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Background The importance of exercise in skeletal health is increasingly recognized by both patients and providers. However, the safety of prescribed or recreational exercise in at-risk populations remains under-reported and under-publicized. Yoga has gained widespread popularity due to its physical and psychological benefits. When practiced in a population at increased fracture risk, however, some yoga poses may increase fracture risk, particularly at the spine, rather than increasing BMD as noted in recent popular press reports. Case report Nine subjects (8 women) with a median age of 66 years (range 53-87), developed vertebral compression fracture (VCF) one month to six years after initiating yoga-associated spinal flexion exercises (SFE). VCF presented with back pain and occurred in the thoracicspine (N.=6), lumbar-spine (N.=4) and cervical-spine (N.=1). Four patients had osteoporosis by BMD criteria prior to VCF and 2 had osteopenia (median T-score -2.35; range -3.3 to +2.0). Interestingly, all patients had their lowest T-scores at the spine. Three patients had a history of fragility fracture prior to the index VCF. While one patient had primary hyperparathyroidism and another was treated with high dose prednisone, no other risk factors for bone loss including medications or secondary osteoporosis causes were identified in the other patients. Clinical rehabilitation impact This study identified patients in whom increased torsional and compressive mechanical loading pressures occurring during yoga SFE resulted in de novo VCF. Despite the need for selectivity in yoga poses in populations at increased fracture risk, both scientific and media reports continue to advertise yoga as a bone protective activity. Accordingly, yoga is misconceived as a 'onesize-fits-all' prescription. Instead, the appropriate selection of patients likely to benefit from yoga must be a cornerstone of fracture prevention.

Objective To analyze injuries that were directly associated with yoga practice and identify specific poses that should be avoided in patients with osteopenia or osteoporosis. Patients and Methods We retrospectively reviewed the medical records of patients with injuries that were primarily caused by yoga. Patients were seen from January 1, 2006, through December 31, 2018. Injuries were categorized into 3 groups: (1) soft tissue injury, (2) axial nonbony injury, and (3) bony injury. Patients underwent evaluation and were counseled to modify exercise activity. Results We identified 89 patients for inclusion in the study. Within the soft tissue group, 66 patients (74.2%) had mechanical myofascial pain due to overuse. Rotator cuff injury was seen in 6 (6.7%), and trochanteric bursopathy was observed in 1 (1.1%). In the axial group, exacerbation of pain in degenerative joint disease (46 patients [51.7%]) and facet arthropathy (n=34 [38.2%]) were observed. Radiculopathy was seen in 5 patients (5.6%). Within the bony injury category, kyphoscoliosis was seen on imaging in 15 patients (16.9%). Spondylolisthesis was present in 15 patients (16.9%). Anterior wedging was seen in 16 (18.0%), and compression fractures were present in 13 (14.6%). The poses that were most commonly identified as causing the injuries involved hyperflexion and hyperextension of the spine. We correlated the kinesiologic effect of such exercises on specific musculoskeletal structures. Conclusion Yoga potentially has many benefits, but care must be taken when performing positions with extreme spinal flexion and extension. Patients with osteopenia or osteoporosis may have higher risk of compression fractures or deformities and would benefit from avoiding extreme spinal flexion. Physicians should consider this risk when discussing yoga as exercise.

Concern about the risk of bone loss in astronauts as a result of prolonged exposure to microgravity prompted the National Aeronautics and Space Administration to convene a Bone Summit with a panel of experts at the Johnson Space Center to review the medical data and research evidence from astronauts who have had prolonged exposure to spaceflight. Data were reviewed from 35 astronauts who had served on spaceflight missions lasting between 120 and 180 days with attention focused on astronauts who (1) were repeat fliers on long-duration missions, (2) were users of an advanced resistive exercise device (ARED), (3) were scanned by quantitative computed tomography (QCT) at the hip, (4) had hip bone strength estimated by finite element modeling, or (5) had lost >10% of areal bone mineral density (aBMD) at the hip or lumbar spine as measured by dual-energy X-ray absorptiometry (DXA). Because of the limitations of DXA in describing the effects of spaceflight on bone strength, the panel recommended that the U.S. space program use QCT and finite element modeling to further study the unique effects of spaceflight (and recovery) on bone health in order to better inform clinical decisions.

Osteoporosis, as a multifaceted disorder, requires a multidisciplinary approach to achieve the most successful management. Osteoporosis, in general, is a preventable disorder. Maintenance of bone mass depends on several factors, including proper level of physical activity (PA), hormones, and nutrition. Early diagnosis of low bone mass and provision of measures to prevent further bone loss are essential. Application of proper mechanical load can stimulate osteogenic activity. The best preventive measures start in childhood, including proper nutrition and PA. Later in life, the level of PA plays a significant role. Maintaining a moderate level of PA through a regular exercise program, combined with a balanced diet and proper calcium and vitamin D intake, is fundamental to bone and muscle health. Prevention of falls and fractures need to be addressed. Both indication and type of spinal orthosis need to be addressed. In the case of osteoporosis and fragility, an exercise program needs to be prescribed according to the level of bone mineral density (BMD), while being progressive and challenging. These exercises will be discussed in detail in a chapter devoted to exercise.

The most effortless posture in humans occurs when anatomical structures that participate in upright posture are aligned with the line of gravity or close to it. In kyphosis and forward thrust of the head, weight of the head will add to the deforming forces of the spine and further development of kyphosis. With bone loss, spinal deformities develop subsequent to the repetitive strain beyond biomechanical competence of the spine. Proper intervention could be biomechanical and include re-education of the spinal facet joints to the correct posture. Among the complications related to kyphosis, I will address flank pain or iliocostal impingement syndrome. There is a paucity of literature on the management of osteoporosis-related postural deformities. In this communication, I present interventions through biomechanical measures and facilitation of exercise to improve postural deformities as much as possible.

Musculoskeletal changes that are related to osteoporosis/osteopenia can be prevented or mitigated through implementation of proper osteoporosis rehabilitation programs. Osteoporosis can affect patients physically and psychologically. We need to treat the patient, not just the low bone and muscle mass. Being positive in our presentation is crucial for patients' compliance with the program. The physical activity (PA) and exercise interventions recommended here are evidence based and are the result of controlled trials and studies. In addition, the author has included a few caveats that are intended to emphasize avoidance of overstraining the spine beyond its biomechanical competence when interested in osteogenicity of exercise and PA. Effective back-strengthening exercises need to be devised according to the patient’s biomechanical competence.

Maintenance of bone health and quality requires mechanical strain, but the mechanical force needs to be within the bone's biomechanical competence. In osteoporosis, compression of vertebral bodies can be insidious. Therefore, absence of pain does not necessarily indicate absence of vertebral microfracture and deformity. Further, patients with previous vertebral fractures are at risk for further vertebral fractures and their associated morbidity. Exercise is a part of the comprehensive management of patients with osteoporosis and has been associated with improvement of quality of life and lowered risk of future fracture. The exercise prescription needs to match the needs of the patient. If exercise is not prescribed properly, then it may have negative consequences. In general, an exercise program, therapeutic or recreational, needs to address flexibility, muscle strength, core stability, cardiovascular fitness, and gait steadiness. As with pharmacotherapy, therapeutic exercises need to be individualized on the basis of musculoskeletal status and an individual's exercise interest. In osteoporosis, axial strength and stability are of primary importance. In particular, a spinal extensor strengthening program should be performed with progressive measured resistance as tolerated. To address falls and fractures, an exercise program should also include balance and lower extremity strength training. Proper dosing of oral cholecalciferol and calcium supplements can enhance the effect of strengthening exercises. Finally, a coordinated approach, such as the Spinal Proprioception Extension Exercise Dynamic (SPEED) program, can improve back extensor strength, the level of physical activity, and locomotion, and reduce back pain and fear and risk of falls.

Objective: The objective of this report is to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. We previously described subjects with known osteoporosis in whom vertebral compression fractures (VCFs) developed after spinal flexion exercise (SFE) and recommended that SFEs not be prescribed in patients with spinal osteoporosis. Methods: This report describes 3 healthy persons with low bone mass and yoga-induced pain or fracture. Results: All 3 patients had osteopenia, were in good health and pain-free, and had started yoga exercises to improve their musculoskeletal health. New pain and fracture areas occurred after participation in yoga flexion exercises. Conclusions: The development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. Although exercise has been shown to be effective for improving bone mineral density and decreasing fracture risk, our subjects had development of VCFs and neck and back pain with yoga exercises. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss. The increased torque pressure applied to vertebral bodies during SFEs may be a risk. Exercise is effective and important for treatment of osteopenia and osteoporosis and should be prescribed for patients with vertebral bone loss. Some yoga positions can contribute to extreme strain on spines with bone loss. Assessment of fracture risk in older persons performing SFEs and other high-impact exercises is an important clinical consideration.

The difference in the shape of sagittal spinal curvature and distribution of vertebral fractures in women of comparable age with osteoporosis from Japan and the United States with different cultures and lifestyles was identified. Back extensor strength was significantly associated with lumbar lordosis in Akita group, indicating the potential importance of strengthening the back extensor. The purpose of the study was to assess the association of osteoporotic spinal deformities with back strength in elderly women in Japan and the United States. Subjects diagnosed with osteoporosis were selected to participate prospectively. In both groups, we measured the angles of thoracic kyphosis and lumbar lordosis with plain lateral radiographs and back extensor strength. The number of vertebral fractures and the ratio of lumbar fractures to thoracic fractures are also evaluated. The level of participants' daily activities was assessed with use of comparable tests in Akita (quality-of-life score) and Minnesota (physical activity score). A total of 102 Japanese women residing in Akita, Japan (Akita group), and 104 white women evaluated in Rochester, MN, USA (Minnesota group), participated in this study. The angle of thoracic kyphosis and lumbar lordosis was higher in the Minnesota group than in the Akita group. The ratio of lumbar fractures to thoracic fractures was higher in the Akita group than in the Minnesota group. In the Akita group, multiple regression analysis revealed that the angle of lumbar lordosis correlated significantly with back extensor strength. We identified the difference in the shape of sagittal spinal curvature and distribution of vertebral fractures in women of comparable age with osteoporosis from two geographic areas of the world with different cultures and lifestyles. Back extensor strength was significantly associated with lumbar lordosis in Akita group, indicating the potential importance of strengthening the back extensor for improving or maintaining lumbar lordosis.

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.

Combining pharmacotherapy with non-pharmacotherapy is fundamental to the successful management of osteopenia and osteoporosis. The choice of pharmacotherapy depends on the patient’s age, bone mineral density and serum biochemical markers of bone. HRT should not be used for treatment of osteoporosis. As with pharmacotherapy, rehabilitation management is challenging and innovative. Non-pathologic spontaneous vertebral fractures that occur at the level of the spine are purely osteoporosis-related. On the other hand, the majority of non-vertebral fractures that are of special clinical significance are fall-related. Therefore, reducing the risk for fracture through the prevention of falls is as important as increasing bone mass. (From the World of Osteoporosis 2009;15:52-8)

This guide is a summary reference on the rehabilitation principles that should be applied in the treatment and prevention of osteoporosis. As this guide addresses primarily rehabilitation issues required by osteoporotic fracture or low bone mass, the health professional is directed to the National Osteoporosis Foundation’s companion piece, Physician’s Guide to Prevention and Treatment of Osteoporosis (‘Physician’s Guide’), for other treatment approaches. Rehabilitation and exercise are often viewed as a means to improve function, such as activities of daily living (ADL) for patients. Psychosocial factors also impact strongly on functional ability and the general health of the osteoporotic patient. The information in this guide is based on scientific evidence from basic research, consensus from an expert panel convened by the National Osteoporosis Foundation (NOF), clinical studies, and randomized controlled clinical trials. The small number of randomized trials points to the need for more of them in the future. The majority of the studies on rehabilitation approaches and exercise recommendations related to osteoporosis are based on studies among white perimenopausal women. Clearly, osteoporosis affects men and non-white women as well. It can also affect younger as well as older individuals with certain chronic conditions and medication use. Until we have additional data, recommendations for these other populations should be on an individual basis. The committee believes that the guidelines have universal application in terms of recommending life-long, safe activities and exercises for all people. This guide’s recommendations are not intended as rigid standards of practice, but must be tailored for use by physicians in consultation with their patients. Executive Summary

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.

We proposed that there are significant correlations between muscle strength and bone mineral density in premenopausal women and that these correlations are site-specific. To test this hypothesis, we examined the relationships among site-specific bone mineral density, physical activity, and muscle strength in a group of 96 healthy premenopausal Caucasian women. Bone mineral density was measured at the lumbar spine and at three sites in the proximal femur (trochanter, femoral neck, and Ward's triangle) with dual-energy x-ray absorptiometry and at the mid-radius with single-photon absorptiometry. The muscle strength of hip and spinal muscle groups was determined with a strain gauge isodynamometer, and grip strength was measured with the JAMAR dynamometer. The strength of shoulder girdle muscle groups was evaluated with the use of free weights. Physical activity was determined by surveying the subjects and by using a standardized scale. Data analysis revealed significant linear correlations of muscle strength with bone mineral density at the mid-radius (r = 0.31; P = 0.002) and at the hip (r = 0.26; P = 0.01). Grip strength was significantly correlated with bone mineral density of both the spine and the femur (r = 0.24, r = 0.34; P < 0.05 for both). Back extensor strength correlated with bone mineral density of the hip (Ward's triangle; r = 0.23; P = 0.023). However, there was no significant positive correlation between the strength of the spinal flexor or extensor muscles and the site-related bone mass (lumbar spine). Only one of the three components of the physical activity score (job) positively correlated with vertebral bone mineral density (r = 0.21; P = 0.04). Physical activity negatively correlated with age (r = 0.24; P = 0.02). We conclude that in premenopausal women, the effect of muscle strength on bone mass is more systemic than site-specific. A positive correlation between vertebral bone mass and components of physical activity demonstrates that even job-related physical activity is an important factor in maintaining adequate bone mass.

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.

Aging and osteoporosis have been associated with skeletal changes. Back extensor strengthening exercises are highly recommended for management of back pain, especially back pain related to osteoporosis. To our knowledge, the correlation of thoracic kyphosis, lumbar lordosis, and sacral inclination with back extensor strength, physical activity, and bone mineral density has not been critically studied in healthy, active, estrogen-deficient women. In a study of 65 such women (ages 48-65 yr), back extensor strength, bone mineral density, and physical activity score were evaluated and measured. These factors were then correlated with radiographic factors: (1) vertebral body ratios (anterior/posterior height) calculated for each vertebra from T-4 through L-5; (2) kyphosis index determined by adding the anterior heights of each vertebral body, T-4 through T-12, and then dividing the total by the corresponding sum of the posterior heights of each vertebral body; (3) thoracic kyphosis; (4) lumbar lordosis; and (5) sacral inclination. Back extensor strength had a significant negative correlation with thoracic kyphosis (r = -0.30, P = 0.019) and a positive correlation with lumbar lordosis (r = 0.26, P = 0.048) and sacral inclination (r = 0.34, P = 0.009). However, bone mineral density and physical activity score did not show any significant correlations with the radiographic factors. The results indicate that the stronger the back extensor, the smaller the thoracic kyphosis and the larger the lumbar lordosis and sacral inclination. We conclude that back extensor strength is an important determinant of posture in healthy women. However, prescribing back extensor strengthening exercises alone may also increase lumbar lordosis, which is not desirable.

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.

The objective of this report is to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. We previously described subjects with known osteoporosis in whom vertebral compression fractures (VCFs) developed after spinal flexion exercise (SFE) and recommended that SFEs not be prescribed in patients with spinal osteoporosis.This report describes 3 healthy persons with low bone mass and yoga-induced pain or fracture.All 3 patients had osteopenia, were in good health and pain-free, and had started yoga exercises to improve their musculoskeletal health. New pain and fracture areas occurred after participation in yoga flexion exercises.The development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. Although exercise has been shown to be effective for improving bone mineral density and decreasing fracture risk, our subjects had development of VCFs and neck and back pain with yoga exercises. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss. The increased torque pressure applied to vertebral bodies during SFEs may be a risk. Exercise is effective and important for treatment of osteopenia and osteoporosis and should be prescribed for patients with vertebral bone loss. Some yoga positions can contribute to extreme strain on spines with bone loss. Assessment of fracture risk in older persons performing SFEs and other high-impact exercises is an important clinical consideration.

Background Increased mobility and physical activity after successful vertebral augmentation procedure might increase the risk of new-onset fractures. Purpose To determine whether new-onset fracture following vertebroplasty is associated with specific type of physical activity. Material and Methods A total of 107 patients underwent at least two procedures of percutaneous vertebroplasty. Among them, 30 patients who sustained a post-vertebroplasty fracture(s), were stratified by fracture-causing activity and examined the incidence of the initial and post-vertebroplasty fractures, time to post-vertebroplasty fractures, duration of anti-osteoporotic therapy, T-score, and body mass index. Results The following percentages correspond to patients with fractures sustained pre- and post-vertebroplasty, respectively; spontaneous fractures in 17% and 7% ( P = 0.20), sitting in 7% and 3% ( P = 0.50), walking or standing in 7% and 20% ( P = 0.10), housework in 3% and 3% ( P > 0.99), coughing or sneezing in 0% and 20% ( P = 0.003), exercise in 7% and 17% ( P = 0.20), lifting in 10% and 17% ( P = 0.40) and falling in 50% and 13% ( P = 0.002). Different levels of activity were not significantly associated with time to incidence of post-vertebroplasty fractures. Anti-osteoporotic medications were administered to 33% of patients before vertebroplasty and 37% after the vertebroplasty ( P = 0.78); medications were administered to these groups for 16 and 25 months, respectively ( P = 0.39). Conclusion A significantly elevated risk of new onset fracture with increased physical activity was not identified. However, patients should be carefully counseled after vertebroplasty to optimize medical therapy for osteoporosis and also to use extreme care when engaging in even moderate physical activity.

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.

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.

The objective of exercise in the treatment of osteoporosis is to improve axial stability through improvement of muscle strength. Therefore, a back extension exercise program specific to one’s musculoskeletal competence and pain can be performed in a sitting position and later advanced to the prone position. When fragility is resolved, back extension is performed against resistance applied to the upper back. To decrease pain and immobility in acute vertebral fracture, use of spinal orthoses become inevitable. Therapeutic exercise should address osteoporosis-related deformities of axial posture, which can increase risk of fall and fracture. Strengthening of the major appendicular muscles decreases fragility. The effect of strengthening exercise is augmented by proper intake of cholecalciferol and calcium. Thus, the role of a therapeutic exercise program is to increase muscle strength safely, decrease immobility-related complications, and prevent fall and fracture. As with pharmacotherapy, therapeutic exercises are individualized.

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.

OBJECTIVE To determine whether patients with osteoporotic compression fractures would have decreased fracture recurrence or a longer time before refracture after percutaneous vertebroplasty (PVP) if they also participated in the Rehabilitation of Osteoporosis Program-Exercise (ROPE) instruction, which includes back-strengthening exercises. PATIENTS AND METHODS We reviewed and collected data from the medical records of 507 patients with osteoporosis who were treated at Mayo Clinic's site in Rochester, MN, from July 1, 1998, through August 31, 2005. Patients older than 55 years with at least 1 radiographically confirmed nontraumatic vertebral compression fracture (VCF) were identified, and those with evidence of secondary osteoporosis, traumatically induced VCF, long-term oral corticosteroid use, or bone malignancy were excluded. The remaining 57 patients were categorized into 3 groups: those receiving treatment with ROPE only (n=20), PVP only (n=20), or both PVP and ROPE (n=17). The end point was the refracture date or date of the last recorded follow-up if no refracture occurred. Statistical analysis of time-to-recurrence data was performed using the Kaplan-Meier method and the log-rank test (P RESULTS The median time before refracture for patients treated with PVP was 4.5 months (95% confidence interval [CI]), 1.4-9.3 months; for patients treated with ROPE only, 60.4 months (95% CI, 27.6 months-upper limit undefined); and for patients treated with PVP-ROPE, 20.4 months (95% CI, 2.8 months-upper limit undefined) (P CONCLUSION This retrospective study showed that a targeted exercise program after PVP significantly decreased fracture recurrence. Refracture rates also were lower in the ROPE-only group vs the PVP-only group. A targeted exercise program after percutaneous vertebroplasty (PVP) significantly decreased fracture recurrence; refracture rates also were lower in the back-extensor-strengthening-only group vs those in the PVP-only group.

Locomotion has always been a major criterion for human survival. Thus, it is no surprise that science supports the dependence of bone health on weight-bearing physical activities. The effect of physical activity on bone is site-specific. Determining how to perform osteogenic exercises, especially in individuals who have osteopenia or osteoporosis, without exceeding the biomechanical competence of bone always poses a dilemma and must occur under medical advice. This article presents the hypothesis that back exercises performed in a prone position, rather than a vertical position, may have a greater effect on decreasing the risk for vertebral fractures without resulting in compression fracture. The risk for vertebral fractures can be reduced through improvement in the horizontal trabecular connection of vertebral bodies.

Randomized controlled study in 80 postmenopausal women with osteoporosis was conducted to investigate the effect of a home-based, simple, low-intensity exercise. Low-intensity back-strengthening exercise was effective in improving the quality of life and back extensor strength.Back-strengthening exercise is effective in increasing back extensor strength and decreasing risk of vertebral fractures. We hypothesized that a home-based, simple, low-intensity exercise could enhance back extensor strength and improve the quality of life and/or spinal range of motion in postmenopausal women in a short-term follow-up.Eighty postmenopausal women with osteoporosis were randomly assigned to a control group (n = 38) or an exercise group (n = 42). Subjects were instructed to lift their upper trunk from a prone position antigravity and maintain the neutral position. Isometric back extensor strength, spinal range of motion, and scores for quality of life were evaluated at baseline and 4 months.Back extensor strength significantly increased both in the exercise group (26%) and in the control group (11%). Scores for quality of life increased in the exercise group (7%), whereas it remained unchanged in the control group (0%). There was a significant difference in quality of life score between the groups (p = 0.012).Low-intensity back-strengthening exercise was effective in improving the quality of life and back extensor strength in patients with osteoporosis.

Improvement of balance along with bone-enhancing pharmacotherapy can improve the level of an individual's physical activity and mobility. Balance can be improved with enhancement of postural proprioception and muscular strength. Postural deformities have been shown to impair quality of life of osteoporotic individuals. Kyphotic posture has been demonstrated to contribute to propensity to fall in osteoporotic individuals. Kyphotic posturing and gait disorders can be managed through proprioceptive training, use of a weighted kypho-orthosis, muscle re-education, and safe resistance exercises. Proprioceptive balance training can reduce falls and fracture. Sarcopenia and osteoporotic fractures create musculoskeletal challenges that cannot be met with pharmacotherapy alone. Bone loss, imbalance, and gait disorder along with cognitive concerns can increase with aging. Even in healthy persons, predisposition to falls increases with age-related neuromuscular changes. Muscle strength decreases approximately 50% from age 30 to 80. Furthermore, the amount of body sway increases with reduction of proprioception. Therefore, measures that can decrease imbalance can reduce the risk for falls and fracture. In normal balance, ankle strategies are recruited rather than hip strategies. Strengthening of the lower extremity muscles reduces the risk for falls. Gait aids can also decrease the risk for falls. During a fall, the risk for hip fracture increases 30-fold if there is direct impact to the hip. The use of hip protectors can decrease the risk for hip fracture during a sideways fall. Training in effective safe-landing strategies should be included in fall prevention programs.

Measures of musculoskeletal rehabilitation play an integral part in the management of patients with increased fracture risk because of osteoporosis or extraskeletal risk factors. This article delineates current scientific evidence concerning nonpharmacologic approaches that are used in conjunction with pharmacotherapy for prevention and management of osteoporosis. Fractures caused by osteoporotic fragility may be prevented with multidisciplinary intervention programs, including education, environmental modifications, aids, and implementation of individually tailored exercise programs, which are proved to reduce falls and fall-related injuries. In addition, strengthening of the paraspinal muscles may not only maintain BMD but also reduce the risk of vertebral fractures. Given the strong interaction between osteoporosis and falls, selection of patients for prevention of fracture should be based on bone-related factors and on risk factors for falls. Rehabilitation after vertebral fracture includes proprioceptive dynamic posture training, which decreases kyphotic posturing through recruitment of back extensors and thus reduces pain, improves mobility, and leads to a better quality of life. A newly developed orthosis increases back extensor strength and decreases body sway as a risk factor for falls and fall-related fractures. Hip fractures may be prevented by hip protectors, and exercise programs can improve strength and mobility in patients with hip fracture. So far, there is no conclusive evidence that coordinated multidisciplinary inpatient rehabilitation is more effective than conventional hospital care with no rehabilitation professionals involved for older patients with hip fracture. Further studies are needed to evaluate the effect of combined bone- and fall-directed strategies in patients with osteoporosis and an increased propensity to falls.

Musculoskeletal changes that are related to osteoporosis can be prevented, challenged, or reduced with implementation of proper rehabilitation programs. The nonpharmacologic interventions recommended here are evidence-based and have resulted from controlled trials and studies.

In men and women, the combination of aging and reduction of physical activity can affect musculoskeletal health and contribute to the development of bone fragility. In general, women's muscle strength and bone mineral density at any time in life are significantly lower than those of men. The level of bone mass in adults depends on the peak bone mass acquired during skeletal maturity and on the rate of bone loss thereafter. Postural changes due to loss of bone, muscle mass, and back strength are more significant in women with increasing age and decreased physical activity, as are skeletal deformities. Muscle loss may contribute to osteoporosis because muscle mass is directly related to bone mass. Women who have osteoporosis also perform strenuous daily physical activities. Therefore, it is not surprising that small-framed osteoporotic individuals experience compression fractures during their activities of daily living. Osteoporosis can affect women and men of all shapes and sizes. However, individuals of small frame and lower muscle and bone mass can be affected even more.

Bone is exposed to constantly changing patterns of loading and adapts to these changes through alterations in bone mass and skeletal geometry. Decreased weight bearing and immobilization are known stimuli to bone resorption. Weightlessness in space travel has been reported to result in a 33% loss of trabecular bone volume over a 25-week period. There is sufficient evidence to support the concept that the absence of pressure forces on the skeleton is primarily responsible for disuse osteopenia. However, the exact mechanism whereby bone mineral is lost is uncertain. Mechanical strain on the matrix stimulates bone formation at the cellular or molecular level. The mechanism by which the mechanical signal is transduced into a biochemical signal is not known.

Objective To determine the influence of back extensor strength on vertebral fractures in 36 women with osteoporosis. Design We conducted a cross-sectional study of female patients with osteoporosis by assessing anthropometric variables, bone mineral density, muscle strength, level of physical activity, and radiographic findings in the spine. Material and Methods The 36 study subjects with osteoporosis, who ranged from 47 to 84 years of age, satisfied specific inclusion and exclusion criteria that minimized confounding factors related to pathophysiologic features, diet, and medications. A physical activity score was determined for each subject on the basis of daily physical activities relating to homemaking, occupation, and sports. Results The range of the physical activity scores—from 2 to 13—indicated that no subject was involved in unusually demanding physical activities. Bone mineral density values ranged from 0.49 to 0.92 g/cm 2 . Thoracic kyphosis ranged from 31.0 to 84.0°. Isometric strength of the back extensor muscles ranged from 7.3 to 34.0 kg. Statistical analysis demonstrated a significant negative correlation between the strength of the back extensor muscles and thoracic kyphosis. Significant negative correlations were also found between back extensor strength and the number of vertebral compression fractures and between bone mineral density and the number of vertebral fractures. Conclusion The negative association between back extensor strength and both kyphosis and number of vertebral fractures suggests that increasing back strength may prove to be an effective therapeutic intervention for the osteoporotic spine. In persons with stronger back muscles, the risk of vertebral fractures will likely decrease.

Strong back muscles contribute to good posture and skeletal support. Osteoporosis, being a metabolic bone disease, should not affect muscle strength. In this study we were interested in comparing the back extensor strength (BES) of osteoporotic and normal women. Fifty-five women ages 40-85 years who had a documented diagnosis of osteoporosis and were referred for initiation of proper exercise programs were included in our study after meeting the inclusion criteria. They all had evaluation of their posture, back and upper extremity strength, and physical activity score through our Rehabilitation of Osteoporosis Program--Exercise (ROPE). In addition, to avoid the interference of pain on application of maximal effort, we did not include subjects with acute back pain or those who experienced back pain with maximal effort during the testing trial. BES for osteoporotic women ranged from 16 to 65 lb (mean +/- SD, 36.5 +/- 15.5) for ages 40-59 years, 9 to 55 lb (mean +/- SD, 29.9 +/- 10.6) for ages 60-69 years, 6 to 52 lb (mean +/- SD, 24.3 +/- 10.2) for ages 70-79 years, and 17 to 27 lb (mean +/- SD, 21.2 +/- 4.2) for ages 80 years or older. Comparison of these data with the BES of 25 normal women, with statistical adjustment for age, demonstrated that the osteoporotic women had significantly lower BES than the normal women. A longitudinal study of a larger group of women would be of great interest for clarifying whether the weakness of back extensors precedes and, indeed, contributes to compression fractures of the spine.

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.

Osteoporosis is asymptomatic until fracture occurs. Fracture of the vertebral bodies can be "silent" and is diagnosed incidentally on radiographic visualization. The occurrence of spontaneous vertebral fracture in an otherwise healthy individual is considered pathognomonic of spinal osteoporosis. Osteoporotic vertebral fractures and kyphotic posture are no longer disorders about which nothing can be done. Resistive training exercises can decrease the risk of vertebral fractures. Proprioception generated within joints, ligaments, and muscles contributes to awareness of the relative orientation of functional units of the spine at rest and in motion. This is fundamental to posture, balance, and locomotion. Proprioception reeducation can be utilized for improving posture and balance. The focus of this review is rehabilitative measures for management of vertebral fractures.

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.

Bone formation and resorption are ongoing phenomena. When bone resorption equals bone formation, bone mass remains stable. When resorption exceeds formation, bone mass is reduced--a process that leads to osteopenia or osteoporosis. Osteopenia is reduced bone mass and osteoporosis is reduced bone mass with resultant fractures. Reduced bone mass may be postmenopausal or related to ovarian failure (type I osteoporosis), it may be age-related (type II osteoporosis), or it may result from several other etiologic factors (secondary osteoporosis). Disuse and inactivity can cause bone loss, whereas weight-bearing exercises may maintain or improve bone mineral density. There is a significant correlation between muscle strength and bone mineral density. There is evidence that strengthening exercises may lead to an increase in the mineral density of the bones to which the muscles are attached. Currently, drug regimens are available to decrease or halt bone loss in osteoporotic patients. Properly designed exercise programs may prove to be effective for retarding age-related bone loss. In patients with osteoporosis, the cause should be investigated before treatment is commenced.