Osteopenia and Osteoporosis Diagnosis, Prevention, Treatment

Help! Do I have brittle bones?

Are you worried that you may have brittle bones or anxious of this occurring as you get older? Perhaps you’ve already been diagnosed with Osteoporosis or Osteopenia and wondering how this will affect you and your lifestyle? You aren’t alone! Around 853,600 (3.4%) people in Australia were estimated to be living with osteoporosis or osteopenia in 2022. This is also likely to be much higher due to undiagnosed cases

This post will help field all your questions around this diagnosis from how to prevent it and what can be done to help slow down the progress of this condition.

What is the difference between Osteopenia and Osteoporosis?

Whilst both these conditions affect bone density (which refers to the mineral content of your bones) they differ in severity.

Osteopenia is a condition where the bone mineral density (BMD) is lower than normal but not low enough to be classified as osteoporosis. This typically occurs as part of the natural aging process, although can be influenced by factors such as poor diet, lack of physical activity, smoking, excessive alcohol use or even certain medication. Osteopenia is often diagnosed through a bone mineral density test, such as a DEXA scan (dual-energy Xray absorptiometry). The results are interpreted as a “T score” which is then compared to the average bone density of a healthy young adult.

• Normal: A T-score of -1.0 or higher
• Osteopenia: A T-score between -1.0 and -2.5
• Osteoporosis: A T-score of -2.5 or lower

Osteoporosis is a more severe form of bone density loss in which the bones are fragile and are more likely to fracture with impact. As outlined above the diagnosis for Osteoporosis is typically defined by a T-score of -2.5 or lower. Like osteopenia, osteoporosis is often associated with aging, but it can also result from other factors, such as hormonal changes (e.g., menopause in women), lack of calcium or vitamin D, sedentary lifestyle, smoking, excessive alcohol intake, or long-term use of medications like corticosteroids.

The key differences between the two conditions is severity. There is a greater risk of fracture with osteoporosis. Having weak bones increases the risk of fractures, even with minor incidents or falls. Severe fractures, especially hip fractures, in individuals with osteoporosis can be associated with an increased risk of mortality, particularly in adults over 65.

What is happening to my bones?

Bone formation starts in utero and completes around late adolescence or early adulthood. This is the window of time where it is important to maximise our peak bone mass which is the size and strength of our bones. There is a limited time frame in which this can be influenced. The recent literature suggests that the best time for building bone mass is during our growing years as most people will reach their peak around their 20’s or 30’s. By the age of 40 our bone mass starts to decline. This is unavoidable, but we can influence the rate that it happens by staying healthy and ensuring that we have enough calcium within our diet, enough vitamin D to aid absorption and perform appropriate exercise.

The physiological process behind osteoporosis involves several factors, primarily affecting bone remodelling, which is a continuous process of bone resorption (breakdown) and bone formation. The key elements in this process include:

Bone Remodelling:

Bone tissue is dynamic, constantly undergoing remodelling, which involves bone resorption and bone formation. In resorption the osteoclast cells break down old bone tissue which releases minerals such as calcium into the bloodstream. Bone formation is where the osteoblast cells form new bone tissue, laying down collagen and mineralising it with calcium and phosphate. In a healthy individual, bone resorption and formation are balanced, maintaining bone density and strength. However, in osteoporosis, this balance is disrupted and there is greater bone resorption, leading to bone loss.

In osteoporosis, osteoclast activity (bone resorption) becomes excessive compared to osteoblast activity (bone formation). This results in a net loss of bone mass. Several factors contribute to this imbalance such as hormonal changes, age and certain deficiencies. Estrogen has a crucial role in regulating bone remodelling. Particularly by inhibiting osteoclast activity. During menopause estrogen levels drop significantly leading to an increase in osteoclast activity and subsequently increased bone resorption. Similarly low testosterone levels in men can also contribute to this process. Age is another factor that can influence osteoporosis. As individuals age the rate of bone formation declines whilst resorption continues at the same rate. Although age is a risk factor that cannot be avoided there are things that one can do to slow down this process which will be discussed later in this post. Having deficiencies in certain minerals can also impact this process. Calcium is essential for bone strength, and vitamin D is necessary for calcium absorption. Deficiencies in either can lead to weakened bones.

Decreased Bone Formation:

As outlined function also diminishes with age / response to hormonal changes. In osteoporosis osteoblasts are even less effective in producing new bone matrix. This means that even as bone is resorbed, less new bone is being created to replace it.

Bone Microarchitecture Degradation:

Osteoporosis not only changes the bone mass but also leads to changes of the bone’s microarchitecture. Spongy bone known as trabecular bone becomes thin and more porous. This reduces the bone’s ability to shock absorb and resist fractures. This increases the fragility of the bones and makes them more prone to fracture from minor trauma or even spontaneously.

The good news:

Although the likelihood of osteopenia, osteoporosis and bone density changes increase throughout life, there are ways to treat, manage and slow the natural progression of these conditions. Changes to one’s lifestyle including things such as having a calcium and vitamin – D rich diet and including weight bearing exercises can help to prevent further bone density changes; subsequently reducing the risk of fractures and the mortality associated with them.

What role does physiotherapy play?

The current literature emphasises that exercises that involve weight-bearing (impact on bones), muscle strengthening (building muscle mass/resistance training) and balance training are particularly beneficial. This may sound counterintuitive as you may think more weight and stress on the bones may cause further chance of damage – however this is not the case.

Wolff’s law was developed by German anatomist Julius Wolff that describes bone remodelling regarding stress and impact on bone. It states that bones adapt to the degree of mechanical loading (such as walking, jumping etc.) An increase in loading causes the architecture of the internal trabecular bone to strengthen followed by an increase in cortical layer strength. Consequently, a decrease in stress will have the opposite effect. This same law is recognised when children start to crawl, walk and run as we see a change in their skeletal structure in response to this newfound mechanical loading.

Strength training or resistance exercises are crucial for building muscle mass and bone density. Muscles pull on bones during movement, stimulating bone growth and improving bone strength. Balance and core training is great at reducing falls and consequently the fractures that may occur following a fall.

Some examples of weight bearing exercises are:

• Walking: This is a weight bearing exercise which works against gravity to stimulate the bone. Evidence suggests that walking 30 minutes per day can improve bone health.
• Stair climbing: Like walking this is an excellent way to build strength and stimulate bone growth.
• Jogging/running: For certain groups this will be unsafe to do so however for others this high impact weight bearing exercise is beneficial.
• Stomping/jumping/skipping: These exercises are slightly more impact that walking but not as much as running.

Some examples of resistance training are:

• Free weights: exercises using dumbbells such as squats, bicep curls and chest presses can strengthen the bones and muscles around the hips, spine and arms.
• Resistance bands: Using bands in exercises such as shoulder presses and leg presses are a safe and effective way to add load. Especially as part of a home exercise programme.
• Weight machines: In the gym setting using equipment such as a leg and shoulder press machine provide controlled resistance safely.

Some examples of balance and core exercises:

• Bridging: These help to strengthen the glutes, hamstrings and muscles around the trunk.
• Pelvic tilts: This helps strengthen the lower back and abdominal muscles while maintaining spinal alignment.
• Tandem walking: Also known as tight rope walking. Don’t worry you won’t be walking on a tightrope! Taking small steps with one foot in front of the other challenges the balance and ultimately strengthens it.
• Single leg balance: Practicing balancing on one leg can help to improve your bodies proprioception (where your body is in space) subsequently improving balance. This can be done on different surfaces and even with eyes closed to create more of a challenge.

Your Physiotherapist can provide you with an exercise programme tailored to your needs with the aim to increase bone density. Depending on the location and the stage of your diagnosis some exercises should be avoided whilst others are encouraged and will be more effective in tackling bone density loss. The physiotherapists at Bend + Mend have the expertise to create a programme that is both effective and safe for you to do.

With any form of exercises, it must be regular and apart of your lifestyle – not just a one off. Australian guidelines suggest that exercises should be completed at least three times per week. Although swimming and cycling are great for cardiovascular health; they are low impact, meaning that are unlikely to have a huge effect on bone health. The exercises above are great at maintaining bone density however variation is important also. Other activities such as tennis, padel, hiking, tai chi are also great ways to integrate weight bearing into your lifestyle that aren’t necessarily formal exercise.

The evidence-based exercises most beneficial for osteoporosis prevention and management include weight-bearing activities, resistance training, balance exercises, and flexibility routines. Incorporating these exercises into a consistent weekly routine can improve bone strength, increase muscle mass, and reduce the risk of fractures, ultimately leading to better quality of life for individuals with osteoporosis.

References

Hoffmann, I., Kohl, M., von Stengel, S., Jakob, F., Kerschan-Schindl, K., Lange, U., Peters, S., Schoene, D., Sieber, C., Thomasius, F., Bischoff-Ferrari, H. A., Uder, M., & Kemmler, W. (2023). Exercise and the prevention of major osteoporotic fractures in adults: a systematic review and meta-analysis with special emphasis on intensity progression and study duration. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 34(1), 15–28. https://doi.org/10.1007/s00198-022-06592-8