the patient as a whole using physiological stimuli. With regard to osteoporosis, this means that the localised use of equipment will bring about improvement. Therapy can influence the regulat- ing systems in cases of osteoporosis; it improves mobility and flexibility through repeated stimulation and induces adaptation. Repeated hydrotherapy and ultraviolet light treatment can have a strengthening effect.
Massage, group physiotherapy, and body awareness training are helpful for improving well-being, self-con- fidence, and ability. Special goals of physiotherapy in cases of osteoporosis include corrective strategies with regard to body posture and movement, stimulation by actively increasing muscle use, and eliminating distur- bances in bone metabolism. For the latter, elimination or at least reduction of pain takes absolute priority.
In the use of physiotherapy to reduce pain, differen- tiation must be made between the kinds of pain experi- enced. Nociceptive pain needs physical stimulation, which influences mainly the chemical composition of body fluids; neuralgia pains require stimulation, which will achieve a positive neuralgic reaction; whilst in psy- chosomatic cases it is necessary to employ measures to treat the patient as a whole. Active mobilising therapy and physiotherapy have common and diverging ele- ments within the treatment of osteoporosis and must be used in accordance with the physical ability of each
patient. Physiotherapy for osteoporosis is essentially diagnostically oriented, stimulative, preventative, cura- tive, and/or rehabilitative, whereby the choice and dos- age depend upon the desired therapy result.
Physiotherapy of the osteoporosis syndrome—special aspects
Whereas the World Health Organisation definition of osteoporosis is essentially oriented to the mechanical functions of bone, physical medicine relies on a diag- nosis of osteoporosis based on morphological and functional aspects.
The specific pathogenetic process of osteoporosis actually proceeds painlessly [16,17, 18]. It is the result- ing conditions that are responsible for the adverse effects in these patients. Only exact differentiation of the cause of the pain can ensure the correct and most physiolog- ically effective form of physiotherapy, due to different levels of severity, manifestation forms, and complica- tions of osteopenia and osteoporosis.
Identification of the osteoporosis pain
Pain identification and pain perception regarding etiol- ogy (dysfunction, destruction, degeneration) and pathomechanism (mechanical, chemical, psychosomatic maltension) are of essential importance. The optimal physiotherapeutic treatment can be found only when exact differentiation of the pain is made (nociceptive, neurogenic, or psychosomatic).
Nociceptive osteoporosis pain shows as a receptor pain in the cords, tendons, muscles, periosteum, inter- vertebral disk, and capsule, whereas neurogenic pain appears from irritation of the spinal cord and the nerve root or peripheral nerves. Psychosomatic pain, however, shows as ‘‘comprehensive psychophysical maltension’’
with changing localisation [19].
Differential physiotherapy
Physical pain therapy includes electric (direct current, low-frequency stimulation current), thermic (hydro- thermic, high-frequency or short-wave thermic, ultra- sound, light-thermic, red light), and mechanical (massage, physiotherapy) stimuli which can be applied regionally, locally, or comprehensively [20, 21]. Effi- cient pain therapy requires that a differentiation be made between acute and chronic pain episodes [22, 23]. Whereas physiotherapy in cases of acute pain demands immediate therapy (normally rest and mild cold applications), in chronic pain it requires adaptive performance therapy of neuronal structures (formative-adaptive physiotherapy, improving trophic thermotherapy, direct current, transcutaneous electric nerve stimulation [TENS]).
Nociceptive pain
Nociceptive pain is apt to be aggravated by axis and exercise loads, whereby the intensification typically does not occur until later as an episode of ‘‘afterpain’’.
According to Senn [24], it is also defined as an irritational syndrome (mechanically and metabolically caused inflammation) of the mesenchymal tissue; it has a dys- trophic effect on all structures and can be the late reac- tion to a phase of increased strain (decompensated strain syndrome). Physiotherapy in this case involves consistent easing of strain on the spine, which entails decreased axis loading, alleviation of physical strain, and mild cryo- therapy (e.g. cold compresses) several times a day.
Acute osteogenic pain, caused by micro- and mac- rofractures or strain-related, extremely high bone resorption, frequently occurs during the night [25]. Here, pharmacotherapy is given top priority, but physiother- apeutic measures include relief positioning and mild cryotherapy several times a day (e.g. cold air at 30°C and 300 l/min for 10 min or cold compresses).
Chronic bone pain responds well to mild thermo- therapy (e.g. 38°C peloid) and active remedial exercise (muscle detonisation, stabilising measures) [21, 26].
Ultrasound (diathermal process), by means of deep warming, results in stepped-up tissue metabolism, hy- peraemia, increased elasticity of connective tissue fibres, and tissue trophic improvement [27]. Primarily, an in- crease in pain is made possible which secondarily leads to relief of pain. Furthermore, by means of an adequate dose of ultrasound (0.7–1.2 W/cm2, 10 min per region, 10–15 treatments), local stimulation of osteogenesis can be induced by mechanical action on the piezoelectric potential of the bone. The application of low-frequency ultrasound dominates the mechanical components of therapy and is definitely more relevant than high-fre- quency ultrasound in the context of osteoporosis as a means of influencing the disturbed remodeling process [28,29].
In tendomyoses (pains along the muscle chain), early- morning-onset pain is a salient feature [30]. In this case, specific physiotherapeutic measures include special massage techniques (friction), remedial exercise therapy, (postisometric relaxation), short-wave, ultrasound, and TENS. Here, the treatment of trigger points by means of
‘‘dry needling’’ (intramuscular stimulation) has proven to be sufficient as well [31].
Neurogenic pain
Especially the treatment of neurogenic pain calls for physiotherapeutic measures that elicit neural, pain- blocking mechanisms and result in analgesia [21, 26].
Pain is projected into the receptor or autonomic region (dermatome, myotome, sclerotome). The predominant physiotherapeutic procedures for treating this type of pain are cryotherapeutic stimuli of short duration (no
longer than 3 min!), low-frequency electric stimuli (TENS), and special connective tissue massage tech- niques. A certain analgetic potency is ascribed to direct current applications, which can be explained by the depletion of neuropeptides (substance P, calcitonin gene- related protein), comparable to the operating mecha- nism of capsaicin [32].
Psychosomatic pain
Anamnesis in osteoporotic cases consists essentially in the determination of psychosomatic pain (nonlocalis- ability, resistance to therapy, accompanying psychoveg- etative instability, signs of autonomous dysregulation) [19]. Osteoporosis patients have a sense of suffering that makes secondary, reactive, psychogenic affects seem plausible.
In contrast to complaints which can be localised, psychosomatic complaints can be addressed with holistic physiotherapeutic measures such as thermoneutral immersion, training in body perception, therapy according to Schaarschuch-Haase, progressive muscle relaxation according to Jacobson, concentrative relaxa- tion, and psychophysical detonisation by means of whole-body massage. At play here are a primary sense perception that triggers physical stimuli and a hedonic, emotional experience as holistic therapeutic agents [33].
Figure1shows the different physiotherapeutic measures for osteoporosis pain from chiefly the curative aspect.
Role of exercise in preventing and treating osteoporosis
Data from retrospective and prospective observational and case-control studies suggest that physical activity
is associated with reduced fracture risk and is benefi- cial to the skeleton [2, 5, 34, 35]. There are several mechanisms by which exercise may reduce the inci- dence of age-related fractures.
Exercise is associated with improved muscle strength, coordination, and balance. The exact mechanical stimuli and corresponding transduction to cellular activity that trigger bone remodeling are not known. Therefore we do not yet know what type, duration, and intensity of loading produces the greatest osteogenic stimulus.
It is frequently observed that the bone mass of trained athletes exceeds that of nonathletic controls. A few investigators have found positive relationships between lifelong physical activity patterns and bone status [36, 37]. For instance, osseous hypertrophy has been noted in the lower arm region of tennis players [38] and squash players [39] and in the lumbar spine in joggers. According to existing studies, an increase in bone density of approximately 26% is possible on certain localisations of the osseous skeleton as a result of physical exercise [40].
Longitudinal studies have also provided evidence of the positive effect of exercise on bone mass [41, 42, 43, 44]. The increase in bone density, however, is dependent on the kind, duration, and intensity of exercise as well as age, sex, and genetic disposition.
Nevertheless, it must be noted that a reduced rate of fractures in general has not been reported for athletes [45, 46]. An interesting detail in a comparative study of rural and urban populations in the context of physical activity’s effect on bone mass is the discovery that the prevalence of osteoporotic fractures was considerably lower among hard-working country people [47].
Fig. 1 Different physiotherapeutic measures for osteoporosis pain
Influence of sport and physical activity on the risk of falling
Physical training has several benefits for older people: it stabilises circulation and improves their ability to react properly if they stumble or fall, concomitantly reducing the risk of falling and rate of fractures [48]. Along with seeing that older people pursue appropriate exercise programmes, the additional intrinsic (e.g. blood pres- sure, pulse, cerebral ischaemia) and environment-related risk factors for falling should be reduced. It has been possible to achieve considerable improvement in balance and risk of falling by means of special heart exercise therapy or Chinese training programmes [49].
Physical activity as a therapeutic measure
Physical activity is the appropriate stimulus for the formation of biological tissues and their functions.
Structurally appropriate, measured motor stimuli are necessary for the elementary structures of the nerve/
muscle/bone motor system to elicit formative, adaptive mechanisms. The nature of remedial gymnastics in the context of osteoporosis is to regulate motor function, improve structure, and educate about movement [21,50].
Muscle traction and pulsating pressure are the ther- apeutic elements that must be applied with remedial gymnastics and sport therapy [51, 52, 53, 54], whereby the type of exercise, intensity of physical therapy, and time structures (duration, intervals) must be geared to the functional condition of the motor system and structural quality of the bone (previous fractures, cor- ticoid therapy!) [55,56,57,58,59]. Randomised clinical studies on the effect of physical therapy exercises on osteoporotic women provided evidence that, compared to no physical exercise, regular endurance training (even normal walking), weight lifting, and heavy exercise led to increased bone density and reduced fracture risk in women of all age groups [60].
The best everyday activities or types of sport for the bones are those that defy gravity. These include climbing stairs and normal walking; good types of sports are cy- cling, jogging/running, cross-country skiing, dancing, mountain climbing, and moderate weight lifting [61].
Weight lifting exercises are best suited to increasing bone density [62].
In contrast to endurance training, aerobics [63], walking, and tap dancing, heavy exercise has no influ- ence on bone density in the femoral neck region [64].
Neither had swimming (‘‘weight-relieving’’) proved to be effective in increasing bone density [65]. There is suffi- cient evidence today that intensive athletic activity in relation to bone loading has a specific influence on the osteogenic effect in the bone region in question.
In light of remedial gymnastics, dynamic stabilisation involving antigravitation with additional pressure on the
body structure (weight bearing) [51,66,67] corresponds to the formative mobility goal. It is furthermore expe- dient to influence local muscle activity purposefully with moderate muscle-strengthening remedial and holistically orientated exercises in keeping with the aims of sport therapy to increase aerobic endurance (fitness) and axis loading to benefit so-called positive trophic bone factors [51, 54, 68]. The positive correlation between muscle strength, physical activity in the context of normal life style, and bone quality has been thoroughly investigated and confirmed [51, 66, 69, 70]. Negative correlations have also been found in cases of inappropriate exercise modes (improper stress and strain) [59, 68,69,71].
Self-help therapy groups for osteoporosis patients have importance particularly psychologically (orienta- tion to physical experience, cognitive therapy partici- pation, and ability). Patients in such groups gain, among other things, motivation to deal with the course their illness has taken, and they receive support in undertak- ing the self-help they need to cope better with everyday life [33, 72]. It is essential that these patients receive instruction in ‘‘proper’’ movement behavior at home, at work, in their spare time, and during athletic activities.
All level-arm movements (torso bending) and kyphotic movements under strain must be strictly avoided, as with jumping exercises, sit-ups, trunk rotation and/or lateral flexion of the spine, and excessive muscle stretching and strengthening movements [17,59,71,73].
Ambivalence characterises the discussion regarding the value of remedial gymnastics in correcting the typical spinal deformations and its role in fracture prophylaxis.
On the one hand, there is the option to improve the upright posture of pelvis and thorax with muscular stabilising techniques and to improve fall prophylaxis through coordination training; on the other hand, these methods have limitations due to pain, progression of the pathogenic process, lack of adaptation capabilities and regulative functions, and age-related reduction of sen- sorimotor abilities [55, 56,74]. Corticosteroid osteopo- rosis and advanced stages of the osteoporotic deformation process both necessitate a differentiated application of remedial gymnastic techniques to bring about a reduction of unnatural strain on the bones.
Holistic tension exercises below the pain threshold, in contrast, are to be recommended [57,58,75].
Isometric muscle tension movements (isolated or in function chains) and proprioceptive neuromuscular facilitation techniques imply for the osteoporosis patient a necessary stability of the motor system [75]. In order to influence the disturbed remodeling process adequately, structurally formative pressure stimuli in the direction of the axis (axis loading) along with isometric traction are essential [54, 60, 68]. Elastic corsets are to be recom- mended if the parameters of the remedial gymnastic measures are limited by the pathogenetic process. In the case of vertebral fracture, providing a corset corre- sponding to the extent of damage is an absolute neces- sity [53]. In the context of osteoporosis, remedial gymnastics and sport therapy have similarities as well as
differences [76]. Whereas remedial gymnastics are pre- dominantly symptom- and syndrome-orientated, sport therapy is directed towards influencing systemic (whole) physical performance.
The relevance of physiotherapy consists on the one hand in sufficiently alleviating pain. It also involves influencing disturbed muscular tension, supporting sta- bilisation (correction of posture problems) by muscle strengthening, and coordination exercises along the lines of fall prophylaxis and training for activities of daily life.
In fall prophylaxis, consideration must be given firstly to elements of the physiological ageing process (bent pos- ture, little steps, reduced balancing reaction) and sec- ondly to the osteoporosis-specific incorrect posture and faulty body mechanisms [24]. The techniques for fall prophylaxis include easy balancing exercises in water (to practise erect posture, walking, and fall behavior, as well as training of static balance (therapy spin, balancing seesaw) and dynamic balance (exercises with partners, balancing over a gymnastic bench).
Specific training programmes geared to remodeling under axial weight bearing are the domain of sport therapy. Especially movement in water has special sig- nificance for the osteoporosis syndrome due to the physical singularities of the medium water and the resulting influences on the physiological regulatory sys- tem [77]. Buoyancy due to the minimisation of gravity brings about an adjustment in proprioception that cor- responds to a relief of strain on structures of the motor system. (Additionally, bone stimulation from gravita- tion is thus lost.) Thus it is possible to exercise joint mobilisation without strain and the accompanying pain, which can only be alleviated through the thermic com- ponents of water. An additional option is movement free of fear without increased risk of falling. Furthermore, by varying the viscosity of the immersion medium, tactile stimulation of the skin contributes to body perception, and moderate muscle training through dynamic stabili- sation (movement against the resistance of the medium) is also possible.
Recommendations for physical activity
In the holistic concept for the prevention and therapy of osteoporosis, there are still no exact qualitative or quantitative minimum standards for sports activity programmes. In the case of osteoporosis of the spine, it is generally recommended that strain on the ventral side of the spine be avoided and that strengthening of the back extensors be effected. Hiking, cycling, dancing, and swimming are considered to be suitable types of sport activities. A current survey publication contains general suggestions for the type and intensity of physical activity depending on the degree of osteoporosis. These recom- mendations correspond to those of the German Society for Sports Medicine and the American College of Sports Medicine, especially in regard to endurance, strength, flexibility, and coordination exercises.
It is of great importance, however, to note the par- ticular needs of persons with reduced bone mass before therapy goals are set. The major criteria for active osteoporosis therapy include the preservation and/or increase of bone mass, reducing the risk of falling, alle- viation of pain symptoms, communication, and normal, everyday fitness.
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