Patients With Osteoporosis Should Move More, Not Less

Patients with osteoporosis shouldn’t be afraid of regular exercise, according to a consensus statement from the U.K.; instead, health professionals should encourage exercise and physical activity to help patients stay "strong, steady, and straight."

Current strategies for managing patients at high risk for osteoporotic fractures include pharmaceutical treatments, patient education and support, and fall prevention strategies. Research has also suggested a strong relationship between physical activity, exercise, and bone health. However, there is uncertainty regarding whether increasing volume and intensity of exercise improves bone strength. What’s more, both patients with osteoporosis and health care professionals are often concerned that increased physical activity would increase fracture risk, leading to significant reduction in activity levels in this population that may have dire implications for bone health, falls, and future fracture risk.

In order to clear up confusion on the relationship between physical activity and osteoporosis outcomes, a multidisciplinary expert panel convened to review evidence and come to a consensus with specific guidelines on physical activity to optimize bone strength, reduce fall and fracture risk, improve posture, and manage vertebral fracture symptoms.

The resulting consensus statement was published in the British Journal of Sports Medicine.

"Key recommendations are that people with osteoporosis should undertake resistance and impact exercise to maximize bone strength; should take part in activities to improve strength and balance to reduce falls; and undertake spinal extension exercise to improve posture, and potentially reduce pain levels caused by vertebral fractures, risk of falls, and vertebral fracture," panel chair Dawn A. Skelton, of the School of Health and Life Sciences at Glasgow Caledonian University in Glasgow, U.K., and colleagues wrote. "Although we recommend avoiding postures involving a high degree of spinal flexion (especially weighted) during exercise or daily life, and that people with vertebral fracture or multiple low trauma fractures should only exercise up to an impact equivalent to brisk walking, there is limited evidence of harms from exercise. People with vertebral fractures may benefit from exercise to reduce pain, improve mobility and quality of life, ideally with advice from a physiotherapist. Most importantly, inactivity should be avoided, physical activity encouraged, and reassurance provided to counter the fear of moving that could detrimentally affect bone strength and health/quality of life more broadly."

A U.K. Expert Exercise Steering Group (EESG), a panel consisting of 12 experts, convened to develop this consensus statement—the panel consisted of "four physiotherapists, three rheumatologists, three academics and an osteoporosis specialist nurse; all but one of whom were female," Skelton and colleagues explained. "Nine were clinically active with mean (SD) 18 (13) years of clinical experience, and ten were research active with 18 (11) years research experience." A U.K. Exercise Expert Working group (EEWG) including 16 experts was also convened, consisting of "nine physiotherapists, two patient representatives, two patient advocates, an exercise instructor, nurse, and physiologist."

After refining the scope and synthesizing the evidence behind the statement via teleconference and email, the EESG and EEWG convened for a full day, in-person meeting in London (September 2017) for discussion.

The consensus group landed on three primary themes for these osteoporosis exercise guidelines:

• "Strong: physical activity and exercise to benefit bone strength.
• "Steady: physical activity and exercise to prevent falls.
• "Straight: physical activity and exercise to reduce risk of vertebral fracture, improve posture, and manage symptoms after vertebral fracture."

Recommendations under each theme were specified for all individuals with osteoporosis (defined as individuals with bone mineral density [BMD] in the osteoporosis range or significant fracture risk with or without fragility fractures); people with vertebral fractures or multiple low trauma fractures; and people living with frailty and unsteadiness or experiencing falls.

The consensus panel concluded that there is "little evidence of harm, including fractures, occurring while exercising" in the existing literature. "Furthermore, cases that were identified comprised a mixture of people with and without osteoporosis (as defined by DXA). Exercise is therefore unlikely to cause a fracture (and specifically a vertebral fracture) and does not need to be adapted for those with osteoporosis according to fracture risk or low BMD (including osteoporosis or osteopenia determined by [dual energy X ray absorptiometry] DXA)."

As for specific guidance, a press release regarding the consensus statement laid out the key recommendations as follows:

• "Progressive resistance training and impact exercise involving major muscle groups to maximize bone strength.
• "Resistance training ideally uses resistance machines or weights, building up gradually to heavy loads (the maximum that can be lifted 8 to 12 times). If this isn’t an option, circuit training; rowing; Pilates or yoga; stair climbing; sit to stands; heavy housework, gardening, DIY may be good muscle-strengthening alternatives.
• "Running, jumping, aerobics, Scottish dancing/Zumba and many ball games are examples of impact exercise.
• "Activities to improve strength and balance to reduce fall risk, such as Tai chi, Pilates, and yoga; referral to recognized falls prevention programs.
• "Spinal extension exercises to improve posture and potentially curb the risk of falls and vertebral fractures: examples available on https://theros.org.uk.
• "Avoidance of postures involving a high degree of forwards bending of the spine, such as toe touches, curl-ups, or picking up heavy objects without bending at the knees and hips.
• "For people with previous fractures, including of the vertebrae, or who are frail/elderly, exercise only up to an impact equivalent to brisk walking.
• "For those at risk of falls, start with targeted strength and balance training.
• "Breathing and pelvic floor exercises can help ease symptoms that may be worsened by severe curvature of the spine (spinal kyphosis)."

The consensus panel noted that while evidence suggests exercise is beneficial in this population, the magnitude of that benefit is "substantially lower than that for osteoporosis medication." Therefore, they concluded that "exercise should be viewed as an adjunct rather than an alternative to pharmaceutical treatment where this is indicated." That said, exercise should be considered even when pharmaceuticals are used in order to stave off the adverse events associated with inactivity.

The panel also noted several limitations to both the process of forming these guidelines and the recommendations themselves. The stakeholder groups consulted for the creation of these guidelines was predominantly White and female; limited evidence, a lack of studies with fracture as a primary outcome, inconsistent adverse event reporting, and a limited number of interventions in certain subgroups weaken the strength of the recommendations; several individual treatments reviewed had small sample sizes; the panel did not formally rate the quality of the reviews included in their analysis; and most studies focused on BMD, "but localized adaptations in bone mean that such changes may not parallel changes in bone strength."

Finally, the panel insisted that in order for the strong, steady, and straight to be fully implemented, "an infrastructure for measuring and monitoring quality assurance and improvement is needed, to ensure ongoing fidelity (the right populations targeted by the right professionals, dose, frequency, intensity, challenge, resistance, etc.). We need to demonstrate impact to justify investment in osteoporosis programs. This is increasingly important as the impact of Covid-19 and increased prevention and rehabilitation needs have the potential to jeopardize the offer of exercise for osteoporosis."

Skelton is a director of Later Life Training, a not-for-profit organization that provides training and qualifications to health and fitness professionals working with frailer older people. No other relevant relationships were disclosed.

Skelton DA, et al "Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis" Br J Sports Med 2022; DOI: 10.1136/ bjsports-2021-104634.

"Don’t be afraid to exercise regularly to boost bone health and cut falls risk, people with osteoporosis advised" EurekAlert 2022; https://www.eurekalert.org/news-releases/952512.