Move Forward Guide
Physical Therapist's Guide to
Osteoporosis is a common disease that causes a thinning and weakening of the bones. It can affect people of any age. Women have the greatest risk of developing the disease, although it also occurs in men. Osteoporosis affects 55% of Americans aged 50 or older; one-half of women and a quarter of men will fracture a bone.
Thin bones are the cause of 1.5 million fractures per year in the United States— hip fractures alone result in 300,000 hospitalizations. It is important to diagnosis osteoporosis early so that steps can be taken to lessen the risk of fracture.
What is Osteoporosis?
Osteoporosis is a bone disease characterized by low-bone density (thickness of the bone), decreased bone strength, and a change in the bone structure, which can lead to an increased risk of fracture. The normal bone structure becomes thinned out and porous, lessening the ability of the bone to withstand the typical forces that are applied in everyday living. Fractures from osteoporosis and low-bone density can be serious, causing pain and affecting your quality of life.
Bone is living tissue. Normally, one type of cell removes bone and another type of cell adds bone in a balanced, ongoing process. In osteoporosis, bones weaken when not enough new bone is formed and/or too much bone is lost. This imbalance commonly begins in women during the first 5 years of menopause. However, it can also occur in men and in children, often due to diseases that affect bone development, such as Celiac disease, inflammatory bowel disease, rheumatoid arthritis, spina bifida, cystic fibrosis, or kidney disease. Some medicines, such as steroids, may increase your risk for developing osteoporosis. Athletes who are underweight during the time of peak bone development are also susceptible.
There are many factors that can cause a person to be at risk for developing the disease. It is important to know your risks so that you can be diagnosed and proactive in your treatment.
Risk Factors for Osteoporosis
- Female gender
- Small frame
- Advanced age
- Hormone levels
- Predisposing medical conditions
- Cigarette smoking
- Excessive alcohol intake
- Inactive lifestyle
- Excessive caffeine intake
- Lack of weight-bearing exercise
- Drugs (eg, steroids, heparin)
- Poor health
- Low weight
- Calcium-poor diet
- Low vitamin D levels
How Does it Feel?
Osteoporosis is a disease that can be "silent," and there may be no outward symptoms until a fracture occurs. If you are middle-aged or older, you may notice a loss of height or the appearance of a humpback, although this is not a diagnosis for osteoporosis in and of itself. Fractures may occur in situations that would not occur in persons with healthy bones, such as breaking an ankle after stepping off a curb, breaking a hip with a fall, or breaking a rib when opening a window. These are called fragility fractures and are a red flag for bone disease. Spinal compression fractures, particularly those in the upper back or thoracic spine (area between the neck and the lower back), are the most common fractures, followed by hip and wrist fractures.
How Is It Diagnosed?
If you are seeing a physical therapist for back pain or other rehabilitation issues, he or she will review your medical, family, medication, exercise, dietary, and hormonal history, conduct a complete physical examination, and determine your risk factors for osteoporosis. The assessment may lead the therapist to recommend further testing.
Osteoporosis is best diagnosed through a quick and painless specialized x-ray called the DXA, which measures bone density. The results are reported using T-scores and Z-scores.
- The T-score compares your score to that of healthy 30-year-old adults. If you have a T-score of -1 or less, you have a greater risk of having a fracture.
- The Z-score compares your bone mineral density to those of the same sex, weight, and age. It is used for those whose bone mass has not yet peaked, premenopausal women, and men older than 50.
Other methods of measuring bone density include x-ray, ultrasound, and CT scan.
How Can a Physical Therapist Help?
Your physical therapist can develop a specific program based on your individual needs to help improve your overall bone health, keep your bones healthy, and help you avoid fracture. Your physical therapist may teach you:
- Specific exercises to build bone or decrease the amount of bone loss
- Proper posture
- How to improve your balance so as to reduce your risk of falling
- How to adjust your environment to protect your bone health
Healthy bone is built and maintained through a healthy lifestyle. Your physical therapist will teach specific exercises to meet your particular needs.
The exercise component for bone building or slowing bone loss is very specific and similar for all ages. Bone grows when it is sufficiently and properly stressed, just as muscle grows when challenged by more than usual weight. Two types of exercise are optimal for bone health, weight-bearing and resistance.
It is best for a physical therapist to provide your individual bone-building prescription to ensure that you are neither over- or under-exercising. Typically, exercises are performed 2 to 3 times a week as part of an overall fitness program.
- Racquet sports
- Heel drops
- Weight lifting
- Use of exercise bands
- Water resistance
- Gravity resistance (eg,push-ups, sustained yoga poses)
If you are diagnosed with osteoporosis or low-bone density, your physical therapist will work with you to:
- Build bone or lessen the amount of bone loss at areas most vulnerable to fracture through exercise—hip, spine, shoulder, arms
- Improve your dynamic balance to avoid falls
- Improve your posture and your work and living environments
- Help you avoid exercises and movements that may contribute to spinal fracture, including any type of sit-up or crunch, and excessive spinal or hip twisting
Conservative treatment of a fracture includes bed rest and appropriate pain medication. Your physical therapist will work with you to:
- Decrease your pain through positioning and other pain-relieving modalities
- Provide appropriate external devices, such as bracing, to promote healing and improve posture
- Decrease your risk of a fall, strengthen your muscles, and improve your postural alignment
If your pain lasts longer than 6 weeks following a fracture, you can discuss surgical options with the physical therapist, primary care physician, and surgeon.
For children and adolescents, physical therapists can educate families and youth groups on proper exercise, posture, and the need to move daily. Children with health issues such as spina bifida, diabetes, Crohn's disease, and cerebral palsy are at a greater risk for bone disease and can particularly benefit from the guidance of a physical therapist. The majority of bone is built during adolescence and peaks by the third decade of life.
If you are middle-aged and older, you may begin to notice postural, balance, and strength changes. Your physical therapist will work with you to:
- Optimize your exercise program to promote bone growth or lessen bone loss
- Improve your dynamic balance to avoid falls
- Improve your posture
- Improve the strength of your back muscles
- Improve your hip strength and mobility
Can this Injury or Condition be Prevented?
Osteoporosis can be prevented by building adequate bone density through childhood, adolescence, and early adulthood. Building strong bones requires an adequate intake of calcium and vitamin D, and regular exercise.
There are steps to take to improve bone health at any age. An active lifestyle that includes resistance and weight-bearing exercise is important to maintain healthy bone. It is also important to avoid habits that promote bone loss, such as smoking, excessive alcohol consumption, and an inadequate intake of calcium in your diet. Maintaining good body mechanics and posture also contribute to good bone health. We have no control over the genetic tendencies we have inherited, but we can choose to manage osteoporosis through proper medication, diet, and appropriate exercise
As with any health issue, an overall healthy lifestyle is important for staying well.
Real Life Experiences
Anna is 69 years old and has a history of breast and ovarian cancer. She has had a total knee replacement due to arthritis. She walks with a cane because of chronic knee and ankle pain, and she has experienced a loss of balance. She has a very rounded upper back, and low back pain. She is seeking the help of a physical therapist.
Anna's physical therapist performs an assessment that includes a medical review for other health issues and osteoporosis risk factors. He evaluates her range of motion and strength, testing her arms, legs, and trunk, especially her upper back. He tests the flexibility of her spine and her balance, walking ability, and risk of falling. Anna's walking style is uneven and she leans heavily on her cane. A DXA scan reveals that Anna has lost bone density in her spine and both hips. An x-ray shows that she has painless compression fractures of her spine. Her physical therapist diagnoses osteoporosis of the spine, and he photographs her posture for future comparison.
Anna first works with her physical therapist to improve her posture and knee function through flexibility and strengthening exercises, so she can walk more normally while working on her balance to lower her fall risk. He teaches her safe trunk movement to avoid spinal fracture. Anna agrees to wear a dynamic trunk brace 2 hours a day to help make her posture more upright. She practices weight-bearing exercises with considerations for her arthritis, and she is also given resistive strengthening exercises for her spine and hip. Anna's physical therapist designs a gentle home exercise program for her as well.
By her last visit, the flexibility and strength of Anna’s trunk and legs and her tolerance of physical activity has improved. The quality of her walking and dynamic balance is measurably improved, and her risk of falling has decreased. Anna feels more confident about managing her condition, and she looks forward to new life experiences.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat those with osteoporosis. However, if you have a diagnosis of osteoporosis or low-bone density, you may want to consider:
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy (OCS) or geriatric physical therapy (GCS). This therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist that specializes in the treatment of osteoporosis.
You can find physical therapists with these and other credentials by using Find a PT, the online tool by the American Physical Therapy Association that can help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have osteoporosis.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of chronic pain. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a Pub Med* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Cheung AM, Giangregorio L. Mechanical stimuli and bone health: what is the evidence? Curr Opin Rheumatol. 2012;24:561–566. Article Summary on PubMed.
Pfeifer M, Kohlwey L, Begerow B, Minne HW. Effects of two newly developed spinal orthoses on trunk muscle strength, posture, and quality-of-life in women with postmenopausal osteoporosis: a randomized trial. Am J Phys Med Rehabil. 2011;90:805–815. Article Summary on PubMed.
Kasukawa Y, Miyakoshi N, Hongo M, et al. Relationships between falls, spinal curvature, spinal mobility and back extensor strength in elderly people. J Bone Miner Metab. 2010;28:82–87. Article Summary on PubMed.
Nikander R, Kannus P, Dastidar M, et al. Targeted exercises against hip fragility. Osteoporos Int. 2009;20:1321–1328. Article Summary on PubMed.
Hongo M, Itoi E, Sinaki M, et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osteoporos Int. 2007;18:1389–1395. Article Summary on PubMed.
Vainionpaa A, Korpelainen R, Leppaluoto J, Jamsa T. Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporos Int. 2005;16:191–197. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Acknowledgments:Mary Saloka Morrison, PT, DScPT, MHS