Invest in your bonesHow exercise helps to build and maintain strong bo - PDF document

Invest in your bonesHow exercise helps to build and maintain strong bones,prevent falls and fractures, and speed rehabilitation Written on behalf of the IOF Committee of Scientific Advisors by Helmut W. Minne, MD, Chairman IOFBad Pyrmont, Germany; German Academy of the Osteological & Rheumatological Sciences Photograph by Yuyung Abdi The IOF ÔInvest in your bonesÕ publications are issued on WorldOsteoporosis Day in support of IOF member activities around theworld and are translated into many languages.Osteoporosis in the WorkplaceOsteoporosis in MenExercise: increased risk of fracture, particularly of the spine, wrist, hip,pelvis and upper arm. Osteoporosis and associated fractures arean important cause of mortality and morbidity.Approximately 1.6 million hip fractures occur worldwide eachyear, by 2050 this number could reach between 4.5 millionIn women over 45, osteoporosis accounts for more days spentmyocardial infarction and breast cancerWomen who develop a vertebral fracture are at substantial Osteoporotic bone Normal bone power into directional motion. While a cheetah can run at incrediblecaterpillars, are restricted to a crawl.Luckily, evolution has ensured that as muscles get bigger and more powerful, bones also getThis is just as true for humans as it is for tiny insects or huge dinosaurs. As we grow ourstrengthening of our bones. Stronger muscles result in stronger bones. It is that simple.Unfortunately, osteoporosis is a condition that causes a reduction in bone mass and a deteri-In turn, fractures cause pain and can put severe limitations on our daily life because theyLess mobility, because of an osteoporosis-related fracture or simply taking no exercise,the production of new, healthy bone tissue. Thus, weaker muscles result in weaker bones.and the risk of stumbling or falling increases. If we donÕt exercise our muscles, we run therisk of falling, and this, in turn, increases our risk of having a fracture. All this justifies the idea that improving muscle strength and muscle function is beneficial forSo, let everyone, people of all ages, mobilize in order to strengthen their muscles.The young Ð it will help them build strong bonesAdults Ð it will help them maintain their bonesThe elderly Ð it will help prevent bone loss and fallsEven patients who have suffered fractures already can benefit from special exercises andSo, letÕs mobilize our energy, letÕs build our bones, letÕs move!Helmut W. Minne 1 Foreword 2 from living tissue, which renews itself continuouslythroughout our life. If our skeleton is to do this effec-tively and remain strong, it needs regular stimulationfrom physical activity.Bone is made of a calcium mineral, which gives bone itsded in a protein mesh of collagen, which is gristly andmakes bone slightly flexible. Bone tissue is not com-pletely solid, but has a honeycomb structure inside athick, solid outer layer. This efficient design maximizesstrength, without making the bones too heavy.huge surface area which is lined with bone cells.These cells continually renew the bone tissue in acalled Ôbone turnoverÕ (or Ôbone remodelingÕ). Thisprocess ensures that new, healthy bone replaces olderthe bone is kept strong. The same process of boneincreased load (e.g., exercise) Ð or conversely to loseSo, Òmove it or lose itÓ is the title of this exerciseunderstanding and awareness of the importance ofto be loaded a bit more than usual (exercise) toHowever, there is an urgent need for further studiesstudies are needed to establish, scientifically, whatlife, and reduce the risk of fracture and fracturerecurrence. In this way we can best overcome theburden of osteoporosis and its life-threatening conse-Invest in your bonesHow exercise helps to build and maintain strong bones,prevent falls and fractures, and speed rehabilitation 3 Exercise Builds andone is a living tissue! DonÕt be fooled by the 65 million-year-old dinosaur bones seen in books, museums, or on the TV. There is nothing permanentUnfortunately, the biggest change comes with age. Aser. Unchecked, this deterioration can be a contributingmaintain healthy bones is throughexercise.So far, it is known that around the world, osteoporosisaffects one in three women and one in five men over age. Despite this, steps to prevent gradual loss ofactions that everyone can take to reduce the risk ofA regular, well structured exercise regimen can help pro-and, can help in rehabilitation. This is true for everyone,not just those over 40. HereÕs why.Exercise Builds Bone in Childrendepends on how well they were made to begin with.essary for the absorption of calcium from food, for thebone foundation that will serve for a lifetime, exercise isjust as important as diet. This is true throughout child-In Finland, for example, Marjo Lehtonen-Veromaa andapproximately equals the amountmineral density, but that later in life, women who had. In another study, boys who did theThe moral of the story: it is never too early (or indeedtoo late, as we shall see) to begin the process of making important as children spend more time in front ofthe television and computer. 4 Exercise Maintains Bone can also help to maintain them in adults. The most dra-matic example of this comes from an unearthly source,beyond the EarthÕs atmosphere, doctors back homeeagerly awaited their return to see how zero gravity hadthat their muscles had wasted away. It was realized soonafter, that so too had their bonesIn zero gravity, muscles do not need to work as hard tohappens in retired weight lifters, the muscle tissue thatis not needed anymore fades away, and with it so canExercise and bone maintenance are inextricably linked.Now, we have a much better understanding of the We know that we cannot depend on gravity alone toPerhaps nowhere is this more obvious than in terrestriallying in bed. As part of a study to investigate the effectsof long-term space travel, Free University of BerlinÕsDieter Felsenberg and colleagues, including those at theEuropean Space Agency, have studied what happens tohealthy, young volunteers who are prevented from using were faced with a myriad of difficulties: Weak muscles,15% of their bone mineral density was lost in as little as Fracture ThresholdAverage 40 55 70 85 90 sedentary woman, respectively.ture threshold (when fractureosteoporosis is made. The graph ÒTerranautsÓ, volunteers who remain bed-ridden forweeks, or even months, are helping scientists separatethe effect of gravity and exercise on bone. The threeimages show a young volunteer before and after 3months (middle photo) of bed rest. Excessive trainingis necessary to restore not only muscle mass, but alsobone density and bone strength, whereby the lattercannot be restored completely (right picture). 5 Exercise Maintains Bone Japan, found that when older, postmenopausal womennot exercise. Their bones were stronger too, particularlyBut what is probably even more important, these backof those who exercised were found to have at least onevertebral fracture, while just over 30% had suffered afracture in the group that had not used the exercise regi-men. Women who had not taken part in the back exer-ing it look like a wedge. Wedging, which can be veryif sufficient numbers of vertebrae are affected. Wedged vertebrae, seen circled in image right, but absent inthe left image taken from the same patient two years prior,can be a major source of pain and immobility in elderlypatients with osteoporosis (image from ref.17).exercise regiment, were half as likely to have wedged verte-brae as control patients. Exercising your backcan help prevent yourvertebrae from when you get older. Back exercise ControlsexerciseNo. of compressionfractureswith fractureControlsBackexerciseControlsBackexerciseControls Back stengthening exercisereduces vertebral fracture riskThis graph demonstrates the effect ofback muscle strengthening on the rateof vertebral compression fractures andwomen. Ten years after a 2-year backexercise program, the proportion ofwomen with fractures was only 11%in the exercise group as compared to30% in the control group. Both wedg-ing and vertebral compression frac-tures were significantly less in the backexercise group than the control groupseveral years after the exercises werediscontinued. (Modified from Ref.18, 6 Exercise HelpsPosture and Balance ÐPrevents Fallsrisk of suffering a bone fracture than someone with nor-mal bone mineral density, studies have shown that it isthey tend to fall more often. In fact, every year abouting fractures, particularly hip fractures, most of whichEvery year, about two out of fivevisual impairment and medication, it is essential thatmuch less likely to fall and are therefore less likely to beinjured. On the other hand, those with a more sedentarylifestyle are more likely to have a hip fracture than thosemore than nine hours a day are 50% more likely to ControlExercise ControlFallInjurous FallExercise Effect of Tailored Exercise on Falls in the Elderly practice regular exerciseand approximately 35%(ref.20). Individually tailored exercise programs include balancetraining to reduce the likelihood of having a fall. 7 been investigating the benefits of exercise in the elderlyWomen who sit for more than 9 hours a day are more likely tohave a hip fracture.When data is pooled from these studies it shows that inIndividually tailored exercise programs are proven to reducefalls and fall-related injuries.The balance aspect of this training may be key. A studyhas shown, for example, that patients practicing Taiduring which the patients received one Tai Chi lessonExercise can help to prevent further fractures, relieve pain and ControlTai Chi Effect of Tai Chi on Falls in the Elderly Patients who perform Tai Chi twice daily have animpressive further risk reduction of almost 50%(ref.20). Tai Chi is an ancient Chinese martialart consisting of a series of slow,as it helps them to develop stronger photo by Kerstin Zillmer strengthening exercise used in tailoredexercise programs 8 Exercise Aidsin preventing osteoporosis and fractures. But exercise can also play a crucial role in rehabilita-tion. Remember, muscle strength and bone strength areExercise and Vertebral Fractureswith kyphosis, or curvature of the spine. This is a conse-due to osteoporotic fractures of the vertebrae, particu-in the center of gravity. Because of these changes, peopleadditional loss of height. Forced into this posture, difficult to cope with daily life and are prone to suffer-ing from depression. type of therapy can greatly improve the quality of life ofregimen designed to prevent future fractures. Patientswith kyphosis often suffer from multiple vertebral frac-tures over time. It has been shown that the Òtime sinceExercise can help relieve the This photo, which shows three generations ofSouth Korean women, clearly illustrates theprogressive effects of osteoporotic vertebralfractures.photo by Dr. Geoff Higgs 9 Exercise Can Aid Recovery from Hip Fracturescan arise from osteoporosis. More than 95% of patients require surgery to repairtheir hip fracture, and of these, fewer than one-third Fewer than one out of three repair a hip fracture will regainnormal function.50% faster and climbed stairs about 30% faster thanEmotionally, patients who had received the exercisepatients were equally as fearful of fallingMove it or lose it! Bone mass and exercise areInvest in your bones! Children should get plentyof exercise to help build their peak bone mass.Exercise, in addition to a healthy diet and lifestyle,down the process that leads to osteoporosis.By improving balance, strength, and agility, exercise helps prevent falls that lead to fractures.Impact and weight bearing exercises are best ÐExercise can help with rehabilitation. It is never too late to start exercising, but consultexercise is best for you. A personalized exercise program is animportant aspect of rehabilitation afterfracture. These images show exercisesused in a specialized rehabilitation program under professional supervision. 10 Exercise your BonesFor people who do not engage in any physical activity,now is the time to start, no matter what age. Those whodo have a regular exercise program should evaluatenot, begin to include activities that do. Here are someExercise for Bone Health¥ Weight-bearing and high impact exercise is required tostimulate bone formation. Sports that involve lifting improving muscle strength, but will not promote boneformation. Here are some examples of exercises forÐ WalkingÐ TennisÐ Volleyball ¥ Start slowly and progress gradually.efficiently. Short sprints are better than a long, slow jog.¥ Two short exercise sessions separated by 8 hours, is¥ If exercise time needs to be reduced, it is better to¥ Exercise that improves posture and balance will helpprotect from falls and reduce the likelihood of having a photo by Kerstin Zillmer Exercise should be fun! Choose an tennis, 11 Exercise for Managing Osteoporosising exercise is important. However, it is recommendedthat a doctor, nurse, or physiotherapist be consultedbefore beginning an exercise program. Here are some¥ Be aware of falling. If possible, enroll in a falls to be especially effective in maintaining bone density Exercise for Rehabilitationafter FractureExercise after fracture aims to relieve pain and to helpan exercise program is best suited to individual needs,and to help reduce the risk of further injury throughfalling. Often exercise in warm water is the first stept Overdo ItIt is possible to exercise too much. Exercise should be¥ Women and teenage girls who exercise to an extremetion) due to estrogen deficiency. Estrogen deficiency intrying to keep their weight below a certain level for¥ Too much exercise can result in stress fractures orfirst. Build an exercise program gradually.¥ Some exercises or sports increase the likelihood ofregimens should be tailored to each individualÕs own Exercise after fracture aims to relieve painand to help patients regain range of motionand independence. Often exercise in warmwater is the first step before other exercisesare attempted. 12 Margaret Austin, New"It is really worth-while to invest inyour bones.daily, she had begun to notice herself stooping, whichthe disease and was at a high risk for fractures. In con-sultation with her doctor, she decided to make immedi-ate changes in her life to try, if not to stop the disease,to at least retard the damage.certainly healthy. Now I made a conscious decision tolowed a regular program three times a week. It includes30 minutes of cardiovascular exercise and 30 minutes ofmen with hormone replacement therapy and a calciumsupplement, but switched three years ago to a combina-However, she and her doctor believe that her level of fit-ness at the time helped in her recovery, which has beenShe has recently retired from her position of chancellorat Lincoln University, but remains the Chair of theNational Commission for UNESCO in New Zealand,Preventing the onset of osteoporosis is ideal, but it iscise and it is possible to feel confident that it is reallyAnne Wong, Hong KongNow I have confidence in fightingosteoporosis.Anne Wong, 64, had suf-ties. She recalls, ÒI was ininterfered with my life and I was depressed. Soon Ifound that my neck and shoulders were humped, but Ithought that the back pain and bent back were commonin old women, so I did not consult a doctor.Ó had osteoporosis and low bone mineral density. Hertry, and also help to reduce falls. Anne decided to incor-men. Now, she does stretching and strengthening exer-cises for one hour twice a week. She also practices TaiAnneÕs physician has found that she had no furtherstronger and happier. Now I have confidence in fighting Celia Marcela Casals,I dared to run inthree marathons!ÒI first heard abouter, despite the fact that my genetic background suggest-ed a high risk of osteoporosis. In January 1993, I metDr. JosŽ Zanchetta (shown in photo), the head of theaware that I had to take care of my own body andchange my lifestyle. work as the latter, attending to individual cases in mycal activity. I now take calcium supplementation andmedication and devote lots of time to exercise. I startedwith expressive rhythmic movement. In 1995, I beganYoga Iyengar, which involves strength and stretching. Iincreasing enthusiasm with each passing day. I accompa-ny all this with weight-bearing exercise, which helps methis gives me enormous pleasure because it connects mewith joy, power, strength, speed and the coordination ofmovements. ItÕs really pleasing to see and feel that with"As from July 2004, I started to jog with a personaltrainer. At present I jog three times a week, very early inmy heart rate. I still take my gym lessons in theÒI am fortunate to have the support and encouragementof my doctor who told me to do all the exercise Iwished but to be careful so as not to suffer any fracturesor lesions which are very difficult to recover from at myÒTests have shown that my osteoporosis as well as myGonul Erdinc, Turkey Exercise has becomepart of my daily life.sis at the age of 64. AfterGonul went to her doctor. A subsequent bone mineralosteoporotic vertebral fracture. Gonul resumed her med-ication, and after treatment of the acute post-fractureNow, Gonul takes her medicine regularly and makessure she follows her doctorÕs advice. Her exercise pro-muscles of the body, especially the back extensorsÕ mus-ÒSince doing these exercises I feel better and moreactive,Ó says Gonul. Before beginning the exercise pro-without pain. However, IÕm careful. When I go shop-Gonul believes that her regular exercise is as effective happy that exercise has become part of my daily life Ð 14 Maureen Dunn, CanadaNo one should lettheir osteoporosishold them back.and broken her wrist afterliked milk and dairy products. Although physicallyPrior to her diagnosis, Maureen was an avid runner, anpassionate about. Despite the fact that she was diag-nosed with osteoporosis at the age of 58, Maureen con-tinues to run today Ð taking more careful steps, perhapsÐ but itÕs still a very big part of her life. In fact, she runsother day. drinking at least one glass of milk a day, eating calcium-returned from a five-week trip to Tuscany, Italy, whereÒI strongly believe that my active lifestyle is helping metheir osteoporosis hold them back.ÓOsteoporosis Society of CanadaÕs 1-800 help line,Maureen has also demonstrated exercises in theSocietyÕs BoneSmart exercise video. Where to Get Additional InformationThere are many excellent resources which provideinformation about exercise. Below is a small selec-tion of English-language resources for the public:Videos¥Be Bone Wiseª Exercise VideoNational Osteoporosis Foundation (USA)Available through www.nof.org ¥BoneSmart VideoOsteoporosis Society of CanadaAvailable through www.osteoporosis.ca ¥ Falls Prevention Exercise VideoOsteoporosis AustraliaAvailable through www.osteoporosis.org.au ¥Exercise for Strong Bones: Your Easy-to-follow Guide to Reducing Your Riskof Osteoporosis by Joan Bassey, Susie Dinan (Carroll & Brown Fitness Book, ¥Exercise and Osteoporosis: Exercises for people with osteoporosisNational Osteoporosis SocietyAvailable through www.nos.org.uk ¥Fit but FragileNational Osteoporosis SocietyAvailable through www.nos.org.uk ¥ Be Taller, Stronger, Longer!Osteoporosis Society of CanadaAvailable through www.osteoporosis.ca Website¥WHO pages on diet and physical activitywww.who.int/dietphysicalactivity/en/comprehensive exercise programs and produced in local languages. Please visit www.osteofound.org to find contact details for your national osteoporosissociety. 15 Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int 7:407-413.Cooper C, Campion G, Melton LJ, 3rd (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos IntKanis JA, Delmas P, Burckhardt P, et al. (1997) Guidelines fordiagnosis and management of osteoporosis. The EuropeanFoundation for Osteoporosis and Bone Disease. Osteoporos Intof clinically diagnosed vertebral fractures: a population-basedstudy in Rochester, Minnesota, 1985-1989. J Bone Miner Resvertebral fracture in the year following a fracture. J Am MedLips P, Invest in Your Bones: Quality of Life. InternationalOsteoporosis Foundation 2003Melton LJ, 3rd, Atkinson EJ, O'Connor MK, et al. (1998)Bone density and fracture risk in men. J Bone Miner ResMelton LJ, 3rd, Chrischilles EA, Cooper C, et al. (1992)Perspective. How many women have osteoporosis? J Boneosteoporotic fracture in Malmo. Osteoporos Int 11:669-674.Kannus P, Wark JD. (2000) Does childhood and adolescenceprovide a unique opportunity for exercise to strengthen theLehtonen-Veromaa M, Mottonen T, Heinonen OJ, et al.eral gain among peripubertal Finnish girls: a 3-year prospectivestudy. Osteoporos Int 15(Suppl.1):S13-S18. Bonjour P. Invest in Your Bones: How diet, lifestyles andgenetics affect bone development in young people.International Osteoporosis Foundation 2001Bass S, Pearce G, Bradney M, Hendrich E, Delmas PD,Harding A, Seeman E. (1998) Exercise before puberty may con-fer residual benefits in bone density in adulthood: studies inactive prepubertal and retired female gymnasts. J Bone MinerJanz KF, et al. (2004) Everyday activity predicts bone geom-etry in children: The Iowa bone development study. Med SciSports Exerc 36:1124-1131.Vico L, Collet P, Guignandon A, Lafage-Proust MH, ThomasT, Rehaillia M, Alexandre C. (2000) Effects of long-term micro-gravity exposure on cancellous and cortical weight-bearingSinaki M, Itoi E, Wahner HW, Wollan P, Gelzcer R, MullanBP, Collins DA, Hodgson SF. (2002) Stronger back musclesreduce the incidence of vertebral fractures: a prospective 10Image from International Osteoporosis Foundation andEuropean Society of Musculoskeletal Radiology vertebral frac-ture initiative resource documentSinaki M. (2003) Critical appraisal of physical rehabilitationmeasures after osteoporotic vertebral fracture. Osteoporos Int21, developed by the National Collaborating Centre for Nursingand Supportive Care, Nov. 2004Wolff SL, Barnhart HX, Kutner NG, McNeely E, Coogler C,Zu T for the Atlanta FICSIT Group. (1996) Reducing frailty andPfeifer M, Sinaki M, Geusens P, Boonen S, Preisinger E,Minne HW for the ASBMR Working Group on MusculoskeletalRehabilitation. (2004) Musculoskeletal rehabilitation in osteo-porosis: a review. J Bone Miner Res 19:1208-1214.Malmros B, Mortensen L, Jensen MB, Charles P. (1998)Positive effects of physiotherapy on chronic pain and perform-ance in osteoporosis. Osteoporos Int 8:215-221. Begerow B, Pfeifer M, Pospeschill M, Scholz M,Schlotthauer T, Lazarescu A, Pollaehne W, Minne HW. (1999)Time since vertebral fracture: an important variable concerningquality of life in patients with postmenopausal osteoporosis.Osteoporos Int 10:26-33.Hauer K, Specht N, Schuler M, Bartsch P, Oster P. (2002)Intensive physical training in geriatric patients after severe fallsand hip surgery. Age Ageing 31:49-57.Kemmler W, Lauber D, Weineck J, Hensen J, Kalender W,Engelke K. (2004) Benefits of 2 years of intense exercise onbone density, physical fitness, and blood lipids in early post-menopausal osteopenic women. Arch Intern Med 164:1084- Are you among the one in three womenand the one in five men over 50 who willbe affected by osteoporosis? Osteoporosis weakens bones. It causessevere disability. It can be fatal. But osteoporosis can be detected early. It can be treated.If you answered ÒyesÓ to any of these questions, it does not mean thatyou have osteoporosis. Diagnosis of osteoporosis can only be made by aphysician through a bone density test. We recommend that you show thistest to your doctor, who will advise whether further tests are necessary.The good news is that osteoporosis can be diagnosed easily and treated.Talk to your local osteoporosis society about what changes you mightmake in your lifestyle to reduce your osteoporosis risk. You can contactyour national osteoporosis society viawww.osteofound.org Are you at risk of osteoporosis? Take the One-Minute Osteoporosis Risk Test YesYes(cortisone, prednisone,etc) for moreYesHave you lost more than 3 cm (just over 1 inch) in height?YesYesDo you smoke more than 20 cigarettes a day?YesDo you suffer frequently from diarrhoea (caused byYesYesYesHave you ever suffered from impotence,lack of libido or other symptoms related to low Yes Committee of National Societies;Clinic Associate editor: Michael Pfeifer, MD, Institute of ClinicalGulseren Akyuz, Turkey; Steven Boonen, Belgium;Moira OBrien, Ireland; Outi Pohjolainen, Finland; Maria Valkama, Finland; Jos Zanchetta, Argentina Writer: Tom Fagan In partnership with: zation which represents a global alliance ofhealth care professionals and the health industry.other organizations around the world to increaseosteoporosis affects millions of people every-where, awareness about the disease is still low,ment is often scarce, or not used to its full poten-those who need it to prevent the first fracture.s growing membership has more than dou-bled since 1999, reflecting the increasing interna-tional concern about this serious health problem.locations worldwide (June 2005).For more information about IOF and to country visit: www.osteofound.org5 Rue PerdtempsTel: +41 22 994 0100Website: www.osteofound.org Sheffield, UKInternational European WomenInternationalEuropean MenInternational Outreach and Education: 06; June 2005If more people were empowered to look after their own health wecould substantially reduce the impact of osteoporosis. IOF is encouragingpeople to take responsibility for their bone health. I like that kind ofpractical, empowering approach. We're not victims, we're responsible.Her Majesty Queen Rania of Jordan, IOF Patron A 2002 WHO resolution urges Member States to celebrate a ÔMove for HealthÕ day each year to promote physical activity asand health within an integrated approach to non communicabledisease prevention and health promotion.