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osteoporosis. Z. Bonakdar Rheumatologist. Osteoporosis is a skeletal disorder characterized by low bone mass with microarchitectural disruption and fragility, resulting in an increased risk of fracture.

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Z. Bonakdar Rheumatologist


Osteoporosis is a skeletal disorder characterized by low bone mass with microarchitectural disruption and fragility, resulting in an increased risk of fracture.

  • Decreased bone mass can occur because peak bone mass is low, bone resorption is excessive, or bone formation during remodeling is decreased.

Bone tissue is in a continual process of building, breaking down and rebuilding. During periods of human growth the rate of bone formation exceeds that of bone loss. The reverse is true as age increases. Bones reach their maximum strength and density (peak bone mass) between the ages of 20 and 30 years.

  • Factors affecting peak bone mass include diet, calcium intake, physical activity and genetics.

After the age of about 40–50 years, the rate of bone loss increases and bone mass is lost. Bone mineral density later in life is determined by the bone mass accumulated during youth and the subsequent rate of bone loss.


Bone accretion occurs during adolescence and peak bone mass is normally achieved after puberty and into the third decade of life.

  • Bone mass declines with age, about 0.3- 0.6% in cortical bone and 0.8- 1.2% in trabecular bone annually.
  • At menopause, an acceleration of bone loss occurs over approximately 5 to 8 years, with an annual 2 to 3 percent loss of trabecular and 1 to 2 percent loss of cortical bone.

Over lifetime, women lose approximately 50 percent of trabecular and 30 percent of cortical bone, where as men lose two thirds of these amounts.

  • After 50 years of age, there is an exponential rise in fractures such that 40 percent of women and 13 percent of men develop one or more osteoporotic fractures.

It is estimated that one in two women and one in four men over the age of 60 will have a fracture due to osteoporosis in their lifetime.

  • Of all reported osteoporotic fractures, 46% are vertebral, 16% are hip and 16% are wrist fractures.

It has been predicted from epidemiological modelling that a 10% increase in peak bone mass could significantly delay the onset of osteoporosis and reduce the risk of osteoporotic fractures later in life.

  • One model showed that a 10% increase in peak bone mineral density was predicted to delay the development of osteoporosis by 13 years.
  • Another study using modeling from epidemiological studies predicted that a 10% increase in peak bone mass would reduce the risk of fragility fractures after the menopause by 50%.

Additionally, it suggests that peak bone mineral density (BMD) may be the single most important factor in delaying the development of the disease.

  • Consistent data from randomized controlled trials show that

exercise training programs can prevent or reverse almost 1% of bone loss per year in both pre- and post-menopausal women.

three frequent types of osteoporotic fracture
Three frequent types of osteoporotic fracture

Fractures of the vertebral

Fractures of the proximal hip

Fractures of the distal radius

Life time risk above age 50 years

Female Male

15.6% 5%

17.5% 6%

16% 2.5%


The percentage of patients with osteoporosis increases progressively with age, of US women, 13% in their 50s, 27% in their 60s, 47% in their 70s, and 67% in their 80s meet the diagnostic criteria for osteoporosis.

  • Bone mass is a major determinant of fracture risk: For every 10% decline in bone mass, there is an approximate doubling of fracture risk in the population.
  • Calcium and vitamin D

prepubertal children 800 mg/day

adolescents 1300 mg/day

women and men 1000 mg/day

women and men over 50 years 1500 mg/day

women and men 400 IU/day

women and men over 50 years 800-1000 IU/day

  • Tea contains fluoride and phytoestrogens with positive role in bone health
  • Excess caffeine > 4 cups should be avoided
  • Excess dietary sodium > 2100 mg/day or 90 mmol/day should be avoided
  • Excessive alcohol should be avoided
  • Cigarette smoking should be stopped
  • Excessive vitamin A should be avoided
  • High protein diet should be avoided
  • Vitamin K may be efficacious in slowing bone loss but has not been shown to be superior to Ca and vitamin D
  • Population with highphytoestrogen intakes have lower rates of fracture
  • Multinutrient supplement 600 mg magnesium, 15 mg zinc, 120 mg vitamin C, 80 mg vitamin K, 3 mg boron- all nutrients believed to be important for bone health
physical activity and falls prevention
Physical activity and falls prevention
  • Impact exercises (high impact aerobics, running, jump training) lead to an improvement in BMD
  • For older men and women at risk of falling, tailored programs, contain exercises to improve strength and balance should be considered

Hip protectors


Environmental modifications


Three types of exercise for osteoporosis are:

  • Weight-bearing(Walking- Hiking- Dancing- Stair climbing)
  • Resistance(dumbbells and barbells, elastic band resistance, body-weight resistance or weight-training machines )
  • Flexibility(Regular stretches-T'ai chi-Yoga)

In a study of healthy, postmenopausal women, a 24-week whole body vibration program was shown to improve muscle strength, balance and hip bone density.

  • The Bone Mass Density (BMD) of the hip increased by 1% .
  • Research indicates that the highest muscle reflex response may occur between 30Hz and 40Hz.
  • The duration of the vibration exercise programs was between 20-30 minutes.

Reduce the risk of premature death

  • Reduce the risk of developing and/or dying from heart disease
  • Reduce high blood pressure or the risk of developing high blood pressure
  • Reduce high cholesterol or the risk of developing high cholesterol
  • Reduce the risk of developing colon cancer and breast cancer

Reduce the risk of developing diabetes

  • Reduce or maintain body weight or body fat
  • Build and maintain healthy muscles, bones, and joints
  • Reduce depression and anxiety
  • Improve psychological well-being
  • Enhanced work, recreation, and sport performance
specific health benefits of exercise
Specific Health Benefits of Exercise
  • Heart Disease and Stroke. Daily physical activity can help prevent heart disease and stroke by strengthening your heart muscle, lowering your blood pressure, raising your high-density lipoprotein (HDL) levels (good cholesterol) and lowering low-density lipoprotein (LDL) levels (bad cholesterol), improving blood flow, and increasing your heart's working capacity.

High Blood Pressure. Regular physical activity can reduce blood pressure in those with high blood pressure levels. Physical activity also reduces body fatness, which is associated with high blood pressure.


Noninsulin-Dependent Diabetes. By reducing body fatness, physical activity can help to prevent and control this type of diabetes.


Obesity. Physical activity helps to reduce body fat by building or preserving muscle mass and improving the body's ability to use calories. When physical activity is combined with proper nutrition, it can help control weight and prevent obesity, a major risk factor for many diseases.


Back Pain. By increasing muscle strength and endurance and improving flexibility and posture, regular exercise helps to prevent back pain.


Osteoporosis. Regular weight-bearing exercise promotes bone formation and may prevent many forms of bone loss associated with aging.


Psychological Effects. Regular physical activity can improve your mood and the way you feel about yourself. Researchers also have found that exercise is likely to reduce depression and anxiety and help you to better manage stress.

regular physical activity
Regular physical activity
  • up to a 35% lower risk of coronary heart disease and stroke
  • up to a 50% lower risk of type 2 diabetes
  • up to a 50% lower risk of colon cancer
  • up to a 20% lower risk of breast cancer
  • a 30% lower risk of early death
  • up to an 83% lower risk of osteoarthritis
  • up to a 68% lower risk of hip fracture
  • a 30% lower risk of falls (among older adults)
  • up to a 30% lower risk of depression
  • up to a 30% lower risk of dementia
recommended physical activity levels
Recommended physical activity levels
  • Children under 5 should do 180 minutes every day
  • Young people (5-18) should do 60 minutes every day
  • Adults (19-64) should do 150 minutes every week
  • Older adults (65 and over) should do 150 minutes every week

Moderate-intensity aerobic activity means you're working hard enough to raise your heart rate and break a sweat. One way to tell if you're working at a moderate intensity is if you can still talk but you can't sing the words to a song.


Examples of moderate-intensity aerobic activities are:

  • walking fast
  • water aerobics
  • riding a bike on level ground or with few hills
  • playing doubles tennis
  • pushing a lawn mower

Daily chores such as shopping, cooking or housework don't count

towards your 150 minutes. This is because the effort needed to do

them isn’t hard enough to get your heart rate up.


Exercise can be divided into three broad categories:

  • aerobic,
  • anaerobic,
  • and agility training
aerobic exercise
Aerobic exercise
  • Most aerobic exercises are done at moderate levels of intensity for longer periods, compared to other categories of exercise. An aerobic exercise session involves warming up, exercising for at least 20 minutes, and then cooling down. Aerobic exercise involves mainly the large muscle groups(swimming, running, cycling and walking ).
anaerobic exercise
Anaerobic exercise
  • The aim of anaerobic exercise is to build power, strength and muscle. The muscles are exercised at high intensity for short durations.
  • Anaerobic exercises include:

Weight lifting


Intensive and fast skipping (with a rope)

Interval training


Any rapid burst of hard exercise


Overall, anaerobic exercise uses up fewer calories than aerobic exercise. The cardiovascular benefits of aerobic exercises are greater than the cardiovascular benefits of anaerobic exercises. However, anaerobic exercise is better at building strength and muscle mass.

agility training
Agility training
  • Agility training aims to improve a person's ability to speed up and slow down, change directions while maintaining balance and control.
  • Agility includes speed, strength, balance and coordination. The following sports are known to require agility :

Tennis Soccer

Rugby American football

Squash Hockey

Badminton Volleyball

Basket ball Martial arts

Boxing Wrestling

yoga and pilates
Yoga and Pilates
  • Some exercises include a combination of stretching, muscle strengthening, balance. A good example is Yoga.
  • Yoga exercises, or movements, improve your balance, flexibility, posture and circulation.
  • Pilates is similar to Yoga, but it focuses more on the core abdominal and back muscles.
exercise for osteoporosis
Exercise for Osteoporosis

Three types of exercise for osteoporosis are:

  • Weight-bearing
  • Resistance
  • Flexibility

Weight-bearing exercise for osteoporosis are:

  • Walking
  • Hiking
  • Dancing
  • Stair climbing

Sports like bicycling and swimming are great for your heart and

lungs. However, these are not weight-bearing exercise for


At least half an hour of moderate to vigorous exercise five times a



Resistance exercise for osteoporosis includes:

  • Free weights or weight machines at home or in the gym
  • Resistance tubing that comes in a variety of strengths
  • Water exercises, any movement done in the water makes your muscles work harder.

For best results, do resistance exercises two or three times a week.

Resistance helps with osteoporosis because it strengthens muscle

and builds bone.


Flexibility exercise for osteoporosis include these:

  • Regular stretches
  • T'ai chi
  • Yoga

Flexibility is another important form of exercise for osteoporosis.

Having flexible joints helps prevent injury.


Low back pain (LBP) is extremely common both in the general population and in those seeking healthcare. Point prevalence estimates for LBP are at least 20% of the general population; yearly prevalence estimates are at least 40%; and lifetime prevalence is around 60%.


In contrast to earlier claimsof a relatively benign natural history for acute back pain, it is now clear that LBP is commonly both highly recurrent and frequently persistent.

  • After initial improvements, there is little further improvement after 3 months, at which point approximately 50% are still experiencing activity limitation; in addition, 66–75% of patients have at least one recurrence within 12 months.

For the internist or family physician, the problem of low back pain (LBP) is one of the most commonly assessed complaints.

  • LBP is the most common cause of limitation of activity in patients younger than 45years old, is the second most frequent reason for a visit to the physician's office.

Lower back pain may be classified by the duration of symptoms as acute (less than 4 weeks), sub acute (4–12 weeks), chronic (more than 12 weeks).


The majority of lower back pain stems from benign musculoskeletal problems, and are referred to as non specific low back pain; this type may be due to muscle or soft tissues sprain or strain.

  • Over 99% of back pain instances fall within this category.
  • Apophyseal osteoarthritis
  • Diffuse idiopathic skeletal hyperostosis
  • Degenerative discs
  • Scheuermann'skyphosis
  • Spinal disc herniation ("slipped disc")
  • Thoracic or lumbar spinal stenosis
  • Spondylolisthesis and other congenital abnormalities
  • Fractures
  • Sacroiliac Joint Dysfunction

When directional preference precedes the prescription of exercises, clinical outcomes (pain relief and ability to return to work) may be better than when non-individualized exercise regimens are prescribed.

  • In particular, exercise regimens matched to the patient's source of pain or directed at specific biomechanical impairments are likely to yield greater pain relief.
  • In general, advice to stay active is better than bed rest for long-term improvement of function in acute LBP.

In contrast to the limited evidence of benefit from exercise for acute LBP, exercise therapy has been shown to have modest benefits in patients with subacute (4 to 12 weeks) and chronic LBP (>12 weeks).  

  • Exercise therapy improves short-term pain relief and function in patients with chronic LBP. In addition, the improvements associated with exercise therapy may be long lasting (≥1-3 years) .
specific exercise programs
Specific exercise programs

In general, exercise therapies for LBP include:

  • Core strengthening (The core refers to the abdominal, paraspinal, gluteal, diaphragmatic, pelvic floor, and hip girdle musculature.
  • Directional preference includes end-range flexion/extension stretches with repeated movements that are designed to improve pain symptoms.
  • Mind body exercise such as  yoga, pilates and Tai chi  which address strength, flexibility, and balance, as well as relaxation techniques
  • Home-based programs

Aquatic therapy

  • Aerobic exercises and functional restoration activities that are commonly designed to motivate the patient .
  • Back schools managed by large companies or occupational health centers. Generally, lessons are provided to groups of patients and supervised by a physical therapist or other therapist trained in back rehabilitation.
  • Functional restoration programs  including physical and occupational therapy .
williams flexion exercises
Williams' Flexion Exercises
  • Pelvic tilt, Single Knee to chest, Double knee to chest, Partial sit-up, Hamstring stretch, Hip Flexor stretch, Squat
mckenzie back exercises
McKenzie Back Exercises
  • Prone lying, Prone lying on elbows, Prone press-ups, Progressive extension with pillows, Standing extension
back strengthening exercises
Back Strengthening Exercises
  • Birddog (Opposite Arm and Leg Extension), Bridge, One-Leg Bridge, Plank

Osteoarthritis is a degenerative joint disease, occurring primarily in older individuals, characterized by erosion of the articular cartilage, hypertrophy of bone at the margins (osteophytes), subchondral sclerosis, and a range of biochemical and morphologic alterations of the synovial membrane and joint capsule.


Risk factors for developing osteoarthritis include age, joint location, obesity, genetic predisposition, joint malalignment, trauma, and gender.

  • Osteoarthritis is a disease process that affects the entire joint structure, including cartilage, synovial membrane, subchondral bone, ligaments, and periarticular muscles.
risk factors and possible causes
  • Age
  • Female versus male sex
  • Obesity
  • Lack of osteoporosis
  • Occupation
  • Sports activities
  • Previous injury
  • Muscle weakness
  • Proprioceptive deficits
  • Genetic elements
  • Acromegaly
  • Calcium crystal deposition disease

The National Health and Nutrition Examination Survey found the prevalence of this disease to be less than 0.1 percent in those aged 25 to 34 years old versus a rate of over 80 percent in people over age 55.

  • Female sex is associated with an increased risk of osteoarthritis. The relative risk of developing osteoarthritis for women has been estimated to be 2.6 after adjustment for age, weight, and smoking.
  • For every two unit increase in body mass index (equivalent to approximately 5 kg), the odds ratio for radiographic knee osteoarthritis increased by 1.36.

SPORTS ACTIVITIES— the following sports were associated

with an increased risk of osteoarthritis in the indicated joints:

  • Wrestling (cervical spine, knees, and elbows)
  • Boxing (carpometacarpal joints)
  • Pitching in baseball (shoulders and elbows)
  • Cycling (patellofemoral joints)
  • Recreational parachuting (spine, knees, and ankles)
  • Cricket (fingers)
  • Gymnastics (shoulders, wrists, and elbows)
  • Ballet dancing (talar joints)
  • Soccer (hips, knees, ankles, cervical spine, and talar joints)
  • Football (knees, feet, and ankles)

Regular exercise can improve physiological impairments associated with OA including muscle strength, joint range of motion, proprioception, balance and cardiovascular fitness.

  • Other potential benefits of exercise for this patient group include improvements in mobility, falls risk, body weight, psychological state and metabolic abnormalities.
nonpharmacologic therapy for patients with osteoarthritis
Nonpharmacologic therapy for patients with osteoarthritis
  • Patient education
  • Self-management programs ( Arthritis Foundation Self-Management Program)
  • Personalized social support through telephone contact
  • Weight loss (if overweight)
  • Temperature modalities

Aerobic exercise programs

  • Physical therapy Range-of-motion exercises
  • Muscle-strengthening exercises
  • Assistive devices for ambulation
  • Patellar taping
  • Appropriate footwear
  • Lateral-wedged insoles (for genuvarum) Bracing
  • Occupational therapy
  • Joint protection and energy conservation
  • Assistive devices for activities of daily living
unconventional options
Unconventional Options
  • Transcutaneouselectrical nerve stimulation
  • Ultrasound therapy 
  • Pulsed electromagnetic fields
  • Static magnets
  • Acupuncture
  • Spa therapy
  • Yoga
physical therapy
  • The physical therapist assesses muscle strength, joint stability, and mobility; recommends the use of modalities such as heat (especially useful just prior to exercise); instructs patients in an exercise program to maintain or improve joint range of motion and periarticular muscle strength; and provides assistive devices, such as canes, crutches, or walkers, to improve ambulation.
  • Similarly, the occupational therapist can be instrumental in directing the patient in proper joint protection and energy conservation, use of splints and other assistive devices, and improving joint function.

Quadriceps weakness is common among patients with knee OA, and that quadriceps weakness may be a risk factor for the development of knee OA, presumably by decreasing stability of the knee joint and reducing the shock-attenuating capacity of the muscle .

  • In addition to quadriceps weakness, sensory dysfunction, reflected by a decrease in proprioception, has been documented in patients with knee OA .
weight loss rest
  • A ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50 percent. The relation between the degree of weight loss and the reduced incidence of OA was linear, suggesting that even modest weight loss may be beneficial.
  • Resting the affected joint may alleviate pain; however, prolonged rest may lead to muscle atrophy and decreased joint mobility. Therefore, rest is recommended for only short periods of time, typically 12 to 24 hours for acute pain and inflammatory signs, after which active and passive joint motion and exercises should resume.
temperature modalities
Temperature Modalities
  • Warm applications can be in the form of warm soaks or heating pads. Individual sessions should not exceed a temperature of 45°C or last more than approximately 30 minutes.
  • The application of warmth should be avoided over certain areas, such as close to the testicles, and in patients with poor vascular supply, neuropathy, or cancer.
  • Benefits of warm applications include decreased pain and stiffness, along with relief of muscle spasm and prevention of contractures.
orthotics and bracing
Orthotics and Bracing
  • Orthotics-ranging from insoles to braces-can be effective in providing symptomatic relief.
  • Studies have demonstrated that lateral wedged insoles provide substantial relief to those with medial compartment knee OA, particularly those with varus deformity.
  • Valgus bracing of patients with medial compartment OA can reduce pain and increase levels of activity.

In one study, medial taping of the patella reduced the pain of those with patellofemoral compartment OA by 25%.

  • Heel lifts have been tried in those with hip OA.
  • For those with calcaneal spurs or foot joint OA in general, appropriate athletic-type footwear is recommended. A good athletic shoe should provide medial arch support and calcaneal cushioning, as well as good mediolateral stability.
  • Use splints for carpometocarpal OA.
  • The appropriate use of a cane can be an important adjunct, particularly in OA of the hip. It has been estimated that a cane can provide up to a 40% reduction in hip contact forces during ambulation.
  • The cane should be used in the hand contralateral to the affected hip or knee and should be advanced with the affected limb while walking.
  • The appropriate cane size is that which results in about a 20-degree flexion of the elbow during use.
  • A useful approximation is a cane that is equal to the distance from the floor to the patient's greater trochanter.
modification in activities of daily living
Modification in Activities of Daily Living
  • Physician advice and occupational therapy can provide useful insights into modifications of daily activities to reduce OA symptoms.
  • These interventions can range from using an elevated toilet seat or shower bench in someone with lower extremity OA to using appliances designed to open jars in patients with hand OA.
  • Exercises that cause low load effects such as swimming, bicycling, walking, or Tai Chi are helpful in developing muscular strength while protecting joints .
  • Range of motion and strengthening exercises can reduce pain and increase mobility in patients with OA .