Osteoporosis is a disease characterised by the progressive loss of bone density and quality making them prone to fracture. Postmenopausal women and those over the age of 50 have been identified as being most at risk because of the role of oestrogen in bone formation and age related loss of bone mineral density (Anon, 2019). Athletes putting their bones under repetitive stress or with a low body weight also risk osteoporotic fracture. Treatment methods focus on increasing and maintaining bone mineral density while reducing the risk of falls. A gold standard pathway should include: consultation with a nutritionist and a pharmacological review, appropriate supplementation of calcium, vitamin D and vitamin K, a six month combined high impact, balance and resistance programme. Adjuncts to this which may also provide some benefit are low frequency whole body vibration and ultrasound therapy.
A nutritionist review of diet will aid the maintenance of bone mass. The Framingham osteoporosis study, which analysed the relationship between diet and bone density of 907 subjects, showed that ‘Men with a diet high in fruit, vegetables, and cereal had significantly greater BMD than did men with other dietary patterns’ (Tucker et al., 2019). Whilst the correlation isn’t as strong in women, the study concludes that to maintain bone density, a diet high in fruit, vegetables, magnesium and potassium should be promoted and intake of dairy, meat and sweet baked goods reduced. Excessive alcohol consumption negatively effects BMD however it is expedient in moderate amounts. Ganry, Baudoin and Fardellone, (2019), focused on the effect of alcohol on a sample of 7,598 women, both studies concluded that 2-3 drinks a day positively affect BMD on photon absorptiometry. As well as consuming a ‘bone healthy’ diet, it is also important to consider whether an individual has an adequate energy intake as low body weight is associated with osteoporosis and fracture (SAGE Journals, 2019). A nutritionist can discuss methods to optimise an individual’s diet for bone maintenance whilst discouraging factors associated with loss and fracture.
Fracture risk can be reduced by supplementing a healthy diet. Vitamin D supplementation with calcium reduces the risk of total fractures and in particular hip fractures. Public health England recommends a daily intake of 700mg of calcium (Assets.publishing.service.gov.uk, 2019) and 10 micrograms of vitamin D (GOV.UK, 2019). The royal osteoporosis society reviews and reports on current best evidence, it concludes that Calcium and vitamin D supplements should be taken separately from bisphosphonates (Theros.org.uk, 2019). The royal osteoporosis society also states that multiple calcium supplements should be divided and taken three hours after high fibre meals to optimise absorption (Theros.org.uk, 2019). Calcium citrate is slightly more easily absorbed than calcium carbonate but research has not indicated it is more effective (Theros.org.uk, 2019). Vitamin D3 may be slightly more effective than vitamin D2 however; D2 is vegan (Theros.org.uk, 2019). A cardiovascular risk associated with calcium supplementation has been proposed but not evidenced, as a precaution supplements should always be selectively advised (Theros.org.uk, 2019). An adequate intake of potassium, magnesium and vitamin D can have a positive effect on BMD although, evidence is inconclusive (Theros.org.uk, 2019; Zhu K, 2019). Where adequate vitamins and minerals are not consumed, supplementation will ensure BMD is optimised, a gold standard approach could involve micronutrient testing to inform supplementation.
Osteoporosis medications reduce bone loss and increase bone formation. The most common pharmacological interventions used for osteoporosis are bisphosphonates and their effect is well documented (Theros.org.uk, 2019). In April 2019, the FDA approved the drug romosozumab in the US (U.S. Food and Drug Administration, 2019). Romosozumab was trialled by its product developer on 7180 postmenopausal women over a 12 month period. In this group, incidence of vertebral fracture whilst taking romosozumab compared with placebo was measured, the researchers found a 73% lower fracture risk after one year. In a smaller group of 128 patients, bone mineral density was measured using dual-energy x-ray absorptiometry. An increase in BMD was found when compared to placebo but were more marked after a change to denosumab at 12 months (New England Journal of Medicine, 2019). Further trials may provide a similar evidence base as bisphosphonates.
A combined exercise programme of weight bearing, balance and resistance training is optimal for increasing BMD and reducing the risk of fall related fractures. The royal osteoporosis society recommends that most people with osteoporosis should complete ‘about 50 moderate impacts on most days’ alongside 20 – 30 mins of resistance and balance exercise on 3 non consecutive days (Theros.org.uk, 2019). There have been positive results for all three modalities in isolation and combination. A systematic review of 28 studies conducted in 2009 revealed that interventions that included weight bearing aerobic exercise improved bone strength when the duration of the programme was at least a year (Kam et al., 2019). The authors also found that in the same time the inclusion of balance exercises resulted in reduced falls or fractures from falls (Kam et al., 2019).A study of 71 older women conducted in 2011 found that after 8 months of 3 times weekly resistance training sessions, BMD increased at the trochanter (2.9%) and total hip (1.5%), body composition was also improved (Marques EA, 2019).To assess the impact of combining these interventions S, M. (2019) conducted a meta analysis of controlled trials. Included trials evaluated the effect of impact exercise on lumbar spine, femoral neck and total hip bone mineral density in postmenopausal women. The authors concluded that programmes combining low impact activity with jogging or impact activity with resistance exercises reduced hip and spine bone loss (S, M. 2019). Positive results have been gained from weight bearing, resistance and balance protocols, patients should therefore receive all of these 3x weekly for a period of at least eight months.
Whole body vibration can be used to reduce falls and increase bone density. It is hypothesised that the vibration activates mechanotransduction in bone and in this way causes osteogenesis. One study conducted in 2011 (C.F. Dionello, 2019) tested this theory on 151 postmenopausal women. The authors compared an 18 month exercise programme with an identical one but for the addition of 15 min vibration training at 25-35Hz. When comparing bone density and falls, it was concluded that vibration training significantly reduced falls and had the same effect as an exercise programme on lumbar spine BMD. A 2016 Meta analysis of 15 RCT’s by Oliveira, Oliveira and Pires-Oliveira,( 2019) found an increase in BMD with WBVT but, due to it excluding comparative studies it is not clear if the effect is greater than that of an exercise programme. An analysis of 6 articles conducted by Um.edu.mt, (2019) explored in greater depth the effect of WBV on fall rates and also found a positive effect in adults over 60. The authors call for further research to establish the optimal dosage. A Meta analysis conducted in 2018 by Verschueren et al., (2019) aimed to evaluate the effect of WBVT on femoral neck and lumbar spine BMD. It found that WBVT increased BMD greater than in control groups. The authors of this analysis found that there was a difference in pre/post BMD but no difference between WBVT and control groups. This suggests, in concordance with Oliveira, Oliveira and Pires-Oliveira, (2019), that although effective, WBVT may not be more effective than an exercise intervention. WBVT has a place in the reduction of falls and building BMD in populations where an effective exercise programme is not possible. This Meta analysis also attempted to establish dose parameters that were called for by Um.edu.mt, (2019). It was concluded that over 20Hz, 5mm/8g should be applied for >108 sessions lasting 600 seconds each however, that there is a positive correlation between dose and improved BMD which leaves parameters yet undefined.
Ultrasound therapy may speed the healing of fractures. Bashardoust Tajali et al., (2019) assessed 23 papers with the PEDro tool for quality. The authors conclude that although data was difficult to pool because of methodological differences, LIPUS can stimulate healing in fresh fractures. Another article published in 2009 by Victoria et al., (2019) delves into the hypothesised effect of LIPUS and EST. The article reviews several studies and also concludes that there is evidence for increased time to fracture healing with LIPUS. The studies on EST are deemed inconclusive by the authors. In a bid to consolidate current knowledge and provide recommendations, Hannemann et al., (2019) conducted a review of over 700 patients from 13 trials. Their conclusion mirrors those of the first two, in that LIPUS is beneficial for speeding recovery, specifically in fresh fractures. In contrast the papers reviewed on pulsed electromagnetic fields by Hannemann et al., (2019) appear to demonstrate a similar positive effect. A similar review published in the BMJ looked at the effect of LIPUS only on fractures. Of 13 RCT’s the authors decided to analyse the 5 that observed functional outcomes. Their review concludes that evidence of functional benefit is low to moderate with conflicting evidence. On the whole there is not a strong body of evidence to support LIPUS but promising results mean that it should be viewed as an adjunct. With larger trials, it may become a standard of care in the future.
A gold standard pathway for bone density should include modification of diet and supplementation to increase the consumption of vitamins and minerals shown to maintain bone density whilst eliminating products that have a negative effect. A pharmacological review by an appropriate healthcare professional can optimise the maintenance of BMD, currently the most used medications are bisphosphonates but research into potential new drugs is ongoing and should be monitored. An exercise programme of weight bearing, resistance and balance protocols should be prescribed 3X weekly for a period of at least eight months, an intervention proven to maintain and build BMD. WBVT has a less definitive body of evidence to support it however, as a method of increasing balance in the elderly it is recommended. There may also be some positive effect on BMD but this is not greater than that of an exercise programme WBVT should therefore be viewed as an adjunct for this particular goal. The use of LIPUS is appropriate where a fracture has been sustained; it is currently used by some professionals in non-unions and there is emerging evidence for its efficacy in fresh fractures. It is not yet as well evidenced as established interventions but should be included in a bone health pathway to speed recovery where a fracture has been sustained.
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