by Niamh Rafter, Physiotherapist and Pilates Instructor, bounceREHAB
co-Author Matthew Craig, Principal Physiotherapist, Director bounceREHAB
How strong are your bones?
Not something you would often think of. For the majority of us, we go about our day, happy and healthy without giving it much thought. We rely on these structures to keep us strong and stable in everything that we do.
The skeleton is the bony scaffolding of the body. Osteoporosis is when this scaffolding deteriorates slowly over time; it is a complex and often poorly managed condition. So what is it, how can we manage it and actively prevent it later in life?
Let’s explore the intricacies of the disease, to gain a better understanding.
Physiology (the science bit)
The bones in our skeleton are made up of two types of bone
A solid, thick structure called cortical bone
A spongy, honeycomb type structure called trabecular bone
These make up the many bones in the skeleton, and are changing constantly across the span of our lives. Bones undergo ‘remodelling’, where old bone is broken down and new bone is generated in a continuous cycle.
We are familiar with the concept that bones grow longer as we age from childhood into adulthood. When this growth ceases, we have reached skeletal maturity. From then onwards, the bones continue to adapt and change. This is where we start to think about our bone density, and how osteoporosis can occur.
Osteoporosis means ‘porous bone’
Bone density is the amount of mineral in your bones – essentially, how much structural bony tissue is present.
The picture here shows the 'basic' normal bone remodelling process in a healthy bone. Cells play different roles to reabsorb old bone, and regenerate healthy new tissue. Bones are undergoing this physiological process, where
· The blue OsteoClasts break down old bone, and
· The red OsteoBlasts regenerate it to form new bone
Osteoporosis is a complex medical condition. See the video below for detailed information.
Decline of bone mineral density is a normal process that happens as we age. Peak bone mineral density is achieved by age 30, and from 30 onwards begins to decline.
Factors which increase your risk of low bone mineral density can be broken down as follows:
'Non Modifiable' Risk Factors
Age > 30
Gender – more common in females with small body frame size
Medications – steroids, anti epileptics
Medical conditions - specifically hormone imbalance disorders
'Modifiable' Risk Factors
Nutrition - vitamin deficiencies
Exercise - lack of resistance and impact training
It has been suggested that non modifiable risk factors contribute 75% to your risk of osteoporosis, and 25% of your risk will come from the modifiable group.
The role of hormones
For both genders, loss of bone mineral density will begin to occur from age 30 and onwards. Osteoporosis is more common in people who have too much or too little of certain hormones in their bodies.
Lowered sex hormone levels tend to weaken bone. The fall in estrogen levels in women at menopause is one of the strongest risk factors for developing osteoporosis. Treatments for prostate cancer that reduce testosterone levels in men and treatments for breast cancer that reduce estrogen levels in women are likely to accelerate bone loss.
After menopause, estrogen levels decrease. This will result in an increased rate of bone resorption, but with an imbalance of bone regeneration. In simpler terms, bone is broken down more than it is regenerated. If a female’s peak bone density in younger years was low, the normal ageing process of menopause can place her at risk of affecting long term bone health and developing osteopenia / osteoporosis.
Too much thyroid hormone can cause bone loss. This can occur if your thyroid is overactive or if you take too much thyroid hormone medication to treat an underactive thyroid.
Osteoporosis has also been associated with overactive parathyroid and adrenal glands.
Should I have a DEXA scan?
Osteopenia is the precursor to osteoporosis. Both will show no symptoms until you first break a bone. Early detection is key to better manage the condition. A DXA scan will determine the density of your bones and rate this compared to normal adult values (T-score above). It is a very safe and easy test to access.
BMD testing is recommended for all women and men at age 65, regardless of whether they have risk factors.
The International Osteoporosis Foundation has a useful online risk assessment tool for self assessment tool here, to help you learn more and discuss your potential need for a scan with your doctor and physiotherapist.
By using early detection with DXA scans, bone fracture risk can be prevented or reduced through lifestyle changes.
How to understand your DEXA Test Scores - click here (it's easy !!!)
Physiotherapy & Exercise Rehabilitation
The Royal Australian College of General Practitioners recommends the following four management strategies for men and women age 50 + , who are at risk of osteoporosis.
Falls reduction strategies (Grade A evidence)
Exercise participation (Grade A evidence)
Modify diet and alcohol/smoking (Grade C evidence)
Education and psychological support (Grade D evidence)
Physiotherapy 1-2 times a week is a key intervention in the long term management of this chronic condition. Physiotherapists are specialists in prescribing safe and specific weight bearing exercises that provide 'osteogenic' loading to your bones, that take into account any osteoarthritis or other musculoskeletal ailments.
So what exercise should we be doing?
Two types of exercise are widely supported in research, causing positive 'osteogenic' adaptations on bone mineral density.
High Resistance training – adding external muscle loads through use weights / machines / other
High Impact training – whole body bone loading exercise; think running / jumping / sport.
'HEALTHY BONES' is bounceREHAB's flag-ship exercise programme designed specifically to improve bone mass, muscle strength and balance and thereby prevent falls and fractures.
Healthy Bones takes the high intensity exercise program principals tested in the successful LIFTMOR
trial, with the addition of a range of exercises known to enhance balance. While Healthy Bones lifting exercises alone will reduce the risk of falls, the dedicated balance exercises included at bounceREHAB are likely to
not ably enhance this effect.
Not all exercises are created equal when osteogenesis (generation of bone) is the goal. Teens and young adults should participate in both resistance and impact training.
The view that general activity (walking, swimming and cycling) is of benefit has been disproved, according to ESSA (Exercise and Sports Science Australia). Walking, even briskly, has been proven to have low to minimal effect on improving bone health. Despite the obvious benefits on other body systems, walking alone will not be enough for the skeletal system health.
Sport participation which involves jumping, landing and changes in direction has positive benefits for skeletal adaptation. Examples of this include: Pilates, Tennis, Field sports, Volleyball, Gymnastics
Heavy resistance training (80% + of 1RM) and power lifting training, with bands, springs or weights performed twice a week, has been proven to place positive stress on bone tissue and generate increased resilience.
Research has shown that females who have a 10% greater than average bone density score (at 30 years of age) , will reduce their lifetime risk of fragility fractures by 50%.
'HEALTHY BONES' at bounceREHAB
Bone Safe Exercise
If you have a diagnosis, it is important to work individually with a physiotherapist to determine suitable exercises for your condition.
Weight bearing and brief high resistance programs can improve bone density in any individual, at any age.
"When it comes to our bones the research tells us not all exercise is equal. In fact, exercise that is targeted, supervised and focuses on resistance and impact training is best" (Professor Beck)
Determining an individualised program is key, and there are safety considerations that apply.
bounceREHAB's Bone Health class is called 'Healthy Bones'. It is a 30-45 minute small group fitness class that places focus on strengthening key back (spine), hip (femur) and arm (radius) muscle groups using resistance training and falls prevention strategies. These classes are supervised by physiotherapists.
The most common osteoporotic fractures occur in the spine, hip and wrist. By targeting these with preventative exercise, research shows reduced risk of future morbidity.
If appropriate, impact training may still be suitable and of benefit to certain age groups. We see many patients in our bounceREHAB clinic who are ageing well and still involved in bone loading exercise, such as running, skipping, tennis and aerobics.
Book into one of our HEALTHY BONES Physiotherapists for a 45 minutes assessment prior to joining our HEALTHY BONES Rehab program online here... or call our frontdesk on 02 95717 606. Alternatively you can enquire via email@example.com
bounceREHAB Exercise Research Conclusion
Pilates Exercises is effective to increase BMD; QOL and walking distance and also beneficial to relieve pain. Physiotherapist can use Pilates Exercises for the subjects with osteoporosis in the clinics.
Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., Horan, S.A. and Beck, B.R. (2018), High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res, 33: 211-220. https://doi.org/10.1002/jbmr.3284
Angın E, Erden Z, Can F. The effects of clinical pilates exercises on bone mineral density, physical performance and quality of life of women with postmenopausal osteoporosis. J Back Musculoskelet Rehabil. 2015;28(4):849-58. doi: 10.3233/BMR-150604. PMID: 26406222.
Küçükçakır N, Altan L, Korkmaz N. Effects of Pilates exercises on pain, functional status and quality of life in women with postmenopausal osteoporosis. J Bodyw Mov Ther. 2013 Apr;17(2):204-11. doi: 10.1016/j.jbmt.2012.07.003. Epub 2012 Aug 9. PMID: 23561868.
Hoke M, Omar NB, Amburgy JW, Self DM, Schnell A, Morgan S, Larios EA, Chambers MR. Impact of exercise on bone mineral density, fall prevention, and vertebral fragility fractures in postmenopausal osteoporotic women. J Clin Neurosci. 2020 Jun;76:261-263. doi: 10.1016/j.jocn.2020.04.040. Epub 2020 Apr 15. PMID: 32305276.
The Role of Diet & Supplementation
Coming Soon (Nutritionist Caroline Zanelli)
Is this relevant to me?
Bone health optimisation is relevant to everyone. Statistics show that one in three women > 50 years old will suffer a osteoporotic fracture, and relates to one in every five men.
It is true that many people won’t consider this relevant to them, but the data shows that bone fractures in the elderly are among the five leading causes of chronic disability. Frailty is preventable and the evidence overwhelmingly supports a preventative approach.
If you can get involved, make it fun and a habit for life you will see the proof for yourself!
Niamh Rafter BSc. (Hons) Physiotherapy
Pilates Instructor bounceREHAB
Matthew Craig Pinc & Steel Cancer Rehab Physiotherapist B.App.Sci. (Physiotherapy) Masters. Musculoskeletal Physiotherapy (fy) CSCS (Strength & Conditioning Specialist), National Advisory Board Member (CPAA) DIRECTOR Bounce Rehab PTY LTD
https://www.osteoporosis.foundation/patients - way more info for patients
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152283/ - bone anatomy and physiology https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383520/ - age related loss in females https://www.bones.nih.gov/health-info/bone/osteoporosis/bone-mass - NIH foundation for osteoporosis