Exercise & Nutrition

for
Osteo porosisDamayanti T
Department of Physical Medicine & Rehabilitation
School of Medicine Airlangga University/
Dr. Soetomo General Hospital

1
0 10 20 30 40 50 60 70 80 90 100

Growth Maturation Menopause Senescence

Genetic factors

Body build. Lifestyle.

Nutritional status

Menopause

Disease
Risk factors
Age-associated hormonal
changes

Minor injuries (fall)

Peak bone Decreases in bone Increase in susceptibility

Bone mass mass mass to fractures

0 10 20 30 40 50 60 70 80 90 100
Age (year)
Accumulation of risk factors for osteoporosis over time 2
 Nutrition deficiency Bad habit
(Calcium, Vit D) (Alcohol use, smoking)
Decreased Underweight
History of
estrogen
prior fracture
Immobilization

Age > 50 years Cellular

activity
Female gender Vertebral body
Trabecular Subregio- integrity
Caucasian race architecture nal BMD Vertebral
Positive family history geometry
Macros
External Bone properties
loads properties

Global
environ-
ment

Body
position

Local
environ-
Intervertebral ment Muscle force
disc integrity & strength 3
Neuromuscular control
 Loss of Quality of Life Years in Osteoporosis
Event QALYs Lost Rationale
Due to Event
Hip fracture
Acute event 0.0833 Complete loss of quality of life for 1 mo (=1/12)
Rehabilitation or short stay 0.0237 Complete loss of quality for 9 days (=9/365)
hospital (9 days)
Readmitted (8 days) 0.0219 Complete loss of quality for 8 days (=8/365)
Home care services (6 mo) 0.25 Quality of life reduced by 0.5 for 6 mo (=0.5x6/12)
Nonmedical home care (6 mo) 0.25 Quality of life reduced by 0.5 for 6 mo (=0.5x6/12)
Post-hospital physician visits 0.011 Quality of life reduced by 0.5 for 8 days
(=0.5x8/365)
ER, ambulance 0.0027 Complete loss of quality for 1 day (=1/365)
Wrist fracture, acute event 0.0404 Quality reduced by 0.3 for 7 wk (0.3x7/52)
Vertebral fracture, acute event 0.0324 33%: clinically silent with no loss of quality
57%:quality of life reduced by 0.5 for 1 mo
10%:complete loss of quality for 1 wk, and then
Patricia Graham, Robert A Adler, et al. The Prevention loss of quality by 0.5 for an additional 7 wk {=(0.57
4
and Treatment of Osteoporosis, Delisa’s,2010 x 0.5)+0.1x(1x1/52)+(0.5x7/25)}
 New Patient
Major risk factors assessment

Detection/Screening of
• Age
1 Low OSTA
•

Osteoporosis Risk
Body weight
• Genetic
No • Endocrine
OMORT Medium-
• Meal and intake
High
Yes • Posture alignment
• Habit
Osteoporosis • Activity
< 0.3 QUS • Recurrent Falls
Risk Nomogram
• Disease

> 0.3

Osteoporotic Fracture Risk

not available
DEXA FRAX

Identification of
+1 to -1
available

-1 to -2.5
< -2.5

Low High

Blood Examination

Detection of Bone
Primary
Osteoporosis Status of BTO rate :

Loss Rate
not available
underlying P1NP/CTx,
disease CTx/NMid
Secondary
available
Osteoporosis
Treat underlying disease Slow Loser Fast Loser
5
2 3
 Management of Disability due to Osteoporosis
Disability Aim Target Action
Prevention
Level I Promotive – Healthy Education about osteoporosis
impairment people Detection/screening of osteoporosis risk factors (Major
prevention Risk Factor, Calcium Intake Estimation, OSTA, US)
Management of changeable osteoporosis risk factors
(endocrine, diet, posture, physical activity & exercise)
Level II Disability Osteopenic Education about osteoporosis and osteoporotic fracture
prevention and Identification of osteoporotic fracture risk (Fall Risk
osteoporo- Assessment, DEXA, FRAX, Biochemical Bone Marker)
tic patients Management of changeable osteoporotic fracture risk
(endocrine, diet, posture, physical activity, exercise and
risk of fall)
Increase quality of life (active and safe life style)
Level III Handicap Osteoporo- Education about osteoporosis, osteoporotic fracture and
prevention tic fracture complications
patients Identification of complication risk factors post
osteoporotic fracture
Management of complication risk factors as much as
possible
Prevention of new fracture
Maintain and increase quality of life (promote 6
independency)
 PMR Roles in Osteoporosis
Management
• Physical medicine and rehabilitation can
reduce disability, improve physical function
and lower the risk of subsequent falls in
patients with osteoporosis
• Rehabilitation and exercise are recognized
means to improve function, such as activities
of daily living
• Psychosocial factors also strongly affect
functional ability of the osteoporotic patient

7
National Osteoporosis Foundation, 2013
Exercise for

Osteo porosis

8
Exercise & Physical Activity
Exercise Planned, structured,
repeated, purposeful

Skeletal muscle
Physical contraction,
Activity purposeful,
increased energy
expenditure

Movement Skeletal muscle

contraction

9
 General Principles of Exercise Prescription to Maintain Health
(suggested by Canadian Society for Exercise Physiology, January 2011)

Encouraged to participate in a variety of physical activities that are enjoyable and safe.
Should be achieved above and beyond the incidental physical activities accumulated in the
course of daily living. More daily physical activity provides greater health benefits.
CHILDREN (5-11y) AND YOUTH (12-17y) ADULTS (18-64y) OLDER ADULTS (≥65-y)
Should be physically active daily as part of Planned exercise sessions, transportation,
play, games, sports, transportation, recreation, sports or occupational demands, in
recreation, physical education, or planned the context of family, work, volunteer and
exercise in the context of family, school and community activities
community activities, that support their
natural development
Accumulate > 60 minutes of moderate- to Accumulate > 150 minutes of moderate- to
vigorous-intensity physical activity daily, vigorous-intensity physical activity per week,
including: including:
• Vigorous intensity activities > 3d/w • Aerobic exercise in > 10 minutes/bout
• Muscle and bone strengthening activities • Muscle and bone strengthening activities
> 3d/w using major muscle groups, > 2d/w
Those with poor mobility
should perform physical
activities to enhance
balance and prevent 10falls
 Hierarchy of Physical Function
Integration level III Role function

Task or
goal-oriented
Integration level II function
(e.g., ADL, IADL)

Specific physical
Integration level I Movements
(e.g., 8-foot walk)
Basic component

Coordination
Balance Strength Flexibility Endurance
Line motor
11
 Mechanotransduction in Bone

Osteocytes sense the fluid flow induced by loading in the lacunocanalicular system; this signal
modulates the secretin in the bone microenvironment of factors which can increase bone
remodeling while stimulating osteoblast differentiation and activity (green arrows) and decreasing
osteoclast activity (red arrow), resulting locally in a positive bone balance

12
Bergmann P, et al. 2011
 Intracellular events as Response to Exercise :
3 Major Steps

Burniston JG, Towler M & Wackerhage H, 2014. Signal transduction and adaptation to exercise: background and methods in: Wackerhage
H(Ed). Molecular Exercise Physiology An introduction. Routledge, New York.
13 5,
Egan B & Zierath JR, 2013. Exercise Metabolism and the Molecular Regulation of Skeletal Muscle Adaptation. Cell Metabolism 17, February
2013. pp 162-178
 Adaptations and Health Benefits of
Aerobic Compared to Resistance Exercise

Egan B & Zierath JR, 2013. Exercise Metabolism and the Molecular
Regulation of Skeletal Muscle Adaptation. Cell Metabolism 17,
February 5, 2013. pp 162-178

14
 0 10 20 30 40 50 60 70 80 90 100

Growth Maturation Menopause Senescence

Genetic factors MECHANICAL LOADING

Moderate-high
Body build. Lifestyle. The benefits of exercise include
Nutritional status intensity weight- increased muscle mass and
bearing exercise, high strength, improved balance and
Vigorous exercise leads to intensity Menopause
progressive coordination, as well as
large increases in peak resistance training & psychosocial benefits (reduced
Risk factors

bone mass and bone impact loading have Disease

depression, anxiety and stress and
strength (up to 30%) been shown to social isolation) that improve well-
increase Age-associated
bone density being and QOL and in turn
hormonal
by more modest
changes contribute to prevention of falls and
amount (1-4%) lower risk of fracture
Minor injuries (fall)
Bone mass

Peak bone Decreases in bone Increase in susceptibility

mass mass to fractures

0 10 20 30 40 50 60 70 80 90 100
Age (year)
Accumulation of risk factors for osteoporosis over time 15
 Exercise For Bone Health
Cardiorespira- Skeletal muscle Skeletal muscle Flexibility Body
tory Endurance strength endurance composition
Weight bearing Increase in Benefits seen in Benefits seen in Benefits seen in
activities may be muscle strength healthy healthy healthy
most beneficial and bone density populations are populations are populations are
for retaining with resistance similar to what similar to what similar to what
bone density training are expected in are expected in are expected in
the osteopenic the osteoporotic the osteoporotic
Endurance patient patient patient
training can
decrease
cardiovascular
disease

16
 The dynamic
stimulus
Frequency &
Amplitude of
loading

3 Rules that
govern Bone
Bone cells
Adaptation accommodate
A case of
to routine
diminishing
loading
returns
Bone
Rest period
mechanical
memory
Robling et al, 2006. Biomechanical and Molecular Regulation 17
of Bone Remodeling. Annu. Rev. Biomed. Eng. 8:455–98 Morris M and Schoo A, 2004
 Metabolism Humoral
Nutrition ↓ Testosteron
↓ Physical activity
Malnutrition ↓ Estrogen
↑ Oxydative stress
↓ GH
↑ Cytokine
↓ IGF-1
Resistance training + daily Adapted from Kvell et al, 2011. Molecular and
activity- & work-oriented Clinical Basics of Gerontology. University of Pécs

special exercises : 30-60 Sarcopenia

min fast walking 3-4x/w
(the pace is slowed down
for 5 min in every 10 min)
↓ Physical Activity

↓ Walking speed ↓ BMR

Osteoporosis

Impaired balance Stiff + pain Impaired Thermoregulation

on LE

↑ Tend to / Osteoporotic
Fear of Falls
↑ Falls Fracture Impaired ADLs
18
 6 Principles for Promoting Bone
Health Through Exercise
Specificity • Exercise provides a local osteogenic effect

Overload • Progressively increasing exercise intensity promotes

continued bone deposition

Initial value • Individuals with the smallest total bone mass show
the greatest potential for bone deposition

Diminishing returns • As one approaches the biologic ceiling for bone

density, further density gains require greater effort

More is not • Bone cells become desensitized in response to

prolonged mechanical-loading session
necessarily better
• Discontinuing exercise overload reverses the positive
Reversibility osteogenic effects gained through appropriate
exercise stress 19
 Prescribing Exercise for Bone Health

Frequency • Zerrath et al., 1997 : 4 x/weeks

Intensity
• Adami et al., 2008 : even minor changes in physical activity
are associated with a clear effect on bone formation marker
• High magnitude – few repetitions

• Prowse, 2010 : Aerobic Exercise affects bone turnover

Type • Weight Bearing better than Non Weight Bearing exercise
• Variable strain distributions throughout the bone structure

Time
• Karlsson et al., 2003 : Duration of activity was correlated with
bone marker in individual exercising 6 h/w or less
• Be long term and progressive in nature
20
1 st Prevention

21
 0 10 20 30 40 50 60 70 80 90 100

Growth Maturation Menopause Senescence

Genetic factors

Moderate-high
Body build. Lifestyle.
Nutritional status intensity weight-
bearing exercise, high
Vigorous exercise leads to intensity Menopause
progressive
large increases in peak resistance training &
Risk factors

bone mass and bone impact loading have Disease

strength (up to 30%) been shown to
increase Age-associated
bone density hormonal
by more modest
changes
amount (1-4%)
Minor injuries (fall)
Bone mass

Peak bone Decreases in bone Increase in susceptibility

mass mass to fractures

0 10 20 30 40 50 60 70 80 90 100
Age (year)
Accumulation of risk factors for osteoporosis over time 22
 Aerobic Training (AT)
• AT is a form of structured physical activity characterized
by rhythmic and repetitive movements of large muscles
• AT is for sustained periods and depends primarily on O2
use to meet energy demands through aerobic metabolism
• It is intended to generate improvements in
cardiorespiratory fitness, body composition and
cardiometabolic health
• Types: brisk walking, jogging,
swimming, water aerobics, tennis,
dancing, bicycle riding
23
Montero-Fernandez N, Serra-Rexach JA. 2013
 Aerobic Training (AT)
• Combining walking with more intense bouts of
exercise may be more beneficial than walking
alone  Multi-exercise endurance training
program
• Programs :
– walking-jogging-cycling-stair climbing
-graded treadmill exercises at 55-75%
VO2max or
– combining moderate-vigorous walking
with stepping exercises, weighted belts,
or stair-climbing
Heinonen et al, 1998 24
Chien et al, 2000
 Resistance Training (RT)
• RT is a safe form of exercise when the
movements are slow, controlled, and
carefully defined also in elderly people
• The fundamentals of effective RT :
– Perform each set or at least the last set(s) of
an exercise to fatigue, the state where the
subject cannot lift one more repetition with
good form
– Gradually increase the workload over time
• To increase muscle size and strength,
medium-heavy loading is needed (70-
80% 1 RM)

1RM = maximum amount of weight one can lift in a25single

Sundell J, 2011 repetition for a given exercise
 Resistance Training (RT)
• It elicit a greater adaptive bone response than walking
or jogging
• The high loads stimulate the skeleton through direct
action of muscle pulling on bone and/or increased
effect of gravity acting on bone
• High-intensity resistance programs 2-3 times/week 
modest increase in bone density (1-3%)
• High intensity progressive resistance wight training in
premenopausal women aged 20-40 years increased
bone density by up to 2% (3 times/week,8-12 reps x 3
sets, 12-14 exercises, 70-85% of 1RM)
Lohman et al,
26 1995
Snow-Harter et al, 1992
 Impact Exercise (IE)
• In healthy premenopausal women progressive
high impact training over 18 months (3
times/week, 60 min jumping, stepping and
calisthenics)  0.7 – 2.4% greater increase in
bone density
• However, high impact work is contraindicated
for individuals with poor balance, strength or
stability, osteoporosis, history of fracture,
osteoarthritis or artificial joints

27
Heinonen et al, 1996
2 nd Prevention

28
 Mobility and Immobility
• The life in universe is created perfectly to MOVE
harmonically with the environment
• MOBILITY is a human ability to MOVE and
transfer to another position with or without
assistive device
• IMMOBILITY is occurred as a consequence of
pathologic condition or as a part of treatment
which causing NOT MOVE (DISUSE)  affect
neuromusculoskeletal-cardiorespiration systems
29
Bone Physiologic Adaptation

H. Frost. The Utah Paradigm of Skeletal Physiology 30

 Bone Disuse = Disuse Osteoporosis

• Immobilization effect on musculoskeletal system induces

– Bone loss secondary to ↑ in resorption and ↓ in formation in the
WB bones  uncoupling bone remodeling  universal mechanism
of disuse-induced bone loss
– Muscle atrophy in parallel to bone loss, mainly at the level of
antigravity muscles
• Muscle activity without load seems insufficient to prevent
bone loss
• Factors that may influence the bone loss in immobilization :
– hypothalamic control of energy expense,
– influence of PTH levels on Ca2+ & P metabolism,
– variations in serotonin levels
31
 Disuse Osteoporosis

Disuse of Bone
(low stress)
↓ bone formation
Growing Bone on periosteal
surfaces

↑ bone resorption
on endocortical &
trabecular surfaces
Mature Bone
↑ bone turnover
on endocortical &
trabecular surfaces Rapid
Bone Loss
Cortical & trabecular thinning
Robling et al, 2006. Biomechanical and Molecular Regulation of Bone 32
Remodeling. Annu. Rev. Biomed. Eng. 8:455–98
 Disuse Osteoporosis
“Mechanical Loading Reverses
Bone Loss”
Frost HM, 1987
One condition to develop and
maintain healthy bones is that the
skeleton is submitted to mechanical
strain and that sensing of these
strains is efficient and correctly
transmitted to competent efector
Rapid
Bergmann P, et al. 2011
Bone Loss Robling et al, 2006. Biomechanical and Molecular Regulation of33Bone
Remodeling. Annu. Rev. Biomed. Eng. 8:455–98
 Prevention of Disuse Osteoporosis
• Exercise : ↑the thickness of cortical > trabecular bone
(Lirani-Galvao et al, 2010)
• Electrostimulation inhibited the loss of trabecular > cortical
bone (Tamaki et al, 2014)
– Dose of electrostimulation which has been studied in man with
SCI was 20-100 Hz, current amplitude 16 mA, for 4 weeks
resulted in higher force-time integrals, especially at the early
stages of disuse atrophy. Even low-magnitude mechanical
stimuli (less than 10 µstrain) increased bone formation in disuse
animal model (Tamaki et al., 2014).
– Dose of electrostimulation in SCI patient with 200 µs pulse
duration, 30 Hz, maximum current amplitude 140 mA, 47
minutes/day, 5 days/week for 14 weeks affected muscle but
not bone mass (Arija-Blazquez et al., 2014).

34
 THE ROLE OF ELECTRICAL STIMULATION IN MAINTAINING
CORTICAL AND TRABECULAR BONE IN IMMOBILIZED MALE RAT
Tinduh D, Prasetyo A, Laswati H, 2015
Animal model of disuse lower extremity with soleus muscle immobilization.
Preliminary study
16 male rattus norvegicus (Wistar strain), 3-4 months old, 150-200 g of weight.

The treatment group The control group

7 rats were immobilized for two weeks using RANDALT splints 9 non disuse rats

The left legs The right legs

Portable ES (Maxtens 1000, Korea)

Constant biphasic, asymmetrical square wave,
Disuse non-stimulated frequency 2 Hz, pulse width 250 μs, duty cycle 5:10s.
Two sets of 3 hours period daily with 2-h rest in
between, 3x/week for 4 weeks

Tibial bone harvesting, decalcification, HE staining

Cortical bone thickness Cortical bone thickness Cortical bone thickness

Trabecular bone thickness Trabecular bone thickness Trabecular bone thickness
Periosteum thickness Periosteum thickness Periosteum thickness35
 Result
µm
300 63.49 DISUSE
51.76 63.81
200
224.73
100 180.34 154.68 *
0
Disuse Disuse+ES Control

Cortical area Trabecular area

Cortical/Trabecular Ratio DISUSE+ES

3.7 3.63
4 2.72

2
0
Disuse Disuse+ES Control
Periosteum thickness
µm
320 303.62
295.32 CONTROL
300
280 264.41
260
240 36
Disuse Disuse+ES Control
Skeletal Muscle Performance in Elderly

Decrease
number of:
• Neurons in Denervation Reduced muscle mass
the spinal
cord
• Functioning
motor unit

Substitution
of fast twitch Reduced
Reduce
muscle fiber balance and
contraction
with slow movement
velocity
twitch muscle velocity
fiber

37
 0 10 20 30 40 50 60 70 80 90 100

Growth Maturation Menopause Senescence

Genetic factors

Body build. Lifestyle. The benefits of exercise include

Nutritional status increased muscle mass and
strength, improved balance and
Menopause coordination, as well as
psychosocial benefits (reduced
Risk factors

Disease
depression, anxiety and stress and
social isolation) that improve well-
being and QOL and in turn
Age-associated hormonal
changes contribute to prevention of falls and
lower risk of fracture
Minor injuries (fall)
Bone mass

Peak bone Decreases in bone Increase in susceptibility

mass mass to fractures

0 10 20 30 40 50 60 70 80 90 100
Age (year)
Accumulation of risk factors for osteoporosis over time 38
 Risk Factors That Can Be Treated
by Exercise
Risk Factors Exercise
Poor balance High level balance challenge exercises
Cane or walker; tai chi
Sarcopenia Resistive exercise; optimize vitamin D
levels
Kyphosis Optimize myofascial release/postural
training
Reduced proprioception Sturdy shoewear; balance training;
cane/walker
Impairments: Mobility training
transfer/mobility
39
Benefits of Exercise in Elderly

40
Clinical Significance of Myoplasticity

Improvement of stroke volume with LV

sistolic and diastolic optimal function

Increase VO2 max 10-30%

41
Social Interaction

42
Safe Exercise Recommendation for Elderly

Screening

Training

Supervision

Important for Patient’s Safety

43
 Types of Exercise for Elderly
Type Purpose / Expected Benefit
Aerobic / Anaerobic Cardiovascular conditioning
Resistance / Weights Strength, tone, muscle mass
Antigravity Prevent osteoporosis
Balance Prevent falls
Stretching Flexibility

44
Sinaki M and Nicholas JJ, 1994.
 Flexibility and Balance Exercise
• Although both exercise do not have a direct role on
the increase of muscle mass and strength, these
exercises help maintain stability and improve balance
and gait performance  preventing falls
• ACSM recommendation
– At least 2 days/week
– Each consists of 10 minutes moderate-intensity
exercise
– Examples: stretching, yoga, Tai-Chi, stair-
climbing, using balance boards, balls or elastic
bands

Montero-Fernandez N, Serra-Rexach JA. 2013

Timiras P, 2007 45
Hazzard, 2009
Prevention of Fall

46
 Balance & Posture

• BALANCE : complex process involving the

reception and integration of sensory
input, planning and execution of
movements, to achieve a goal requiring
upright POSTURE  ability to control the
COG over the BOS in a given sensory
environment
• POSTURE : Biomechanical alignment of
the body + orientation of the body to the
environment

47
(Nashner, 1994)
Reflexes Automatic Postural
• Vestibulo-Occular Reflex  Responses
coordination of eye-head • Ankle Strategy
movements • Hip Strategy
• Vestibulo-Spinal Reflex  • Suspensor Strategy
control movement + • Stepping & Reaching
stabilize the body
Motor Strategy
Component
of Balance
To counteract the
destabilizing consequences Self initiated of the COG
of voluntary movement to accomplish a goal

Anticipatory Postural Volitional Postural

Adjustment Movement
48
- Neuromuscular function
- Environmental hazards Risk of fall
- Time at risk

- Type of fall
Force of
- Protective response
impact Risk of
- Energy absorption fracture

- Bone mineral mass

- Geometry of bone Bone
- Quality if bone Strength
- Bone turnover

Relationship between risk of fall, force of impact, bone

strength and risk of fracture (After Kannis5) 49
 50
www.physiopedia.com
51
52
 Physical Activity to Reduce Falls Risk
in Elderly – the evidence
• Cardiovascular fitness programs
– Aim : improve general fitness, and have an associated
effect on general activity level (often include walking,
bicycle riding, aerobic exercise, or swimming/aquarobic)
– Target : increase exercising heart rate to 50-75% of MHR,
or to exercise between levels 12 to 14 on the Borg Rating
of Perceived Exertion Scale
• Combined balance, strength, cardiovascular programs
– Several studies also recommend to incorporate a
combination of two or more of balance, flexibility,
coordination, strength and cardiovascular fitness activities

American Council on Exercise,

53
1998
Awerbuch, 2001
 Physical Activity to Reduce Falls Risk
in Elderly – the evidence
• Balance training programs
– Improve balance performance in older people
• Strength training programs
– Graduated strength training program can improve
muscle strength in frail and less frail elderly
– RCTs also demonstrated its effectiveness in
improving mobility and function in community-
dwelling elderly

Ledin et al, 1990 Bravo et al, 1996

Rose and Clark, 2000 Chandler et al,
54 1998
Fiatarone et al, 1994 Skelton et al, 1995
Mechanism of Balance Maintenance

55
Tai Chi
56
3 rd Prevention

57
Aims of Rehabilitation After Fracture
• To shift attention towards recuperation and
mobilisation
• Enable patients to make the most of their potential
and so get back to their previous level of physical
activity and capabilities
• To be able to ensure patients
to make the best possible
progress which could be
gained by graded physical
activity
58
 Principles of Rehabilitation After Fracture

• Pain of fracture usually settles over a period of 6 weeks

(normal fracture healing time)
• Rehabilitation after fracture
– Analgesics – co-prescription of
opioids
– Tricyclic antidepressants
– Anti-resorptive treatments
– Hydrotherapy
– Graded exercises
– TNS (transcutaneous nerve
stimulation) machine
– Postural advice
– Falls assessment
– Home safety assessment
– Correction of falls risk etc.
– Hip protectors, walking aids
– Local group support,
osteoporosis educational
groups
– Specialised pain services
59
Role of Exercise in the Management of
Patients with Osteoporotic Fractures
• Efficacy of exercise in elderly
– Reduce risk of falls
– Increase balance, muscle strength and coordination
– Improve ROM, aerobic capacity, posture, and gait
re-education
– Pain control
– Improve psychological wellbeing

60
• High-intensity aquatic exercise is proven to be effective
in postmenopausal women with and without fractures
– Women with fractures: increments in BMD and T score of
femoral head
– Women without fractures:
• Protective factor for the occurence of fractures due to
– Increased spine extension strength
– Decreased pain perception
– Improvements of flexibility and neuromuscular variables
• High-intensity aquatic exercise is proven to be safe for
the spine even with the presence of fractures 61
Fronza FCAO et al, 2013
 NOF Recommendations for
Osteoporosis Rehabilitation, 2013
• Evaluate and consider patient’s physical and
functional safety as well as psychological and
social status, medical status, nutritional status
and medication use before prescribing a
rehabilitation program
• Training for performing safe movement (lifting,
transfer, ambulation, avoid forward bending and
twisting) and ADL, prescribe assistive devices if
necessary
• Evaluate home environment for fall’s risk
62
National Osteoporosis Foundation, 2013
 NOF Recommendations for
Osteoporosis Rehabilitation, 2013
• Based on the initial condition of patient,
provide a complete exercise recommendation
that includes
– weight bearing aerobic activities
– postural training
– progressive resistance training for muscle and
bone strengthening
– stretching for tight soft tissues and joints
– balance training

63
National Osteoporosis Foundation, 2013
 NOF Recommendations for
Osteoporosis Rehabilitation, 2013
• Avoid long-term immobilization and recommmend
partial bed rest (with periodic sitting and
ambulating) only when required and for the shortest
periods possible
• Effective pain management. The benefit of pain
relief should not be outweighed by the risk of side
effect
• Individuals with recent, painful vertebral fractures
that fail conservative management may be
candidates for emerging interventions (kyphoplasty
or vertebroplasty)
64
National Osteoporosis Foundation, 2013
Nutrition for

Osteo porosis

65
Bone Nutrient

66
Calcium & Diet Quality

67
68
69
Vitamin D Sources

70
 Blueberries:
Hipuric acid, Phenylacetic

Bone Nutrient acid, Hydrobenzoic acid

β-Cat
GSK3
Hesperidin 7-0-G
Dietary (Orange juice)
antioxidants: β-Cat
N-acetyl-cystein,
Vit A, Vit E, Plum TCF/LEF SMADs
Resveratol
ERK
(grape, red wine)
AMPK
FoxO Fatty acids:
Runx2
P53 Apoptosis PPARγ Saturated fat, high
VDR Vit D ω-6/ω-3
Collagen
Syntheses Osteoblas- Adipo-
togenesis genesis
ROS Vit C Osx ATP
COX ω-6
ER-β
ER-α
Quercetin Soy isoflavons:
Kaempferol Genistein, NFκβ
Catechine Daidzein cAMP
Curcumin
Lutein
RANKL

OPG

FAS RANK

Apoptosis Activation

71
 Summary
Calcium Vitamin D Physical Activity Bone Density Testing Patient at
(mg/d) (IU/d) Increased
Risk
Infant

0-6 months 210 200

Interactive play As clinically indicated in high Frequent
6-12 months 270 risk patients fractures,
Children and Adolescents anorexia,
amenorrhea,
1-3 years 500 200 chronic hepatic,
Moderate-vigorous activity As clinically indicated in high renal,
4-8 years 800 at least 60 min/day. risk patients gastrointestinal,
Emphasize WB activity autoimmune
9-18 years 1300
disease,
Adults medication

18-50 years 1000 200 Moderate activity at least As clinically indicated in high
30 minutes per day, on risk patients
most preferably all, days of
51-70 years 1200 400 Bone density testing by DXA
the week. Emphasize WB
in all women over age 65,
> 70 years 1200 600 activity. For prevention
consider in women under Individuals with
programs, modified for the
age 65 with risk factors. No risk factors
frail elderly and spine
consensus on men
fracture patients 72
THANK YOU

73