By Lange, U; Teichmann, J; Strunk, J; Mueller-Landner, U; Uhlemann, C
For the treatment of osteoporosis, appropiate physiotherapy needs to use the given or remaining abilities of a patient to modulate and optimize the biological functions and structures (bone, muscle) in an adaptive, stimulating and regenerating sense. In addition physiotherapy can set serial physical stimuli to minimize pain perception by bio-psychosocial effects. Physiotherapy for osteoporosis has to be seen equivalent to pharmacotherapy with respect to prevention, cure and rehabilitation. In general, 2 different aims for effective treatment can be defined: 1. Aims that can be achieved solely with physical therapy, such as structural improvement of the existing and pharmacologically increased bone mass, slowdown of round-back formation and fall prophylaxis. 2. Aims that can be mainly achieved with physiotherapy and pharmacotherapy, such as increase of bone density and differentiated amelioration of pain. This article summarises the current knowledge on exercise and physiotherapy in preventing and treating osteoporosis, and focuses specifically on the diagnostic-orientated stimulating preventative, curative and/or rehabilitative effects, in which the choice of the individual regimen and the dosage need to be optimized for every patient individually.
Key words: Osteoporosis, diagnosis – Osteoporosis, therapy – Exercise – Physiotherapy.
Physical activity/exercise and bone
Exercise plays an important role in the prevention and treatment of osteoporosis. The overall aims of physiotherapy and sports therapy are the stabilization of the skeleton, a substantial remineralization, amelioration of pain and prophylaxis of fall.
Unfortunately, a randomized double-blind placebo-controlled study demonstrating that physical activity and exercise in youth, adulthood or in the elderly reduces fragility or osteoporosis- related fractures is difficult (or even impossible) to perform. On the other hand, a well-known relation between reduced physical activity and loss of bone mass exists, especially after post surgical immobilisation following spinal cord injury. Immobilised patients may lose 40% of their original bone mass in 1 year, whereas physical activity, e.g. standing in upright position for as little as 30 min each day prevents substantial bone loss.1
Role of exercise in prevention of fractures
It is widely accepted that physical activity is beneficial for the skeleton. Therefore, physical exercise is recommended to preserve skeletal health and to prevent age-related fractures.2 In addition, there is compelling evidence that exercise diminishes the risk factors for fall, and that exercise results in improved muscle strength as well as co-ordination and balance capabilities.
It needs to be noted that the extraskeletal effects of physical exercise, particularly with respect to the improvements in circulation, coordination, general well-beeing, sleep, social contacts, and even preventing of infectious disease,3 all contribute to an improved quality of life, and may also indirectly reduce the risk of falls and fractures.4 Assuming that a large proportion of osteoporosis fractures are a consequence of traumatic falls and are not spontaneous due to osseous instability, preventive physical therapy should target the muscular weakness, overall mobility and the visual capabilities.
There is several mechanisms by which exercise can reduce the incidence of age-related fractures. Of there, fitness programms that have been started in childhood have demonstrated a substantial positive effect on bone geometry, mass and mineral density. In this context, the benefical effect of exercise on bone mineral density (BMD) can especially be observed during growth: the higher BMD is the result of surface-specific periostal modelling, which increases bone mass and endostal (endocortical, trabecular, intracortical) thickness.5 However, no data are available whether the cortices themselves become less porous (due to few or smaller haversian canals). Mechanical stimuli and their effect on cellular activity trigger bone remodelling and osteoclastogenesis that, however, at present the type, duration and intensity of mechanical load will produce the most intensive osteogenic stimulus is not known. Therefore, to examine the influence of physical activity on bone mass, it is important to understand how physical activity contributes to the mechanical loaddependent mineralization of a given skeletal tissue.
In young adults, for example, exercise increases the peak bone mass, which lowers the risk for fractures at a higher age. In early menopausal women, exercise attenuates the rapid bone loss associated with estrogen deficiency, and in elderly individuals, exercise retards age-related decreases in general bone mass, reduces the incidence of falling and decreases the severity of falls.
On the other hand, the basis for the idea that exercise reduces fractures is derived from studies with rather low levels of evidence, namely retrospective and prospective observation cohort studies and case-control studies, but the contradictory null hypothesis that exercise has no effect on frature risk, can also not be rejected.
Fractures and exercises in women
There are several studies, which show that individuals with a lower prevalence of past or current physical activity are at an higher risk for hip-fractures 6,7 and that daily activity climbing stairs and walking are associated with a lower risk for hip- fractures.8,9 A longitudinal study of osteoporotic fractures6 and some prospective studies 10-14 demonstarted also that physical activity was protective. In addition, the European Vertebral Osteoporosis Study (EVOS), a longitudinal study, reported a protective effect of continuous exercise to reduce the number of vertebral fractures.15
Fractures and exercise in men
A protective effect of vigorous physical activiy and exercise to prevent hip fractures has been demonstrated in the Leisure World Study,11 a longitudinal study. Similar results could be observed in 4 prospective studies.11-14
Physiotherapeutic strategies in osteoporosis
Defined and validated physiotherapeutic regimen for the various forms of osteoporosis do not exist at present. However, physiotherapeutic strategies for the prevention and therapy of manifest osteoporosis have to be regarded a mandatory supplement to osteoprotective medication.
Physiotherapy offers the possibility of ameliorating local symptoms (i.e. pain and malfunction), improves the functional capabilities and affects the whole organism by positive physiological stimuli. In general, all pysiotherapeutic strategies improve mobility and flexibility by repeated stimulation and induce adaptation to an altered mechanical load.
Of the physiotherapeutic strategies used in daily practice, repeated application of hydrotherapy and exposure to ultraviolet light exerts a strengthening effect, and massage, group physiotherapy and body-awareness training are helpful procedures to achieve well-being, increased self-competence, and empowerment. Special goals of physiotherapy in patients with osteoporosis include strategies to optimize body static and movement schemes and stimulating techniques for muscle strength.
In addition, aberrant pathways of bone metabolism needs also to be eliminated, especially the reduction of pain.
When targeting the latter, it is necessary to differentiate between the different forms of pain in osteoporotic patients. Nociceptive pain needs physical stimulation, which influences predominately chemical composition of body fluids; neuralgic pain requires a stimulation, which results in a positive neuralgic reaction; whilst in the case of psychosomatic pain, it is necessary to use to treat the person as a whole. Active mobilising therapy and physiotherapy have common and diverging elements within the treatment strategies for osteoporosis and must be used in accordance with the actual physical ability of each patient.
In summary, physiotherapy for osteoporosis is mainly a diagnostic- orientated stimulating, preventive, curative and/or rehabilitative therapy.
Physiotherapy of the osteoporosis-syndrome special aspects
The specific pathogenetic process of osteoporosis itself proceeds painlessly.16-18 Therefore, based on the different levels of severity, manifestation forms and complications of osteopenia and osteoporosis, a functional diagnostic under pathomorphological and pathofunctional aspects is indespensable.
Identification of the pain in osteoporosis
Identification of the origin of pain as well as the nociception regarding its etiology (dysfunction, destruction, degeneration) and pathomechanism (mechanical, chemical, psychosomatic maltension) are of essential importance for the adequate choice of physiologically optimal physiotherapeutic treatment.
Nociceptive pain in osteoporosis presents as a receptor pain in the following structures: cords, tendons, muscles, periost, intervertebral disk and capsule, whereas neurogenic pain presents as irritations of the spinal cord and the roots of the peripheral nerves. Psychosomatic pain, however, presents as a comprehensive psychophysic maltension with changing localisation.19
Differential physiotherapy
Physical pain therapy includes electric (direct current, low- frequency stimulation current), thermic (hydrothermic, high frequency thermic – short-wave, ultrasound, li\ght-thermic – red- light) and mechanical (massage, physiotherapy) stimuli which can be applied regionally, locally or comprehensively20,21 (Figure 1). An efficient pain therapy requires that a differentiation can be made between acute and chronic pain episodes.22,23 Whereas physiotherapy in acute pain demands immediate therapy (normally rest and mild cold applications), it has to fulfile an adaptive performance therapy of neuronal structures in chronic pain (formative-adaptive physiotherapy, improving trophic thermotherapy, direct current, transcutaneous electric nerve stimulation, TENS).
Nociceptive pain
Nociceptive pain can be aggravated by longitudinal and exercise loads. This intensification usually occurs later like an episode (after pain). According to Senn,24 it is also defined as an irritational syndrome (mechanically and metabolically caused tissue inflammation) of the mesenchymal tissue; it has a dystrophic effect on all mesenchymal structures and can also be the late reaction to a phase of increased strain (decompensated strain syndrome). The physiotherapy in this case consists of a contineous easing of stress on the spine, which entails decreased axis loading and alleviation of physical strain, and of “mild” cryotherapy (e.g. cold packs) several times a day.
Acute osteogenic pain, causes by micro- and macrofractures or by stress-related, extremely high bone resorption, occurs frequently during the night.25 In this cases, pharmacotherapy has the top priority, and the physiotherapeutic applications include relief positioning and mild cryotherapy several times a day (e.g. cold air at – 30C, 300 L/min, 10 min or cold packs).
Chronic bone pain, on the other hand, responds well to mild thermal therapy (e.g. peloids at 38C) and active exercise therapy (muscle detonising, stabilising techniques).21,26
Diathermal ultrasound, which exerts its main effect in the subcutaneous tissue compartments results in an upregulated tissue metabolism, hyperemia, increased elasticity of connective-tissue fibres, and tissue-trophic improvement.27 It needs to be noted at frequently an increase in pain occurs, which secondarily leads to a relief of pain. Furthermore, appropiate doses of ultrasound (0.7- 1.2 Watt/cm^sup 2^, 10 min per region, 10-15 treatments) results in a stimulation of osteogenesis, most likely by a mechanical action on the piezoelectric potential of the bone. The application of low- frequency ultrasound dominates the mechanical components, which is by far more relevant than high-frequency ultrasound in the context of osteoporosis for influencing the altered process of remodelling.28,29
Figure 1.-Differential physiotherapy procedures for pain in osteoporosis based on curative aspects.
Tendomyoses (pain along the muscle chain) usually present with pain at early morning hours.30 In these patients, specific physiotherapy includes special massage techniques (frictions), exercise therapy (postisometric relaxation), short-wave ultrasound and TENS. Here, the treatment of trigger points by dry needling (intramuscular stimulation) 31 prove to be efficient as “well.
Neurogenic pain
Physiotherapeutic applications that activate neural mechanisms especially the inherited pain-blocking mechanisms of the organism resulting in analgesia can be used for the treatment of neurogenic pain, which is projected into the receptor- or autonomy region (dermatome, myotome, sklerotome).21,26 The most important physiotherapeutic procedures to treat this type of pain are cryotherapy short-time stimuli with an application time of less than 3 min, low-frequency electric stimuli (TENS), as well as special connective-tissue-massage techniques. A certain analgetic potency can also be achieved by direct-current applications, which is based on the depletion of neuropeptides (substance P, CGRP) comparable to the operating mechanism of capsaicine.32
Psychosomatic pain
The key accers to psychosomatic pain is the determination of the type of pain, e.g. nonlocalisability, resistance to therapy, accompanying psychovegetative instability, signs of autonomous dysregulation,19 as patients with osteoporosis have a sense of suffering that facilitate secondary, reactive, psychosomatic reactions. In contrast to treatment of localised symptoms for psychosomatic complaints holistic physiotherapeutic techniques such as thermoneutral immersion, training in body perception, therapy according to Schaarschuch-Haase, progressive muscle relaxation according to Jacobson, concentrative relaxation or psychophysical detonisation including whole-body massages can be used. At play here are a primary sense perception that triggers physical stimuli and a hedonic, emotional experience as a holostic therapeutic agent.33
Role of exercise in preventing and treating osteoporosis
Data from retrospective and prospective observational and case- control studies support the idea that physical activity is associated with a reduced fracture risk and that physical activity is beneficial to the skeleton.2,5,34,35 Exercise is associated with improved muscle strength, coordination and balance which is illustrated by the observation that bone mass of trained athletes exceeds that of nonathletic controls. There are several mechanisms by which exercise may reduce the incidence of age-related fractures, but the exact stimuli and the respective effect on cellular activity that trigger bone remodelling are not known, the type, duration, and intensity of mechanical load that will produce the most intensive osteogenic stimulus.
Various investigations have revealed a positive relationship between lifelong physical activity patterns and bone remodelling.36,37 For example, tennis players38 and squash players39 can develop an osseous hypertrophy in the region of the lower arm, joggers in the lumbar spine. According to published studies, an increase in bone density of approximately 26% is possible in certain localisations of the osseous parts of the skeleton as a result of physical exercise.40 Longitudinal studies have also provided evidence of a positive effect on bone mass.41,44 The increase in bone density that can be achieved, however, is dependent on the kind of exercise, the duration and the intensity as well as on the age, sex, and genetic disposition of the individual. Nevertheless, it must be noted that a reduced rate of fractures in general has not been reported for athletes.45,46 An interesting detail revealed a comparative study of rural and urban populations in the context of the effect of physical activity on bone mass: the prevalence of osteoporotic fractures was considerably lower among the hardworking country population.47
The influence of sport/physical activity on the risk of falling
Physical training has several benefits for elderly individuals: it stabilises circulation and improves their ability to avoid stumbling or falling, and reduces subsequently also the rate of fractures.48 However, all additional intrinsic risk factors for falling (e.g. blood pressure, pulse, cerebral ischaemia) as well as the environment-related ones should be reduced. For example, it has been possible to achieve a considerable improvement in balance and a reduction in the risk of falling by using special cardio-exercise therapy or Chinese training programmes.49
Physical activity as a therapeutic principle
Physical activity is a strong stimulus for the formation of biological tissues and the modulation of their individual functions, and appropriate stimuli are also necessary for the homeostasis of the interacting and adaptative systems nerve – muscle – bone. For effective treatment of osteoporosis physical therapy should be motor- function-regulative, structure-formative and movement0 – educative.21,50 Muscle traction and pulsating pressure are the therapeutic elements that need to be combined with gymnastics techniques and/or concepts and with sports medicine.”51-54 On the other hand, the type of exercise, the intensity of the physical therapy and the application schedule with respect to duration and intervals must be adapted to the function and individual condition of the motor system and the structural quality of the bone. In this context, previous fractures and corticoid therapy need to be taken into account.55-59 The evaluation of randomised clinical studies on the effect of physical therapy on osteoporosis in women provided evidence that regular endurance training (even normal walking), weightlifting, and heavy exercise leads to an increase in bone densitiy and a reduction of the risk of fractures in women of all age groups when compared to women without physical exercise.60 The best everyday activities or types of sport for the bones are those that force the patient to act against gravity. Usual everyday activities include climbing stairs and normal walking, even better types of sports with regard to bone protection are cycling, jogging/ running, cross-country skiing, dancing, mountain climbing and moderate weightlifting.61 Of these, especially weightlifting exercises are best suited to increasing bone density.62
Heavy exercise, however, in contrast to endurance training and aerobics,63 walking, or tap-dancing, has no influence on the bone density in the femoral neck region.64 Of interest, weight-relieving sports such as swimming did not show any effect on increasing bone density.65
With regard to gymnastics, dynamic stabilisation involving antigravitation with additional pressure on the body structure (weight bearing) 51,66,67 facilitates effects towards formative mobility. Regional remineralization and counteracting osteoclastogenesis can be achieved by moderate muscle-strengthening and holistic-orientated exercises such as aerobic endurance (fitness) and axis loading.51,54,68 This positive correlation between muscle strength, physical activity in the context of a normal life style and bone quality has been thoroughly investigated and confirmed.51,66,69,70 Nega\tive correlations have also been found in cases of inappropriate exercise, especially inadequate stress and tension.59,68,69,71
Osteoporosis patient associations have also a particular psychologic effect, specifically on experience orientation, cognitive therapy participation, empowerment, and a long-term motivation to deal with the course of the disease.33,72
One of the key parts of patient education are the instructions in proper movement behavior at home, at work, in their leisure time, and in their athletic activities.
For example, bending of the torso and kyphotic movements under stress must be strictly avoided, similar to jumping exercises, sit- ups, trunk rotation, and/or lateral flexion of the spine as well as excessive muscle stretching- and strengthening movements.17,59,71,73
Hower, the role of gymnastics to counterbalance and/or even correct subject to the deformations of the spine and to prevent fractures is still discussion. On one hand, the erection of the pelvis and thorax by muscle-stabilisation techniques and the prophylaxis of falls by coordination training can significantly ameliorate the situation of the patients, on the other hand, these attempts have limitations due to pain, progression of the pathogenetic process, lack of adaptationcapable structures as well as regulative functions and the age-related reduction of sensorimotor abilities.55, 56,74 of note, both corticosteroid- dependent osteoporosis and advanced stages of the osteoporotic deformation process necessitate a differentiated application of physiotherapy techniques, which includes also the reduction of unnatural stress on the skeleton. In this case, holistic tension exercises below the individual pain threshold, are recommendable.57,58,75
Isometric muscle-tension movements (isolated or in function chains) as well as proprioceptive neuromuscular facilitation (PNF) techniques facilitate an additional stability of the motor system for the patient with osteoporosis.75 Here, to modulate adequately the disturbed remodelling process, a structure-formative pressure stimulus in the direction of the axis (axis loading) along with isometric traction is essential.54,60,68
Elastic corsages should be recommend if the targeted parameters of gymnastics are limited by the pathogenetic process, and in case of vertebral fractures, an adequate corsage protecting the fractored area is mandatory. 53
In the context of osteoporosis, gymnastics and sport therapy have similarities as well as differences.76 Whereas gymnastics are predominantly symptomsyndrome orientated, sport therapy is directed towards influencing systemic (holistic) physical performance.
The relevance of physiotherapy within the concert of osteoprotective strategies consists on one hand in ameliorating pain; on the other hand, it improves disturbed muscular tension, supporting muscle-strengthening stabilisation (correction of posture problems), and consecutively fall prophylaxis and ADL training (everyday activites). In fall prophylaxis, the result of physiological ageing (bending-forward posture, taking little steps, reduced balancing reaction) and osteoporosis dependent incorrect posture and altered mechanisms of movement must be taken into account.24 The techniques for fall prophylaxis include balancing exercises in water (easy exercises to practice standing up straight, walking and fall behavior) as well as training static balance (therapy spin, balancing seesaw) and dynamic balance (exercises with partners, balancing over gymnastic bench).
Specific training programmes aimed at muscle remodelling under axial weigth bearing are the domain of sport therapy from the aspect of physiological training. Especially movement in water has a distinct significance for the osteoporosis syndrome due to the physical properties of water and the resulting influence on the physiological regulatory system.76 The advantageous buoyancy due to the minimisation of gravity, although the loss positive-trophic bone stimulation of gravitation, results in an adjustment of the nominal value of proprioception that corresponds to a relief of stress on the structures of the motor system. Thus, it is possible to exercise the joints without stress and stress dependent pain, which is amplified by the thermic components of water, and the diminished fear to fall during exercise. Furthermore, by varying the viscosity of the immersion medium, a tactile stimulus of the skin can be used for modulating and improving body perception. In addition moderate training by a dynamic stabilisation (movement against the resistance of the medium) is possible.
Osteoporosis – Recommendations for physical activity
In the holistic therapy concept for prevention and therapy of osteoporosis, at present no validated qualitative and quantitative minimum standards for physiotherapy exists. In general, in osteoporosis of the spine it is recommended that stress on the ventral side of the vertebral column is avoided, which should be combined with a strengthening of the back extensors. Hiking, cycling, dancing and swimming are preferentail sports activities. A current survey provides general suggestions for the type and intensity of physical activity depending on the individual severity of a given osteoporosis patient.62 These recommendations correspond to those of the German Society for Sports Medicine and the American College of Sports Medicine expecially with regard to training endurance, stength and flexibility and selecting coordination exercises.
Recommendation for therapy of osteoporosis in daily practice
The recommendations for therapy of osteoporosis in daily practice according to Lange et al.77,78 are the following:
1. Acute pain, in the bones as well as in soft parts, (fractures, irritation syndrome) requires analgetic cryotherapy in the form of mild cold (.e.g. cold compresses 150 -20, 10-15 min and/or cold air – 30C 300 L per minute for 10 min) along with stress-free positioning over a period of 5-7 days. It needs to be noted that active gymnastics are counterproductive.
2. For chronic pain caused by incorrect posture, dystrophic structures of the motor system and limitation of mobility, tratments with heat, massages and galvanisation from daily to 3 times a week in a series of 10-15 treatments are effective. Appropriate physiotherapeutic techniques with thermic effects are ultrasound (1.0 Watt/cm^sup 2^, 10 min per region), peloids (mudpacks 40C 30 min, fango packs 38C 30 min), haysack therapy (alternative-medicine morphine!) 48C, 30 min and short wave (codenser field method, 80 watts, 10 per region). With regard to massage therapy, the general massage that uses specific hand techniques to treat altered soft- tissue structures must be distinguished from the connective-tissue massage as a reflex-zone massage for the treatment of neurogenic pain (e.g. for algodystrophy). In addition, the analgetic potency of galvanization (direct current) is used with the hydroelectric-full- bath therapy (38C, 200 mA, 20 min) for pain in the entire body has proven to be effective.
3. Gymnastic exercise programmes can be used both as individual therapy and as group therapy (including a psychotonus-stimulating option), but muscle strengthening, joint mobilising, and coordinative techniques to influence posture and maintain agility as well as fall prophylaxis are also an essential component of the treatment.
In the latter, the ideal is series of treatments for 2-3 times a week for a period of 6-9 weeks.
4. Mobility therapy in water is of significant importance because of the lacking weight of the body during the exerise. However, the motor system is not only relieved of stress and of stress-related pain but also from the fear of falling.
5. Physiotherapy as pain therapy and exercising therapy regarded as an influence on positive-trophic factors must be interreted in the context of formative-training sport therapy.
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U. LANGE1,2 J. TEICHMANN3, J. STRUNK1,2, U. MUELLER-LANDNER1,2, C. UHLEMANN4
1 Kerckhoff Clinic, Department of Rheumatology Clinical Immunology, Physical Medicine and Osteology, Bad Nauheim, Germany
2 Department of Internal Medicine and Rheumatology University of Gien, Gieen, Germany
3 Medical Clinic C, City-Hospital Ludwigshafen Ludwigshafen, Germany
4 Institute of Physiotherapy, University Jena, Jena, Germany
Address reprint requests to: Priv.-Doz. Dr. med. U. Lange, Kerckhoff Clinic, Department of Rheumatology, Clinical Immunology, Physical Medicine and Osteology, Sprudelhof 11, 61231 Bad Nauheim, Germany. E-mail: [email protected]
Copyright Edizioni Minerva Medica Jun 2005
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