International Encyclopedia of Rehabilitation

Osteoporosis and physical activity

Ann-Charlotte Grahn Kronhed, RPT, Ph.D.
lotta.grahn-kronhed@telia.com

Brief summary

Physical activity is beneficial for bone mass, muscle strength, balance performance and pain relief in persons suffering from osteoporosis. Back extension exercises in specific are recommended to osteoporotic persons. Prevention of fragility fractures should focus both on the prevention of osteoporosis and the prevention of falls. Osteoporotic patients need adequate and skilled supervision for their individual rehabilitation and training. Physiotherapists should play a major role in motivating, encouraging, and advising osteoporotic persons to begin exercising and to become physically active for all their life.

Epidemiology and costs

In the year 2000 there were an estimated 9 million osteoporotic fractures of which 1.6 million were at the hip, 1.7 million at the forearm, and 1.4 million were clinical vertebral fractures. Seventy percent of hip fractures occurred in women. The greatest number of osteoporotic fractures occurred in Europe (34.8%) (Johnell et al. 2006). Scandinavian women have the highest incidence of hip fractures in the world (Johnell et al. 1992). The mean fracture-related costs estimated in euros (€) the year after a fracture were at €14 221 for hip, €12 544 for vertebral, and €2 147 for wrist fractures in Swedish patients. As regards to reduction in quality of life due to these fractures the yearly burden of osteoporosis in Sweden was estimated to €0.5 billion (Borgström et al. 2006).

Forearm fractures are very common in middle-aged women. Low forearm bone mineral density (BMD) is a risk factor for sustaining a forearm fracture. Forearm fracture in both genders might be a predictor of a later vertebral and/or hip fracture (Bengnér et al. 1985, Peel et al. 1994). The incidence of forearm fractures increases more in wintertime than for hip and vertebral fractures. A great proportion of falls occurs outdoors for distal forearm fractures, while hip fractures more often occur indoors (Arden et al. 1998, Nevitt et al. 2003). The incidences of humerus and hip fractures increase steeply with increasing age (Bengnér et al. 1988). The increased incidence results from a combination of decreasing BMD and an increased propensity of falling in higher ages (Kristinsdottir et al. 2000, Low Choy et al. 2007). Most hip fractures occur in the very elderly at an average age of 80 years (Löfman et al. 2002, Nilsson et al. 1991, Obrant 1996).

Health-related quality of life in persons with osteoporotic fractures

Osteoporotic hip and vertebral fractures are associated with considerable morbidity and mortality. Osteoporotic persons may have severe pain caused by vertebral fractures, though it has been estimated that at least half of all vertebral fractures are asymptomatic (Eastell 1998). Thus, there is only a moderate correlation between pain and the number of vertebral fractures, whereas disability often correlates better with the number of fractures (Lips 1998, Ross et al. 1994). A recent study in the U.S. showed that vertebral and hip fractures had a more prolonged impact on health-related quality of life (HRQL) two years after fracture, estimated by the SF-36 questionnaire, than forearm and humerus fractures (Hallberg et al. 2004). The disease-specific questionnaire called QUALEFFO-41 (the quality of life questionnaire of the European foundation for osteoporosis) was developed specifically for patients with established vertebral osteoporosis. An association between a deteriorating HRQL measured by QUALEFFO-41 and an increasing number of vertebral fractures was confirmed (Lips et al. 1999, Lips et al. 2005).

Definition of osteoporosis and FRAX®

The World Health Organization (WHO) established diagnostic categories for osteoporosis in 1994 based on BMD values in healthy young adult women, which is referred to as the T-score. Osteopenia is a BMD value that lies between 1 and 2.5 SD below the young adult mean value, osteoporosis is a BMD value more than 2.5 SD below the young adult mean value, and established (or severe) osteoporosis is a BMD value more than 2.5 SD below the young adult mean value in the presence of one or more fragility fractures. The WHO definition is quantitative and based on measurements techniques using DXA (dual energy X-ray absorptiometry) at measurement sites such as the lumbar spine and the hip (WHO 1994).

The FRAX® tool has been developed by the WHO to evaluate fracture risk of patients. The FRAX® algorithms give the 10-year probability of a hip fracture and major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture) (Kanis et al. 2008).

Prevention of osteoporosis and fractures by physical activity

A primary factor associated with risk for osteoporosis is the maximal BMD of the skeleton (peak bone mass) developed during childhood and early adult years. The age of bone mineralization onset and the age of attainment of peak bone mass vary, according to gender and the bone region being studied. Peak bone mass usually occurs before the third decade (American College of Sports Medicine 2004, Lu et al. 1994). Peak bone mass is dependent primarily on genetic factors (70-80%), but it is also considerably influenced by physical activity and dietary calcium intake during adolescence (Mundy 1998). The age-related decrease of bone mass (regardless of gonadal hormone levels) generally is starting some time after the age of 50. The age-related bone loss is about 0.5% per year during the sixth and seventh decades, but accelerates substantially with advancing ages (Heaney 1998). In women there is an increased acceleration of bone loss at menopause (American College of Sports Med 2004, Mundy 1998).

There is a strong correlation between a bone's architectural properties and the mechanical forces that it experiences. Mechanical load perturbs interstitial fluid. Upon detecting these perturbations, osteocytes which are embedded deep within mineralised bone remotely coordinate the adaptive response by directing the actions of effector cells such as bone-forming osteblasts and bone-resorbing osteoclasts. Osteocytic cells detect and communicate biophysical signals to osteoblasts and also enhance the signal enabling osteoblasts to rapidly respond to a signal that they cannot themselves detect (Taylor et al. 2007). The following rules govern bone adaptation:

  1. it is driven by dynamic rather than static loading
  2. only a short duration of mechanical loading is necessary to initiate an adaptive response
  3. bone cells accommodate to a customary mechanical environment making them less responsive to routine loading signals (Turner 1998)

The best osteogenic response will be achieved by dynamic weight-bearing activity, in specific if the mechanical load is repeated regularly and influences the skeleton by high muscle strains in various directions (American College of Sports Medicine 2004). Thus, training programs including jumps have considerable higher effect on bone mass than cycling or swimming loading (Bassey et al. 1994, Bassey et al. 1998, Heinonen et al. 1996). Both gravity and the pull of the muscles are necessary for stimulating bone mass. This is obvious in astronauts who have deteriorated bone mineralisation after some weeks of weightlessness (Am College of Sports Medicine 2004). Absence of physical activity and loading such as being confined to bed for a long period will negatively affect the trabecular and cortical bone in the weight-bearing parts of the skeleton (the vertebrae, the hip and the pelvis). A study found that the decrements in bone mineral density were not fully reversed after 6 months of normal weight-bearing activity (Bloomfield 1997, The Swedish Council on Technology Assessment in Health Care 2003). Physical activity can increase peak bone mass in young people, reduce age-related bone loss and might also increase bone mass some percentages in the elderly (Heaney 1998, Marcus 2001). Healthy adults benefit from strength training at high intensity and jumps, which mean high muscle strains and great loading (Bassey et al. 1994, Bassey et al. 1998, Heinonen et al. 1996). Premenopausal women who performed 50 vertical jump once a day for half a year increased bone mineral density at the greater trochanter (Bassey et al. 1994, Bassey et al. 1998). In another study premenopausal women who performed various jumps 3 times a week for 18 months increased bone mineral density at the femur, the femoral neck and the lumbar spine (Heinonen et al. 1996). In premenopausal women (aged 35-40 years) bone mineral density at the hip was improved by high intensity aerobics for one year (Vainionpää et al. 2006). In healthy women aged 50-59 years the natural progression of thoracic kyphosis may be prevented by back extension exercises performed 3 times a week for 1 year (Ball et al. 2009). A dose-response association has been found between physical activity level and the risk of a hip fracture. There is about 30-40% lower hip fracture incidence amongst physically active elderly compared to physically inactive. The decrease in fracture incidence in the elderly by being physically active is probably caused by the improvement of muscle strength, bone mass and balance performance (American College of Sports Medicine 2004, Englund et al. 2005, Gregg et al. 2000, Hřidrup et al. 2001, Järvinen et al. 2008, Jessup et al. 2003, Joakimsen et al. 1997, Korpelainen et al. 2006, Pfeifer et al. 2004). Thus, the prevention of fractures should focus both on the prevention of osteoporosis and on the prevention of falls (Järvinen et al. 2008).

Rehabilitation training and physical activity for osteoporotic persons

Osteoporotic patients need adequate and skilled supervision for their individual rehabilitation and training. A knowledgeable physiotherapist can motivate fragile persons to begin exercising not only for the rehabilitation period of a fracture, but also to become physically active for all their life. Correct supervision, feedback, and follow-ups are extremely important to encourage further physical activity in osteoporotic patients. Strength training of moderate intensity and balance exercises are beneficial for most osteoporotic persons (American College of Sports Medicine 2004). It is important to begin an exercise session with a gentle 10-minute warm-up (Karinkanta et al. 2007, Khan et al. 2001). Weight-bearing exercises, which are performed in stable positions, are adequate for fragile persons. The exercises should be safe to minimise the risk of arthritic complications, falls and fractures. It is important that the physiotherapist individualises the loading when training equipment and weights are used (Englund et al. 2005, Grahn Kronhed et al. 1998, Hourigan et al. 2008, Malmros et al. 1998). The loading should be site-specific and be increased progressively to attain the best possible effect on bone mass (Layne 1999, Marcus 2001). In a training study with osteopenic/osteoporotic women (mean age 73 years), the intensity of the training stimulus was set at 50-60% of one repetition maximum (1RM) using 2 sets and 10-15 repetitions. Thereafter, the intensity progressed to 70-80% of 1RM with 3 sets and 8-10 repetitions. After one year of combined resistance and balance-jumping training physical function, dynamic balance and muscle strength of the lower limbs were improved (Karinkanta et al. 2007).

In the acute phase of a vertebral fracture pain might induce reflex inhibition resulting in overuse of spinal flexors. Vertebral fractures may cause postural deformities such as hyperkyphotic changes in the spine with inappropriate stretching of ligaments and thus leading to chronic back pain. Multiple vertebral fractures, severe kyphosis and height loss may lead to iliocostal contact, resulting in iliocostal friction syndrome and flank pain (Arden et al. 1998, Eastell 1998, Francis et al. 2008, Hallberg et al. 2004, Lips 1998, Malmros et al. 1998). Severe vertebral fractures in the thoracic spine result in decreased lung capacity, which may result in respiratory symptoms. Vertebral fractures in the lumbar spine result in decreased abdominal volume and causes the abdomen to protrude (Eastell 1998). A spinal orthosis might decrease the kyphotic angle, reduce pain and improve quality of life (Pfeifer et al. 2004). Body height loss is a strong indicator of vertebral deformities caused by vertebral fractures or degenerative changes in the intervertebral discs (Eastell 1998). The importance of measuring body height and inquiring body height in early adult life should be emphasised for physiotherapists working in the clinic to get an eventual hint of possible osteporotic vertebral osteoporosis (Moayyeri et al. 2008). Physical activity is beneficial for pain relief and an obvious effect was found in osteoporotic women suffering from backache (Malmros et al. 1998). Performing isometric contraction of paraspinal muscles might decrease post vertebral fracture pain and oedema. Physiotherapists should supervise osteoporotic persons to perform back strengthening exercises for instance "back-ups" lying prone (with a pillow under the stomach) and raising the upper part of the body a bit from the surface without the support of the arms, in order to improve muscle strength, vertebral bone mass, and to relieve back pain. Such back strengthening exercises may help to reduce the risk of further vertebral fractures (Francis et al. 2008, Hongo et al. 2007, Malmros et al. 1998, Sinaki et al. 2002). Flexion exercises such as "sit-ups" should be largely avoided, and also trunk rotation exercises might be harmful and may increase the risk of vertebral compression in osteoporotic persons (Francis et al. 2008, Sinaki and Mikkelsen 1984). Middle-aged postmenopausal women, who performed 10 back extension exercises ("back-ups") at each training session 5 days/week for a 2-year period and were free to continue in any self-selected physical activities for another 8 years had significant fewer vertebral compressions compared to a control group at a 10-year follow-up (Sinaki et al. 2002). Similar home-training back extension exercises for 4 months improved both back muscle strength and HRQL in postmenopausal osteoporotic women (Hongo et al. 2007). Other adequate home-training programs are exercises which are performed in stable positions e.g. positioned on the knees and hands ("all fours") and trying to lift one arm and the opposite leg simultaneously while holding in a diagonal, standing with the palms placed against the neck or at the hips and simultaneously forcing the elbows back and straightening the back, and rising from a stable chair without using the arms (Albertsson et al. 2007, Kalapotharakos et al. 2005, Khan et al. 2001). A home-training program including such exercises improved muscle strength, mobility, and also quality of life in osteopenic/osteoporotic postmenopausal women who performed the exercises regularly 7 days/week for 12 weeks (Chien et al. 2005).

Decreased muscle strength and deteriorated vestibularis function are important causes to impaired balance ability and increased frequency of falls amongst the elderly (Frischknecht 1998, Kristinsdottir et al. 2000, Low Choy et al. 2007, Ödkvist et al. 1998, Rosenhall and Rubin 1975). Age-related changes are found both in strength and somatosensation at the age of 50-60 years (Low Choy et al. 2007). Postural sway during quiet standing has been found to increase with each decade of life in healthy adults aged 40-80 years (Vandervoort et al. 1990). The vestibular system shows a reduction in function, with a loss of 40% of the vestibular hair and nerve cells at the age of 70 years (Rosenhall and Rubin 1975). Falls generally result from an interaction of multiple and diverse risk factors and situations. Age, disease, and the presence of environmental hazards influence the incidence of falls and the severity of fall injuries. A fall should be defined as "an unexpected event in which a person comes to rest on the ground, floor, or lower level." A person should be asked, "In the past month, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?" (Lamb et al. 2005).

Persons reporting a single fall should be observed, when rising from a chair without using their arms (Albertsson et al. 2007). Those persons who have sustained a fracture should be thoroughly tested for balance ability by physiotherapists. The Falls Efficacy Scale-International (FES-I) and the Short FES-I are good and feasible measurements to assess fear of falling in older persons (Kempen et al. 2008, http://www.profane.eu.org). The assessment by Timed Up&Go can quantify basic mobility in older persons. Other risk factors for falls should be identified (American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2001, Lundin-Olsson et al. 1998, Podsiadlo et al. 1991).

Balance performance can be improved considerable at high ages by strength training of the lower extremities and by specific training which is directed towards stimulating of the sensory systems (visual, vestibular and somatosenory) and their central integration (Grahn Kronhed et al. 2001, Kammerlind et al. 2001). Balance exercises can be performed in a training group by walking around and changing direction eventually combined by turning head or moving eyes, whole-body rotation 360°, walking on tiptoes and on heels, walking forward (heel to toe) and walking backward (toe to heel) on a line, jogging around a chair and turning to the left or right on command, standing on a foam support with the eyes open and closed, rising from the sitting to standing position and bowing to the left or right, exercising on balance boards, and also by various ball exercises (Ekvall Hansson 2007, Grahn Kronhed et al. 2001, Kammerlind et al. 2001, Madureira et al. 2007). Home exercises can be performed standing in a corner (eventual with the back of a chair placed close to the person to prevent falls) with both feet together on a firm or a foam support and trying to close the eyes for one minute, standing on one leg with the eyes open for half a minute if possible, rising up on toes 5-20 times, and careful knee bends 5-20 times (eventual holding on the back of a chair) (Albertsson 2007). Regularly participation in Tai Chi or in balance training groups have decreased risk for falls and falls injuries among the participants (American College of Sports Medicine 2004, Bean et al. 2004, Howe et al. 2007, Kannus et al. 2005, Madureira et al. 2007). Linedance is proposed as adequate training for postmenopausal women due to positive effects on balance performance (Shigematsu and Okura 2006, Young et al. 2007).

According to a consensus statement the recommendation for promoting health runs: "In all ages, people should accumulate 30 minutes or more of moderate-intensity physical activity on most, preferably all, days of the week" (Pate 1995, US Department of Health and Human Services 1996). However, people suffering from established osteoporosis are recommended to walk at a quiet pace. An increased risk of falls associated to brisk walks (progressively increased pace) was found in women (mean age 66 years) with a previous humerus fracture since 2 years (Ebrahim et al. 1997).

After a period of inactivity (for instance after a healed fracture) it is extremely important that physiotherapists encourage osteoporotic patients to practise physical activity regularly in order to reduce their risk for falling accidents, dependence and helplessness. In women (mean age 68 years) with a recent fall-related distal forearm fracture a decline was found concerning walking capacity and hand grip strength on the non-fractured side the first year after fracture. Though the patients were apparently healthy they exhibited risk factors for new falls and fractures. Thus, it is important to screen patients with a previous fracture for fall and fracture risk and targeted them for preventive measures besides fracture treatment (Nordell et al. 2005). Physiotherapists should play a major role in maintaining and improving general physical functions in osteoporotic patients. Furthermore, the use of a physical activity referral (PAR) scheme may improve physical activity level in patients visiting primary health care centres (Leijon et al. 2008).

References

Albertsson D, Mellström D, Petersson C, Eggertsen R. 2007. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Annals of Family Medicine 5(1):48-56.

Albertsson D, Petersson C, Mellström D, Grahn B, Eggertsen R. 2007. Improved ability to rise and less falls among women aged over 70 at high hip fracture risk – results from an intervention study (Paper III). In: Albertsson D. Hip fracture prevention by screening and intervention of elderly women in Primary Health Care. Göteborg: Sahlgrenska Academy at Göteborg University, Medical Dissertation.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. 2001. Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society 49(5):664-672.

American College of Sports Medicine. 2004. Position stand. Physical activity and bone health. Medicine and Science in Sports and Exercise 36(11):1985-1996.

Arden N, Cooper C. 1998. Present and future of osteoporosis: epidemiology. In: Meunier P, editor. Osteoporosis: Diagnosis and management. London: Martin Dunitz. p 1-16.

Ball JM, Cagle P, Johnson BE, Lucasey C, Lukert BP. 2009. Spinal extension exercises prevent natural progression of kyphosis. Osteoporosis International 20:481-489.

Bassey EJ, Ramsdale SJ. 1994. Increase in femoral bone density in young women following high-impact exercise. Osteoporosis International 2:72-75.

Bassey EJ, Rothwell MC, Littlewood JJ, Pye DW. 1998. Pre- and postmenopausal women have different bone mineral density responses to the same high-impact exercise. Journal of Bone and Mineral Research 12(13):1805-1813.

Bean JF, Vora A, Frontera WR. 2004. Benefits of exercise for community-dwelling older adults. Archives of Physical Medicine and Rehabilitation 85(3):S31-42.

Bloomfield SA. 1997. Changes in musculoskeletal structure and function with prolonged bed rest. Medine and Science in Sports and Exercise 29:197-206.

Bengnér U, Johnell O. 1985. Increasing incidence of forearm fractures. Acta Orthopaedica Scandinavica 56:158-160.

Bengnér U, Johnell O, Redlund-Johnell I. 1988. Changes in the incidence of fracture of the upper end of the humerus during a 30-year period. Clinical Orthopaedics 231:179-182.

Borgström F, Zethraeus N, Johnell O, Lidgren L, Ponzer S, Svensson O, et al. 2006. Costs and quality of life associated with osteoporosis-related fractures in Sweden. Osteoporosis International 17(5):637-650.

Chien MY, Yang RS, Tsau JY. 2005. Home-based trunk-strengthening exercise for osteoporotic and osteopenic postmenopausal women without fracture – a pilot study. Clinical Rehabilitation 19:28-36.

Cummings SR, Nevitt MC. 1994. Non-skeletal determinants of fractures: The potential importance of the mechanics of falls. Osteoporosis International 4(Suppl 1):67-70.

Eastell R. 1998. Practical management of the patient with osteoporotic vertebral fracture. In: Meunier P, editor. Osteoporosis: diagnosis and management. London: Martin Dunitz. p 175-190.

Ebrahim S, Thompson PW, Baskaran V, Evans K. 1997. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. Age and Ageing 26(4):253-260.

Ekvall Hansson E. 2007. Vestibular rehabilitation – For whom and how? A systematic review. Advances in Physiotherapy 9:106-116.

Englund U, Littbrand H, Sondell A, Pettersson U, Bucht G. 2005. A 1-year combined weight-bearing training program is beneficial for bone mineral density and neuromuscular function in older women. Osteoporosis International 16:1117-1123.

Francis RM, Aspray TJ, Hide G, Sutcliffe AM, Wilkinson P. 2008. Back pain in osteoporotic vertebral fractures. Osteoporosis International 19:895-903.

Frischknecht R. 1998. Effect of training on muscle strength and motor function in the elderly. Reproduction Nutrition Development 38:167-174.

Grahn Kronhed AC, Möller M. 1998. Effects of physical exercise on bone mass, balance skill and aerobic capacity in women and men with low bone mineral density, after one year of training - a prospective study. Scandinavian Journal of Medicine and Science in Sports 8:290-298.

Grahn Kronhed AC, Möller C, Olsson B, Möller M. 2001. The effect of short-term balance training on community-dwelling older adults. Journal of Aging and Physical Activity 9:19-31.

Gregg EW, Pereira MA, Caspersen CJ. 2000. Physical activity, falls and fractures among older adults: A review of the epidemiologic evidence. Journal of the American Geriatrics Society 48:883-893.

Hallberg I, Rosenqvist AM, Kartous L, Löfman O, Wahlström O, Toss G. 2004. Health-related quality of life after osteoporotic fractures. Osteoporos International 15:834-841.

Heaney RP. 1998. Non-pharmacologic prevention of osteoporosis: nutrition and exercise. In: Meunier P, editor. Osteoporosis: diagnosis and management. London: Martin Dunitz. p. 161-174.

Heinonen A, Kannus P, Sievänen H, Oja P, Pasanen M, Rinne M et al. 1996. Randomised controlled trial of effect of high-impact exercise on selected risk factors for osteoporotic fractures. Lancet 348:1343-1347.

Høidrup S, Sørensen T, Strøger U, Lauritzen J, Schroll M, Grønbaek M. 2001. Leisure-time physical activity levels and changes in relation to risk of hip fracture in men and women. American Journal of Epidemiology 154:60-68.

Holmberg A, Johnell O, Âkesson K, Nilsson P, Nilsson J-Â, Berglund G. 2004. Forearm bone mineral density in 1294 middle-aged women. Journal of Clinical Densitometry 7(4):419-23.

Hongo M, Itoi E, Sinaki M, Miyakoshi N, Shimada Y, Maekawa S, et al. 2007. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osterporosis International 18:1389-1395.

Hourigan SR, Nitz JCD, Brauer SG, O'Neill SO, Wong J, Richardson CA. 2008. Positive effects of exercise on falls and fracture risk in osteopenic women. Osterporosis International 19:1077-1086.

Howe TE, Rochester L, Jackson A, Banks PMH, Blair VA. 2007. Exercise for improving balance in older people. Cochrane Database of Systematic Reviews (4) Art no: CD004963.

Järvinen T, Sievänen H, Khan K, Heinonen A, Kannus P. 2008. Shifting the focus in fracture prevention from osteoporosis to falls. British Medical Journal 336:124-126.

Jessup JV, Horne C, Vishen RK, Wheeler D. 2003. Effects of exercise on bone density, balance, and self-efficacy in older women. Biological Research for Nursing 4:171-180.

Joakimsen RM, Magnus JH, Fonnebo V. 1997. Physical activity and predisposition for hip fractures: A review. Osterporosis International 7:503-513.

Johnell O, Gullberg B, Alander E. 1992. The apparent incidence of hip fracture in Europe – A study of national register sources. Osterporosis International 2:298-302.

Johnell O, Kanis JA. 2006. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osterporosis International 17:1726 -1733.

Kalapotharakos VI, Tokmakidis SP, Smilios I, Michalopoulos M, Gliatis J, Godolias G. 2005. Resistance training in older women: Effect on vertical jump and functional performance. Journal of Sports Medicine in Physical Fitness 45(4):570-575.

Kammerlind AS, Hâkansson J, Skogsberg M. 2001. Effects of balance training in elderly people with non-peripheral vertigo and unsteadiness. Clinical Rehabilitation 15:463-470.

Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. 2008. FRAX and the assessment of fracture probability in men and women from the UK. Osterporosis International 19(4):385-397.

Kannus P, Sievänen H, Palvanen M, Järvinen T, Parkkari J. 2005. Prevention of falls and consequent injuries in elderly people. Lancet 366(26):1885-1893.

Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, Pasanen M, Ojala K, et al. 2007. A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: Randomized, controlled trial. Osterporosis International 18:453-462.

Kempen GI, Yardley L, van Haastreqt JC, Zijlstra GA, Beyer N, Hauer K, Todd C. 2008. The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age and Ageing 37(1):45-50.

Khan K, McKay H, Kannus P, Bailey D, Wark J, Bennell K. 2001. Exercise prescription for people with osteoporosis. In: Khan K, McKay H, Kannus P, Bailey D, Wark J, Bennell K, editors. Physical activity and bone health. Leeds: Human Kinetics p 181-198.

Korpelainen R, Keinänen-Kiukaanniemi S, Heikkinen J, Väänänen K, Korpelainen J. 2006. Effect of impact exercise on bone mineral density in elderly women with low BMD: A population-based randomised controlled 30-month intervention. Osterporosis International 17(1):109-118.

Kristinsdottir EK, Jarnlo G-B, Magnusson M. 2000. Asymmetric vestibular function in the elderly might be a significant contributor to hip fractures. Scandinavian Journal of Rehabilitation Medicine 32(2):56-60. Lamb SE Lamb S, Jørstad-Stien E, Hauer K, Becker C on behalf of the Prevention Falls Network Europe and Outcomes. 2005. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus. Journal of the American Geriatrics Society 53(9):1618-1622.

Layne JE, Nelson ME. 1999. The effects of progressive resistance training on bone density: A review. Medicine and Science in Sports and Exercise 31:25-30.

Leijon ME, Bendtsen P, Nilsen P, Ekberg K, Stâhle A. 2008. Physical activity referrals in Swedish primary health care – Prescriber and patient characteristics, reasons for prescriptions, and prescribed activities. BMC Health Services Research 8:201.

Lips P. 1998. Quality of life in osteoporosis. In: Meunier P, editor. Osteoporosis: Diagnosis and management. London: Martin Dunitz. p 251-256.

Lips P, Cooper C, Agnusdei D, Caulin F, Egger P, Johnell O, et al. 1999. Quality of life in patients with vertebral fractures: Validation of the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Working party for quality of life of the European Foundation for osteoporosis. Osterporosis International 10(2):150-160.

Lips P, van Schoor N. 2005. Quality of life in patients with osteoporosis. Osterporosis International 16:447-455.

Löfman O, Berglund K, Larsson L, Toss G. 2002. Changes in hip fracture epidemiology: Redistribution between ages, genders and fracture types. Osterporosis International 13:18-25.

Low Choy N, Brauer S, Nitz J. 2007. Age-related changes in strength and somatosensation during midlife. Rationale for targeted preventive intervention programs. Annals of the New York Academy of Sciences 114:180-193.

Lu PW, Briody JN, Ogle GD, Morley K, Humphries IR, Allen J, Howman-Giles R, Sillence D, Cowell C. 1994. Bone mineral density of total body, spine and femoral neck in children and young adults: A cross-sectional and longitudinal study. Journal of Bone and Mineral Research 9: 1451-1458.

Lundin-Olsson L, Nyberg L, Gustafsson Y. 1998. Attention, frailty, and falls: The effect of a manual task on basic mobility. Journal of the American Geriatrics Society 46:758-761.

Madureira MM, Takayama L, Gallinaro AL, Caparbo VF, Costa RA, Pereira RMR. 2007. Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: A randomized controlled trial. Osterporosis International 18:419-425.

Malmros B, Mortensen L, Jensen MB, Charles P. 1998. Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osterporosis International 8:215-221.

Marcus R. 2001. Role of exercise in preventing and treating osteoporosis. Rheumatic Disease Clinics of North America 27(1):131-141. Moayyeri A, Luben R, Bingham S, Welch A, Wareham N, Khaw KT. 2008. Measured height loss predicts fractures in middle-aged and older men and women: The EPIC-Norfolk prospective population study. Journal of Bone and Mineral Research 23(3):425-432.

Mundy GR. 1998. Bone remodeling and mechanisms of bone loss in osteoporosis. In: Meunier P, editor. Osteoporosis: Diagnosis and management. London: Martin Dunitz. p 17-35.

Nevitt MC, Cummings SR, and the Study of Osteoporotic Fractures Research Group. 1993. Type of fall and risk of hip and wrist fractures: The study of osteoporotic fracture. Journal of the American Geriatrics Society 41:1226-1234.

Nilsson R, Löfman O, Berglund K, Larsson L, Toss G. 1991. Increased hip-fracture incidence in the county of Östergötland, Sweden, 1940-86, with forecasts up to the year 2000: An epidemiological study. International Journal of Epidemiology 20(4):1018-1024.

Nordell E, Kristinsdottir EK, Jarnlo GB, Magnusson M, Thorngren KG. 2005. Older patients with distal forearm fracture. A challenge to future fall and fracture prevention. Aging Clinical and Experimental Research 17(2):90-95.

Obrant K. 1996. Prognosis and rehabilitation after hip fracture. Osterporosis International 6(Suppl 3):52-55.

Ödkvist LM, Malmberg L, Möller C. 1988. Age-related vertigo and balance disorders according to a multiquestionnaire. In Claussen CF, Kirtane MV, Schlitter K. Vertigo, nausea, tinnitus and hypoacusia in metabolic disorders. Amsterdam: Elsevier Science p 423-427.

Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC et al. 1995. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA: the Journal of the American Medical Association 273(5):402-407.

Peel NFA, Barrington NA, Smith TWD, Eastell R. 1994. Distal forearm fracture as risk factors for vertebral osteoporosis. British Medical Journal 308:1544-1545.

Pfeifer M, Sinaki M et al. for the ASBMR working group on musculoskeletal rehabilitation. 2004. Musculoskeletal rehabilitation in osteoporosis: A review. Journal of Bone and Mineral Research 19:1208-1214.

Pfeifer M, Bergerow B, Minne HW. 2004. Effects of a new spinal orthosis on posture, trunk strength and quality of life in women with postmenopausal osteoporosis. A randomised controlled trial. American Journal of Physical and Medical Rehabilitation 83:177-186.

Podsiadlo D, Richardson S 1991. The timed "Up&Go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society 39:142-148.

Rosenhall U, Rubin W. 1975. Degenerative changes in the human vestibular sensory epithelia. Acta Otolaryngology 79:67-81.

Ross PD, Davis JW, Epstein RS, Wasnich RD. 1994. Pain and disability associated with new vertebral fractures and other spinal conditions. Journal of Clinical Epidemiology 47(3):231-239.

Sinaki M, Mikkelsen BA. 1984. Postmenopausal spinal osteoporosis: Flexion versus extension exercises. Archives of Physical Medicine and Rehabilitation 65(Oct):593-596.

Sinaki M, Itoi E, Wahner HW, Wollan P et al. 2002. Stronger back muscles reduce the incidence of vertebral fractures: A prospective 10 year follow-up of postmenopausal women. Bone 30:836-841.

Shigematsu R, Okura Y. 2006. A novel exercise for improving lower-extremity functional fitness in the elderly. Aging Clinical and Experimental Research 18(3):242-248.

Taylor AF, Saunders MM, Shingle L, Climbala JM, Zhou Z, Donahue HJ. 2007. Mechanically stimulated osteocytes regulate osteoblastic activity via gap junctions. American Journal of Physiology - Cell Physiology 292:545-552.

The Swedish Council on Technology Assessment in Health Care 2003. Osteoporos – Prevention, diagnostik och behandling. Technical Report 165/1 (In Swedish). SBU-report ISBN 91-87890-86-0.

Turner CH. 1998. Three rules for bone adaptation to mechanical stimuli. Bone 23 (5): 399-407.

US Department of Health and Human Services. 1996. Physical Activity and Health: A report of the Surgeon General. Office of the Surgeion General, Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

Vainionpää A, Korpelainen R, Vihriälä E, Rinta-Paavola A et al. 2006. Intensity of exercise is associated with bone density change in premenopausal women. Osterporosis International 17(3):455-463.

Vandervoort A, Hill K, Sandrin M, Vyse MV. 1990. Mobility impairment and falling in the elderly. Physiotherapy Canada 2:99-107.

World Health Organization Study Group. 1994. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Geneva: World Health Organization Technical Report Series No 843, p 2-25.

Young CM, Weeks BK, Meck BR. 2007. Simple novel physical activity maintains proximal femur bone mineral density, and improves muscle strength and balance in sedentary postmenopausal Caucasian women. Osterporosis International 18:1379-1387.

Read this article in other formats and languages

Cite this article

Grahn Kronhed A. 2010. Osteoporosis and physical activity. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/41/

Copyright

Copyright © 2008-2014 by the Center for International Rehabilitation Research Information and Exchange (CIRRIE).

All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system without the prior written permission of the publisher, except as permitted under the United States Copyright Act of 1976.

This publication of the Center for International Rehabilitation Research Information and Exchange is supported by funds received from the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant number H133A050008. The opinions contained in this publication are those of the authors and do not necessarily reflect those of CIRRIE or the Department of Education.

Search

Copyright © 2008-2014 CIRRIE