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RESEARCH to PRACTICE

Fitness for Reducing Osteoporosis

Colleen Christmas, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 10 - OCTOBER 2000


The incidence and prevalence of osteoporosis and fractures increase substantially with age in both women and men (1), such that one in five women older than age 50 has osteoporosis (2). This translates to nearly 1.5 million fractures of all types attributable to osteoporosis each year in the United States, a total that exacts an astounding toll on healthcare costs. Postfracture outcomes are also disappointing. Less than one third of those who fracture their hip recover sufficiently to do basic and instrumental activities of life (3). Many become dependent on others for their care. Finally, the mortality rate of those with hip fractures from osteoporosis is higher than that of their unaffected peers (4).

The bleak outcomes and the threat of dependence instill a deep fear of osteoporosis in many older Americans. Preventing osteoporosis and fractures, then, is a critical component of the quality of life for the growing population of older Americans. Osteoporosis is one of the physical activity-related concerns from other focus areas in the Healthy People 2010 report. Recent research has examined the impact of exercise on limiting osteoporosis, falls, and functional debility in older individuals.

Activities to Mitigate Osteoporosis

Patient activities. In addition to an adequate calcium intake, weight-bearing exercises are a key component of any program to reduce the loss of bone mass associated with menopause and aging. Walking programs (5) and resistance exercises (6) have demonstrated improvements in bone mineral density in older women, while resistance exercises (7), tai chi, and other forms of exercise (8) have been shown to reduce falls. Further research is warranted to delineate the most efficient modality and duration of exercise to reduce osteoporosis and fractures, and also to motivate and enhance compliance with a fitness regimen in older individuals. For many, suggestions to reduce sedentary behavior and begin a simple walking program will be acceptable. Patients can start with an achievable goal such as 10 minutes of walking a day, with progression to 30 minutes a day of cumulative exercise on most days of the week. The type of exercise is probably less important than finding a program to which the patient will adhere.

Physician advice. Perhaps the most important steps physicians can take are to discuss the risks of osteoporosis and its potential sequelae and to explain how exercise can reduce these risks. The primary care provider is in the best position to do this, but other opportunities may arise. For example, physicians may caution patients when densitometry reveals weakening of bones or when they notice that patients have become less active. Most women with kyphosis and a height loss of more than 1.5 in. will have osteoporosis and should be counseled appropriately. Physicians may also explain benefits of exercise when treating patients who are recovering from a hip fracture (remember, they have another hip!). A physician's stern recommendation can motivate patients to take their physical fitness seriously and begin a more healthy lifestyle. To emphasize this, the clinician may give the patient a recommendation written on a prescription pad.

Addressing barriers. It is helpful to obtain a history from patients about their lifelong exercise patterns and interests, and to elicit perceived barriers to exercise. Here, strategies to overcome any barriers can be addressed and the prescription tailored to patient preferences and health concerns. In addition, this should be documented in the medical record to serve as a baseline for follow-up discussions.

Progress and barriers should be readdressed periodically to enhance compliance and to make adjustments when life situations change. Being aware of resources available to the community can be helpful. Such resources may include senior centers, malls that open before hours for walking, and exercise facilities that offer senior discounts on exercise specials and personal trainers familiar with geriatric patients.

Exercise resources. The local chapter of the Arthritis Foundation can often help identify exercise facilities that are affordable to many. Web sites of the American Academy of Orthopedic Surgery (www.aaos.org) and the National Osteoporosis Foundation (www.nof.org) have easy-to-read patient education pages that can be distributed to patients in the office. A guide to addressing exercise with older patients has recently been published (9). It presents an overview of the benefits of exercise for this group and gives tips on how to prescribe and monitor exercise.

Future Research

New research must focus on what exercise regimen and types are the best for arresting or preventing osteoporosis. Exercise can improve bone strength and reduce falls, but factors to motivate and enhance compliance—with exercise in older individuals and with counseling in physicians—also need further examination. Finally, with the burgeoning elderly population, delineation of the most effective forms of exercise to reduce the various consequences of osteoporosis, such as fractures, pain, and dependency, are imperative to guide clinical care of the frail elderly.

References

  1. Riggs BL, Melton LJ III: Involutional osteoporosis. N Engl J Med 1986;314(26):1676-1686
  2. Looker AC, Johnson CC Jr, Wahner HW, et al: Prevalence of low femoral bone density in older US women from NHANES III. J Bone Miner Res 1995;10(5):796-802
  3. Jette AM, Harris BA, Cleary PD, et al: Functional recovery after hip fracture. Arch Phys Med Rehabil 1987;68(10):735-740
  4. Lyons AR: Clinical outcomes and treatment of hip fractures. Am J Med 1997;103(2A):51S-63S; discussion 63S-64S
  5. Nelson ME, Fisher EC, Dilmanian FA, et al: A 1-y walking program and increased dietary calcium in postmenopausal women: effects on bone. Am J Clin Nutr 1991;53(5):1304-1311
  6. Nelson ME, Fiatarone MA, Morganti CM, et al: Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures: a randomized controlled trial. JAMA 1994;272(24):1909-1914
  7. American College of Sports Medicine Position Stand: Exercise and physical activity for older adults. Med Sci Sports Exerc 1998;30(6):992-1008
  8. Province MA, Hadley EC, Hornbrook MC, et al: The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials: Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273(17):1341-1347
  9. Christmas C, Andersen RA: Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc 2000;48(3):318-324

Dr Christmas is an assistant professor in the division of geriatric medicine at Johns Hopkins University and the Johns Hopkins Geriatric Center in Baltimore. Address correspondence to Colleen Christmas, MD, Johns Hopkins Geriatric Center, 5505 Hopkins Bayview Cir, Baltimore, MD 21224; e-mail to [email protected].


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