Strong, Steady and Straight - An Expert Consensus Statement on Physical Activity and Exercise for Osteoporosis

Key Points

1. Practitioners should promote physical activity consisting of resistance and impact exercise.
2. Practitioners should individualize and progress exercise programs depending upon physical ability and prior fractures.
3. Practitioners should provide reassuring messages and movement variety, not avoidance.

BACKGROUND & OBJECTIVE

The prevalence of osteoporosis itself is difficult to determine and likely under reported. However, in the UK over 1/3 women and 1/5 men will sustain a fragility fracture in their lifetime, and at age 75-84 the absolute 10-year risk for sustaining a fragility fracture is approximately 24% for women and 14% for men (1,2). It is also the most common “red flag” presentation for spinal pain.

There is significant variation between individual practitioners’ understanding of what is safe and effective for those with osteoporosis or who have sustained an osteoporotic fracture. This consensus statement aimed to reduce that variation with evidence-based recommendations across three sections “strong, steady, straight”. These sections broadly cover increasing muscle and bone strength, reducing falls, and promoting confident, varied functional movements.

In the UK over 1/3 women and 1/5 men will sustain a fragility fracture in their lifetime.

Clinically, the most effective physical activity for the individual will be the highest intensity they can tolerate.

RECOMMENDATIONS:

Promote physical activity (strong), especially weightbearing and muscle strengthening exercises with variety as these have the best evidence behind them for promoting bone strength. Impact exercise is recommended to be kept at a lower level for those with previous fractures due to the unknown risk of further fractures.

Balance exercises for those at risk of falls (steady), and safe techniques for lifting/avoidance of sustained, repeated or end range flexion (straight) are also recommended.

LIMITATIONS

It is important to note that there is a paucity of evidence especially around osteoporosis in men (1,2), and with regards to recommendations for exercise prescription. There is a level of caution in those who have sustained vertebral fractures or multiple low trauma fractures that I suspect could be relaxed were appropriate trials to be undertaken showing it to be safe to do so.

There is also a paucity of evidence around specific movements and lifting as a cause for vertebral fractures, and the recommendations are mostly based around the theoretical biomechanical models of spinal movement. Clearly forward flexion creates higher forces at the anterior portion of the vertebrae, but it is not clear that this is causative.

CLINICAL IMPLICATIONS

Clinically, the most effective physical activity for the individual will be the highest intensity they can tolerate. It is of importance to assess on an individual basis current physical function, risk of further fractures/falls and design the program appropriately. In those with previous fractures a graded increase in intensity is necessitated by lack of evidence proving or disproving safety of impact exercise.

Reassurance is key for this population, and teaching varied options for movement rather than avoiding movement will promote physical activity and reduce fear. It is very unlikely that someone will sustain a fracture from their resistance or impact exercises. It is much more likely they will sustain a fracture from a fall or continued deterioration in Bone Mass Density (1,2).

+STUDY REFERENCE

National Osteoporosis Society (2018) Strong, Steady and Straight: An Expert Consensus Statement on Physical Activity and Exercise for Osteoporosis.

SUPPORTING REFERENCE

1. Cauley J – Osteoporosis: fracture epidemiology update 2016, Current Opin Rheumatol 2017, 29:150–156
2. Rosen CJ. The Epidemiology and Pathogenesis of Osteoporosis. [Updated 2017 Feb 21]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000