The Missing Ingredient in Osteoporosis Prevention Formulas

What if there was an osteoporosis therapy supported by sound clinical research, that was biochemically effective but carried almost no risk of harm?

Such a treatment exists, only it isn’t a medication. It is physical activity—the missing ingredient in most osteoporosis prevention protocols.

Wolff’s law established that bone remodeling takes place in response to stressors and loads exerted on the skeleton. This fundamental law is the premise for non-pharmaceutical approaches towards osteoporosis treatment.

In terms of preventing or slowing osteoporosis, weight-bearing exercise can make all the difference in the world. Examples include exercise bone strengthwalking, jogging, running, tennis, incline activities such as hiking or stair climbing, Tai Chi, jumping rope and dancing. The osteogenic effects and the locations of these effects vary by exercise, but all of them have a positive influence on bone remodeling.

For instance, studies have found that walking has no significant impact on lumbar spine bone mineral density (BMD), but does have a positive impact on femoral neck BMD in postmenopausal women in interventions lasting six or more months.

Studies of high-impact activities show increases in lumbar spine and femoral neck BMD. In the case of running, BMD increases occur throughout the skeleton (Moreira, et al. Arquivos Brasileiros De Endocrinologia E Metabologia, 2014; 58(5), 514–522).

While higher-impact activities may result in greater BMD increases, studies of postmenopausal women show that even moderate activity for 4-6 hours a week, can improve hip BMD significantly (Muir, et al. BMC Musculoskeletal Disorders, 2013; 14, 253).

Be Specific

Exercise directives, whether for osteoporosis prevention or for any other health benefit are much more likely to be effective if they are clear and specif. General recommendations to “get more exercise” don’t usually go anywhere.

Dan Tripps, PhD, Director of Exercise Science at Speck Health and POTENTRx, documents a linear relationship between the influence of exercise precision on its effectiveness. He has found that a specifically-tailored exercise “prescription” is roughly 30% more effective than a general recommendation. If that prescription is customized based on a condition and individual test results, the level of effectiveness increases markedly, Dr. Tripps explained at the Institute for Functional Medicine’s 2016 Annual International Conference.

Elizabeth Pegg Frates, MD, Director of Wellness Programming at Spaulding Rehabilitation Hospital, Charlestown, MA, echoed Dr. Tripps’ comments. She finds that exercise recommendations are far more effective when a physician clearly defines the type of exercise, the frequency, the intensity, and the time/duration.

During her presentation at the IFM conference, Dr. Frates offered the following exercise prescription for preventing or slowing osteoporosis:

  • Aerobic activity: At 40-70% peak heart rate for 30-60 min, 3-5 times per week.
  • Strength training: 75 % of 1 Repetition Maximum (the most amount of weight a person can lift for a defined number of reps) for 8-12 Reps; 20-40 min; 2-3 days per week.
  • Flexibility: Stretching with with prolonged holding for at least 30 seconds as tolerated, 5-7 days per week.
  • Balance: 2-5 days/wk for 20-30 min.

She noted also that exercising at “65% 1RM with 1016 Reps will benefit patients for activities of daily living due to the greater activation of slow twitch fibers.”

In an interview, Dr. Frates told Holistic Primary Care that she recommends having patients complete a Physical Activity Readiness Questionnaire (PAR-Q), prior to making any exercise recommendations. She also recommends the IFM’s Health History and Daily Activity Questionnaire.

Strength and balance assessments are also a good idea before directing patients on any type of walking or exercise program. During a physical exam, evaluate the strength of the major muscle groups and perform a tandem gait test. If a patient shows limitations such as balance issues or general weakness, you’ll need to tailor the exercise prescription or in some cases, refer the patient to a physical therapist.

Any exercise prescription should reflect “the patient’s current fitness level, activity level, strength, current limitations, patient goals and patient preferences.”

Low Impact, High Efficacy

For building bone or preventing bone loss, exercise programs need not be high-impact. In fact, there are studies showing that low-impact or even no-impact exercise can help.

It allows for muscle forces, at the tendon attachment points, to trigger a bone building response. A systematic review of studies looking at weight training in postmenopausal women revealed that weight training was effective in building site-specific BMD. The training required high loading, with an intensity of 70-90 percent of one maximum repetition, for 2-3 sets of 8 to 12 repetitions per set. Best results are obtained with 45-70 minute workout sessions done 3 to 5 times per week over a year (Bemis-Dougherty, et al. Journal of Geriatric Physical Therapy, 2005; 28(3), 115).

Rick Davis, MS, an exercise physiologist and Strength and Conditioning Specialist, uses no-impact resistance training with osteopenic and osteoporotic clients. He emphasizes the need for supervised progress to gradually increase the stress on the muscles.

Anecdotally one client of his, working with him three times a week for a year, was able to double her DEXA scan scores. Mr. Davis reinforces a key point equally noted in the Bemis-Dougherty systematic review: maintaining bone density is an ongoing process, and bone mineral density losses correspond with exercise cessation.

Studies of resistance training for osteoporotic conditions indicate limited potential for harm due to exercise, provided individuals recognize their limits and don’t attempt to overdo it. Patients and practitioners alike need to be mindful of the potential for muscle pain/soreness, joint pain, cardiovascular reactions, falls and fractures under certain adverse conditions such as moving too quickly between positions (Giangregorio, et al. Osteoporosis International; 2014, 25(3), 821–835).

Yoga Improves BMD

YogaElderYoga represents another approach to physical activity that can have positive effects on bone health. Yoga poses that stretch or compress muscles also place force on bones.

Dr. Loren Fishman, MD, medical director of Manhattan Physical Medicine and Rehabilitation at Columbia Medical School, has developed a protocol of 12 common yoga poses specifically aimed at osteoporosis prevention. For each pose, three modifications are offered based on physical limitations and skill level: elementary, intermediate, and classical.

In a ten-year study of 741 volunteers, participants were asked to engage in each of the twelve poses and hold them for 30 seconds daily as demonstrated in an instructional DVD.

Of the 227 moderately and fully compliant participants, BMD rose in the spine (0.0029 g/cm², P=.005) and femur (0.00022 g/cm², P=.053) over a period of two years. The mean gain for hip BMD in one cohort was 50%. Due to variations in individual data, perhaps due to the variable skill levels of the participants, the confidence interval rose and the total hip values (0.000357 g/cm²) were not deemed statistically significant (Lu, et al. Topics in Geriatric Rehabilitation, 2016; 32(2), 81–87). But the trend is suggestive, nonetheless.

According to Dr. Fishman, in over 100,000 hours of practice of these poses, there were no yoga-related fractures or serious injuries reported.

YogaBoneBookIndividuals interested in pursuing this yoga-based protocol can do so on their own with the DVD or the Book, Yoga for Osteoporosis: The Complete Guide, authored by Dr. Fishman and Ellen Saltonstall, But Dr. Fishman recommends combining these with direction from a certified yoga therapist, a certified lyengar yoga instructor, or a yoga teacher specifically certified in Dr. Fishman’s method.

Aside from specifically directed physical exercises, there are other mechanisms to create osteogenic loading. One involves whole-body vibration training. Typically this involves performing both static and dynamic knee-extensor exercises on a vibration platform (PowerPlate).

In a study of postmenopausal women who trained three times a week for a maximum of 30 minutes over 24 weeks, this approach resulted in significant hip bone mineral density increases.

Over the course of the six months, the training volume systematically increased either by duration, by number of repetitions, or by quantities of exercises performed. Training intensity likewise rose by increasing amplitude or decreasing rest periods. At the end of the study period, BMD of the total hip was increased (+.93%; 95% CI, 0.13-1.71; P=0.03).  There were no vibration-related side effects noted (Verschueren, et al. Journal of Bone and Mineral Research, 2004; 19(3), 352–359).

Osteogenic Loading

Osteogenic loading equipment like the OsteoStrong SPECTRUM system, represents another promising approach. OsteoStrong makes use of multiple-of-bodyweight axial bone loading. It was designed to isolate the optimal ranges of motion most often observed to increase bone density, and to impart high levels of force on these targeted areas beyond that which regular exercise could achieve.

For each session, a participant completes four individual movements: one targeting each of the lower and upper extremities; one targeting spinal compressive forces; and one to activate the core. The participant holds each exercise for 5 seconds, and the whole combination of exercises take between 10-15 minutes to complete. The amount of force is self-directed by the individual. Sensors within the apparatus capture, measure, and document it.

Over a 24-week observational trial with postmenopausal women, this type of osteogenic loading resulted in significant BMD gains of 14.9% (+/- 11.5% SD) in the hip and 16.6% (+/- 12.2% SD) in the spine (Hunte, et al. Journal of Osteoporosis and Physical Activity, 2015; 3:30).

Dr. John Jaquish, PhD, the inventor of the apparatus, explains the benefits of this therapy for at-risk populations:

“We apply loading in a slow and controlled manner in order to use comfort and neural inhibition as a natural limiter. (While) it is possible for someone to abruptly load using an osteogenic loading device, thereby removing the inherent safety aspects of the therapy, as long as the proper osteogenic loading training protocols are adhered to, the chances of injury are very low.”

Dr. Jaquish notes that in most cases, the BMD gains become apparent at the five to nine-month mark (with slower adaptations evident the closer to the zero T-score). He recommends that users work with OsteoStrong for a year before retesting their bone density with a DEXA scan.

While the risk of injury is low, Dr. Jaquish noted that osteogenic loading therapy is contraindicated for individuals with unmedicated hypertension or muscular dystrophy. “As long as someone is relatively pain-free and ambulatory, they can achieve bone density gains.”

There have never been more ways for people to exercise and obtain the bone benefits it can confer. That said, achieving optimal results usually requires professional guidance and access to technical resources. For many at-risk people with limited incomes, paying for these can be challenging.

If a patient is employed, and the employer has a wellness initiative within their health plan, partial compensation may be available either directly or via a deductible credit. Alternatively, if someone has a flexible spending account (FSA) or health savings account (HSA), a targeted exercise program designed to improve BMD may be an eligible expense.

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Christina Brockett, MS Nutrition & Integration Health is an integrative clinical intern and recent graduate of The Maryland University of Integrative Health. She has recently completed her BCNS boards and is currently nearing the completion of her board certification clinical hours. Once board certified and licensed, she will begin her clinical practice with Encompass Integrative Wellness, LLC and as staff nutritionist with Hauser Health in Frederick, Maryland.