Search

Back pain from osteoporosis is commonly related to compression fractures. The patient with vertebral compression fractures additionally suffers from an ongoing risk of recurrent fractures and postural abnormalities that can result in impaired respiratory function, leading to increased risk of morbidity. Weakened back muscles, especially the back extensor group, are felt to contribute significantly to this risk. The combination of pharmacologic and nonpharmacologic interventions, through physical activity, exercise, and modalities, are potential interventions that could be used to help reduce the pain of osteoporotic compression fractures as well as potentially reducing recurrent fracture rates.

To determine the outcome of intervention with a spinal weighted kypho-orthosis (WKO) and a spinal proprioceptive extension exercise dynamic (SPEED) program on the risk of falls in ambulatory community-dwelling persons older than 60 years with osteoporosis-kyphosis at risk for falls.The study had 3 stages. At stage 1 (baseline), the 12 women in the kyphotic group were compared with 13 healthy controls to assess the risk of falls and balance disorder in the kyphotic group. At stage 2, the 12 kyphotic women began the SPEED program with a WKO (2 supervised sessions in an outpatient clinic and a 4-week, daily home-based training program). At stage 3, baseline and follow-up data of the kyphotic group were compared to determine the effect of intervention.At baseline, there were significant differences between the osteoporotic-kyphotic group and the control group in balance (P=.002), gait (P.05), and strength (P.05). After a 4-week intervention, comparison of the kyphotic group's baseline and follow-up results showed a significant change in balance (P=.003) and several gait parameters (P.05). Mean back extensor strength improved significantly from baseline (144.0-46.5 N) to follow-up (198.6+/-55.2 N; P.001). Lower extremity muscle strength was not changed significantly, except for improved left ankle plantar flexors (P=.02). Back pain decreased significantly (P=.001).Balance, gait, and risk of falls improved significantly with the 4-week SPEED program.

Nonpharmacologic interventions are important variables in the management of osteoporosis. These measures, as a prelude to, or in conjunction with, pharmacotherapy, can be extremely beneficial for improving musculoskeletal health. In this article, the rehabilitation and nonpharinacologic measures that can be implemented for the prevention and treatment of musculoskeletal challenges of osteoporosis are discussed. Results of studies in musculoskeletal rehabilitation of osteoporosis have substantiated the significance of the role of these measures in reducing axial deformity, loss of back strength, and the risk of fall and fracture.

The long-term protective effect of stronger back muscles on the spine was determined in 50 healthy white postmenopausal women, aged 58-75 years, 8 years after they had completed a 2 year randomized, controlled trial. Twenty-seven subjects had performed progressive, resistive back-strengthening exercises for 2 years and 23 had served as controls. Bone mineral density, spine radiographs, back extensor strength, biochemical marker values, and level of physical activity were obtained for all subjects at baseline, 2 years, and 10 years. Mean back extensor strength (BES) in the back-exercise (BE) group was 39.4 kg at baseline, 66.8 kg at 2 years (after 2 years of prescribed exercises), and 32.9 kg at 10 years (8 years after cessation of the prescribed exercises). Mean BES in the control (C) group was 36.9 kg at baseline, 49.0 kg at 2 years, and 26.9 kg at 10 years. The difference between the two groups was still statistically significant at 10 year follow-up (p = 0.001). The difference in bone mineral density, which was not significant between the two groups at baseline and 2 year follow-up, was significant at 10 year follow-up (p = 0.0004). The incidence of vertebral compression fracture was 14 fractures in 322 vertebral bodies examined (4.3%) in the C group and 6 fractures in 378 vertebral bodies examined (1.6%) in the BE group (chi-square test, p = 0.0290). The relative risk for compression fracture was 2.7 times greater in the C group than in the BE group. To our knowledge, this is the first study reported in the literature demonstrating the long-term effect of strong back muscles on the reduction of vertebral fractures in estrogen-deficient women.

Objective: People affected by osteoporosis are at particular risk for bone fractures caused by falls. Preventive intervention depends on first describing the risk factors for falls present in this population as a group and as individuals. In this preliminary study, balance characteristics of women with and without osteoporosis were measured with computerized dynamic posturography (CDP). Design: A case control design was selected to compare the balance characteristics of each group of patients with osteoporosis. Setting: Testing was performed in the vestibular assessment area of our multispecialty clinic. Subjects: Patient groups were selected from within our case load. Ten women with osteoporosis were compared with six women with osteoporosis and kyphosis (Cobb angle more than 54°) and with five age-matched normal subjects. Interventions: Because this was an observational study, no interventions were used. Main Outcome Measure: Averaged results from all trials of sensory organization tests 5 and 6, with use of sway amplitude and balance strategy scores, were used to compare the performance of each patient group. Results: Both groups with osteoporosis had different balance control strategies than the group without osteoporosis. Specifically, those with osteoporosis had greater use of hip strategies for maintaining balance than did the normal group. Those with kyphosis also had greater postural sway than either of the other two groups. Conclusion: Results of this study suggest that there are differences in balance control strategies and sway amplitude between patients with and those without osteoporosis. Further study is recommended in which CDP is used to clarify and confirm these differences. Individual CDP results can be used to optimize habilitative management of these patients.

The objectives of this study were to evaluate (1) the effect of spinal muscle strengthening by loading exercises on the bone mineral density (BMD) of the spine, and (2) the effect of upper extremity loading exercises on the BMD of the midradius and femur in healthy, premenopausal women. The study design was a randomized, controlled trial of 3 years' duration. Ninety-six healthy, premenopausal, white women aged 30-40 years participated; 67 completed the study. All subjects were in good health (normal menses) and were active, but not athletic (that is, not involved in a regular sport activity). Subjects were randomized to an exercise or control group. The exercise group performed a supervised, non-strenuous, weight-lifting exercise program. Exercise performance was supervised once a week at the medical facility. In addition, the subjects performed the exercises twice a week on their own. Dietary calcium intake was to be maintained at 1,500 mg/day in both groups. Bone density was measured at the lumbar spine and hip with dual-energy X-ray absorptiometry at 0, 1, and 3 years. BMD of the midradius was measured with single photon absorptiometry. Measurements of muscle strength were obtained at baseline and every 3 months for 3 years. Maximal oxygen uptake was measured, and the level of physical activity was recorded. Compliance with the exercise program was excellent during the first year of the study, but decreased thereafter. At the end of 3 years, subject withdrawal was about 34% from the exercise group and about 22% from the control group (total subject withdrawal was about 30%). Muscle strength in the exercise group increased significantly at all involved skeletal sites (p values all < 0.001). There was a modest positive correlation between the BMD of Ward's triangle with spinal flexor strength (r = 0.32, p = 0.008) and with grip strength (r = 0.38, p = 0.001). Comparing study groups, we found no significant effect of the loading and nonstrenuous strengthening exercises in the exercise group or free physical activity group (our control group) on BMD at the spine, hip, or midradius measurement sites. In active, but not athletic premenopausal women, additional moderate weight-lifting exercises showed no significant effect on BMD.

To determine the effect of application of back supports on back strength in subjects with osteoporosis.In a prospective, randomized, controlled study, we compared compliance and evaluated changes in back strength in 45 women with osteoporosis who were older than 40 years of age and were randomly assigned to one of three groups: (1) postural exercise only, (2) postural exercise and a conventional thoracolumbar support, or (3) postural exercise and a Posture Training Support (PTS) (a weighted kypho-orthosis).Of the 45 study participants, 15 were assigned to a PTS group, 15 to conventional thoracolumbar support, and 15 to no orthosis. All subjects were instructed in basic body mechanics and postural exercises. Back extensor strength, grip strength, and patient's physical activity were measured at baseline and at subsequent 8-week intervals for a 16-week period. Each patient's compliance during the study period was also recorded.compliance was poor among the thoracolumbar group; only 5 of the 15 subjects completed the study (P0.001), in comparison with 11 of the 15 patients in the control group and all 15 in the PTS group. Analysis revealed statistically significant mean increases in back strength in the PTS group (23%) and the control group (13%) and a nonsignificant increase in the thoracolumbar group (15%), although poor compliance in the thoracolumbar group yielded insufficient power to detect a significant difference in this group. No statistically significant difference was found between the improvements in the PTS and control groups, possibly because of the small sample size in this pilot study. One patient who wore the PTS for only 4 hours a day rather than 8 hours had the largest percentage increase in back extensor strength of this group (78%). At 16 weeks, decreases in back strength of more than 5% below the initial measurements were noted in 1 of 11 subjects (9%) who completed the control arm of the study, 2 of 14 (14%) who completed the PTS arm, and 2 of 5 (40%) who completed the thoracolumbar arm.Compliance with use of the PTS was better than that with the thoracolumbar support. Back extensor strength may increase in patients who comply with the PTS and postural exercise program. We caution, however, that this pilot study requires replication in a larger series to determine the clinical and statistical generalizability of these findings to a wider population.

Back supports are often used to minimize or prevent complications of osteoporosis. Nevertheless, the few related studies to date reveal that the currently available thoracolumbar and lumbosacral supports have substantial limitations, including (1) poor compliance because of discomfort or restricted motion, (2) expense, (3) unacceptable cosmetic and aesthetic appearance, and (4) medical contraindications to the use of rigid supports. We report the initial results of a clinical trial of the Posture Training Support (a thoracolumbar support) in 29 women and 1 man with osteoporosis or osteopenia of the spine (ages 37 to 87 years), who were referred because of back pain or kyphosis. We hypothesize that this inexpensive, unobtrusive device promotes improvement in posture and reduces back pain either by acting as a proprioceptive reinforcer or by producing a force posteriorly below the inferior angles of the scapulae and thus decreasing the anterior compressive forces that are commonly exerted on the spine. Among the 23 patients who reported substantial back pain before use of the support, relief of the pain was "significant" in 17 and minimal in 6. Nineteen patients noted improvement in their posture. No patient reported worsening of back pain or posture, nor did any patient discontinue use of the device for cosmetic reasons, discomfort, or other complaints. Four patients previously could not tolerate other back supports, and 14 had previously used other supports without substantial improvement. These preliminary results suggests that the Posture Training Support may be of considerable symptomatic and prophylactic value to patients with osteoporosis who cannot tolerate conventional back supports.

The correlation of muscle strength at various sites of the axial and appendicular skeleton with physical activity and aerobic capacity was assessed in women 29 to 40 years old. Muscle strength of the spine and upper extremities was determined with strain gauges in 96 healthy white women, and power grip was used as an indicator of upper extremity strength. The physical activity score, which reflected the level of daily weight-bearing activity and was based on a standardized scale, ranged from 3 to 15. Maximal oxygen uptake (aerobic capacity) was measured in 69 of the 96 subjects. The mean values for maximal oxygen uptake were 1.9 liters/min and 27.9 ml/kg per minute when normalized for weight. In general, muscle strength was significantly correlated between axial and appendicular sites; thus, the axial musculature usually represents overall muscle strength. Maximal oxygen uptake in milliliters per kilogram per minute was not correlated with back extensor strength or upper extremity strength. Physical activity score was significantly correlated with back extensor strength but not with maximal oxygen uptake (aerobic capacity) either in liters per minute or in milliliters per kilogram per minute. Thus, maximal oxygen uptake is an invalid marker for level of daily weight-bearing physical activity.

Considerable concern has been expressed about the type and level of exercise that are safe for women with osteopenia and osteoporosis; however, published information on the effect of golfing on the osteoporotic spine is meager. We describe three postmenopausal patients with acute compression fractures of the vertebrae that occurred during midswing while golfing. These healthy, active women were long-term golfers; their ages at the time of the trauma were 63, 58, and 66 years. In one patient (case 1), osteoporosis was diagnosed before the golf-related injury. The two other patients (cases 2 and 3) sought medical attention after the trauma and were found to have osteoporosis. The bone mineral density of the lumbar vertebrae (L2-4) in the three patients at the time of or shortly after the trauma was as follows: case 1, 0.77 g/cm2 (3rd percentile of normal, corrected for age); case 2, 0.63 g/cm2 (less than 1st percentile of normal, corrected for age); and case 3, 0.69 g/cm2 (2nd percentile of normal, corrected for age). These findings raise the issue of the safety of golfing for women with previously diagnosed osteoporosis and for those with predisposing risk factors for the disease. Research studies of the kinematics and kinetics of the spine during the golf swing should be conducted. In the interim, a rigid back support for golfers with osteoporosis may be helpful until more conclusive evidence is available from controlled trials.

Improvement of back extensor strength (BES) can be used as a therapeutic method for patients with chronic back pain and osteoporosis. The method of evaluation must be reliable and accurate without compromising the condition of the patient. We report the development of a back isometric dynamometer (BID-2000) designed specifically by two of us to address these concerns in elderly patients with osteopenia or osteoporosis. As the demographics of the general population change, increasing numbers of patients will need the type of monitoring that the BID-2000 provides. Aging has been shown to cause a reduction in the number of functional muscle motor units. To examine this effect on BES, we tested 50 normal, healthy women who were 30 to 79 years old. Proper testing of BES in patients with fragile vertebrae should include isometric measurement in the prone position, maneuverability of the device to allow comfortable positioning of the patient, and simplicity of technique to minimize repetitious performance of maximal contraction. The BID-2000 incorporates each of these features and also provides meaningful results inexpensively. The device offers a safe, reliable (coefficient of variation = 2.33%), and valid (P = 0.001) method of evaluation. The results of our study demonstrated moderate, steady reduction of BES with increasing age and with each successive decade.

To the Editor: We read with interest the excellent review article on osteoporosis by Mauck and Clarke in the May 2006 issue of Mayo Clinic Proceedings, which summarized current strategies for the diagnosis, screening, prevention, and treatment of this disorder. However, we found one area that we believe deserves further elaboration—the role of exercise in the prevention and treatment of osteoporotic compression fractures. In their article, Mauck and Clarke reported that “weightbearing exercise appears to be effective in maintaining or increasing bone density at the lumbar spine and hip in postmenopausal women, but currently, no evidence suggests that it decreases fractures.” They referenced the report by Bonaiuti et al in the 2002 Cochrane Database of Systematic Reviews, which included studies up to 2000. However, since that time evidence has accumulated that substantiates the use of targeted back extensor–strengthening (BES) exercise to reduce the risk of vertebral compression fractures in the postmenopausal population. For example, in 2002, Sinaki et al published the results of a prospective 10-year follow-up study showing a statistically significant reduction in vertebral compression fractures in a group of women who had participated in BES exercises compared to a control group of women who did not participate in such an exercise program (Figure 1). Stronger back extensors reduced the risk of vertebral fractures by 3-fold with no specific pharmacotherapy. In 2003, Turner and Robling noted that regular exercise can “effectively reduce fracture risk” while increasing bone strength. Pfeifer et al reviewed the literature in 2004 and concluded that exercise was associated with reduced risk of hip fracture. In a recent pilot study of the effects of BES exercise and refracture rates after vertebroplasty, we found not only a decreased refracture rate but an increased fracture-free interval when BES exercise was included. Bone mineral density accounts for less than 50% of fracture risk; the remaining risk depends on other factors such as muscle strength and risk of falls. Thus, given the safety of an appropriately designed exercise program in this population, we believe that targeted BES exercise should be considered for fracture prevention and as a treatment option for all osteoporotic individuals.

A considerable increase in muscle strength and bone mass can be achieved in young adults through athletic exercise programs. We studied a less demanding nonloading exercise program for the back extensor muscles in postmenopausal women who were not on estrogen therapy. We randomly assigned 65 healthy Caucasian women without evidence of or risk factors for osteoporosis into an exercise group and a control group. The strength of the back extensor muscles and bone mineral density of the lumbar spine were measured at baseline and every 6 months for 2 years. In addition, a physical activity score was determined. Compliance was assessed by regular interviews and review of diaries. During the 2-year study, the mean rates of bone loss in the two groups were not statistically different. The strength of the back extensor muscles increased in both groups but significantly more (P – 0.002) in the exercise group. We conclude that postmenopausal bone loss is unaffected by a modest exercise program despite an increase in muscle strength. Nonloading muscle exercise may be ineffective in retarding vertebral bone loss in ambulatory, healthy postmenopausal women.