The role of physical activity in prevention of osteoporosis

Pavel Oana Roxana,Popescu Mihaela,Pavel Laurentiu,

Faculty of Medicine,UMF Craiova,Hospital Helios Craiova

Abstract.Osteoporosis is the most common bone pathology, being defined as a systemic disease characterized
by loss of bone mass and deterioration of bone microarchitecture, with serious consequences for bone fragility
and bone fracture risk. The decrease in bone mass and increase of bone fragility is due to the impossibility of
obtaining a peak bone mass, increase bone resorption and decrease in bone formation. Osteoporosis is
encountered in both sexes and all human races, its prevalence increasing with age. WHO criteria for diagnstic of
osteopenia and osteoporosis is based on a comparison of patients with those with peak bone mass and using
standard T-scor. Exercices properly conducted gradually, preferably under the guidance of a physiotherapist is
recommended and beneficial to most patients with osteoporosis. Physical activity acts on bone metabolism both
directly and indirectly through hormonal mechanisms.

Key words: Osteoporosis,fractures,physical activity,T-score

Introduction. Osteoporosis is the most common bone pathology, being defined as a systemic disease
characterized by loss of bone mass and deterioration of bone microarchitecture, with serious
consequences for bone fragility and bone fracture risk. (1)

According to World Health Organization standards, osteoporosis is defined as BMD of the hip or
spine less than or equal to 2.5 standard deviations reported in the corresponding BMD young adult.
This reference score that predicts fractures has been shown in large prospective studies on
postmenopausal women.

Osteoporosis is encountered in both sexes and all human races, its prevalence increasing with age.

The risk for an osteoporotic fracture after the age of 50 years is 40% in females and 13% at males.
(2), and this risk is constantly increased.This fractures, especially of vertebral and femoral head affects
the quality of life and increase mortality.

Although most vertebral fractures are initially not diagnosed correctly, they are accompanied by pain
and disability. (3) . Multiple vertebral fractures on the chest can lead to restrictive respiratory failure,
and those at the lumbar spine-abdominal symptoms. (4). One of vertebral fracture is a major predictor
for the risk of another fracture.

Fractures of the femoral neck and distal radius causes functional impotence and pain.

Quality of life is impaired also,by the osteoporotic fractures ribs.

Pathophysiology of osteoporosis. The decrease in bone mass and increase of bone fragility is due to
the impossibility of obtaining a peak bone mass, increase bone resorption and decrease in bone
formation(5).

Peak bone mass corresponds to the quantity of bone present at late bone maturation .It is a major
osteoporotic fracture risk at women and men. Increase in bone mass by 10% is associated with
reduced by 50% of the risk of fracture(6).

Peak bone mass depends on the sex, race, heredity, nutrition and physical activity.Men have a higher
bone mass. Calcium intake in the period to achieve maximum bone mass is extremely important.(7).

Bone resorption.After age of 20, when peak bone mass is reached, begin in the next three decades a
slight bone loss, without semnificativ risk of fracture .In menopause, bone resorption increases
massively, causing bone fragility .Osteoresorbtion affect bone microarchitecture in a much shorter
time than bone formation(8).

Bone remodeling occurs in successive cycles after which old bone is resorbed and replaced by new
bone.In bone remodelation participate actively two types of bone cells, osteoclasts and osteoblasts.

Increased bone remodeling in postmenopausal is maintained with age, as evidenced by elevated

biochemical markers of bone turnover, and is associated with increased risk of bone fracture,
independent of BMD. (9).

Bone formation.Osteoblastele are cells of mesenchymal origin.They have receptors for the main
hormones involved in bone metabolism-PTH, vitamin D, estrogen, androgen, glucocorticoids, thyroid
hormones .Sub their action, activated osteoblasts synthesise bone matrix proteins (collagen type 1),
and noncolagenic proteins(alkaline phosphatase, ostocalcine).

Differentiated osteoblasts migrate to the bone surface in process of remodeling, forming new bone
(osteoid) and his mineralization .Ulterior process is deposition of hydroxyapatite crystal on collagen
layers of osteoid, forming lamellar bone.

Bone mineralization is dependent by enzymes and noncolagenic proteins secreted by osteoblasts

activated and by adequate intake of calcium and extracellular phosphate. (10).

At the young, although the rate of bone resorption is high,. increasing bone mass is maintained .Onset
of menopause break this positive balance, decreasing bone mass, this may be due and growth factors
change with age.

Reduction of bone mass occurs asymptomatic ,for a long period of time until time of spontaneous or
minimal trauma fractures.It is one of the few situations in medical pathology, when clinical onset of
the disease is from its main complication, and so this situation makes early diagnosis difficult, but not
impossible.

Diagnostic of osteoporosis. WHO criteria for diagnstic of osteopenia and osteoporosis is based on a
comparison of patients with those with peak bone mass and using standard score T.

BMD T score = BMD measured - BMDaverage young adult/DS young adult,

where BMD SD of the reference group are of statistical tables. T score is considered normal when
values are between 2.5 and -1 DS.

It has been estimated that each SD decrease in BMD is associated with a 2.3-fold increase in the
incidence of vertebral fractures and an increase of 2.6 times of the hip.

The risk of fracture becomes a gradient that increases with decreasing bone mass in postmenopausal
osteopenia.Women diagnosed with osteopenia can receive treatment aimed at preserving bone mass.

normal T-Score -1 DS
osteopenia -1 DST-Score -2,5 DS
osteoporosis T-Score -2,5 DS
Severe osteoporosis T-Score-2,5 DS and least one fracture

Patients with osteopenia, in the presence of risk factors: increased bone turnover, age, etc., can suffer a
fragility fracture.

The most commonly used technique for the measurement of BMD is represented by dual x-ray
absorption DEXA.DEXA technique measured BMD in the spine, hip, punch, wholebody, calculated
lean mass and fat mass (11).

FRAX algorithm calculates the probability of a major osteoporotic fractures based on clinical risk
factors and BMD in about 10 years. FRAX begins with a questionnaire, for ofactors identified as
significant risk for fracture prediction, the result automatically displays a value of the absolute risk of
suffering a fracture over the next 10 years (procentual). He integrates BMD at the femoral neck with
clinical risk factors that are independent of BMD such as age, sex, race / ethnicity, fragility fracture
earlier, family history of hip fracture, current smoking, use of glucocorticoids long-term , rheumatoid
arthritis or other secondary causes of osteoporosis, consumption of> 3 alcoholic drinks per day.

FRAX is most useful in patients with low BMD at the femoral neck. Using FRAX in patients
with low BMD at the lumbar spine, but a relatively normal BMD at the femoral neck fracture
underestimate risk in these individuals. Specifically, WHO algorithm has been validated for use not
BMD at the lumbar spine. NOF recommends treatment of people with osteoporosis present in the
lumbar spine and hip.
Clinical applications of FRAX:

- FRAX is intended for menopausal women and men over 50 years; not for use in adults or children.

-FRAX has not been validated in patients previously treated for osteoporosis or present. In these
patients, clinical judgment should be exercised in interpreting scores FRAX osteoporotic .Patients
who discontinued medication for 1-2 years can be considered untreated.

-FRAX can be calculated either femoral neck BMD and BMD of the total hip, but, when available,
femoral neck BMD is preferred. BMD is not recommended at other locations.

- WHO has determined that in several secondary causes of osteoporosis, fracture risk was mediated
primarily through its impact on BMD. For this reason, when the femoral neck is inserted into the
FRAX , secondary osteoporosis cases are automatically inactivated(12).

FRAX does not change the concept after that osteoporosis is defined as a decrease T score below
-2.5 SD measured by DXA at the hip, but brings many advantages such as:

- Include people with osteopenia (T-score between -1 and -2.5 SD) among those whose risk of frac-
ture can and should be known,

- Allow stratification of fracture risk for sex and ethnicity,

- Include patients with comorbidities .

Patients with osteoporosis should be informed of postural adjustment related to bone fragility.

Physical activity and prevention of osteoporosis. The role of exercise in the treatment of
osteoporosis has not been fully defined (13). It seems that the recommended 30 minutes of exercise a
day in patients who can tolerate this (14) .These intense 30-minute walk three times a week for at least
7 months, increases BMD in the spine with 1.1% . Localizated exercise (ex.forarm) supported and
various ,performed three times per week, about 5 months, increase BMD with 3.8% (15) .For
unfortunately these increases are transient, returning to baseline BMD after a period of inactivity
(16) .The role of physical activity asuppra on the bone is closely related to intake of calcium and
vitamin D (17), especially after menopause, when estrogen deficiency causes decreased absorption
intestinal of calcium.

Paravertebral isometric muscle exercise can help relieve pain accompanying osteoporotic vertebral
fractures (18) .In contrast, exercises should be avoided spine flexion and rotation of the trunk, because
they increase the risk of vertebral compression (19).
They are useful the exercises performed to maintaining, improving their risk of falling, and thus the
risk of fracture (20).

Lack of exercise and rest in bed for a long time affect cortical trabecular bone, especially in the areas
of pressure (column, hip, pelvis) (21).

It showed the decrease with 30 - 40% in the risk of hip fracture in the elderly active women versus
inactive, which is due to increase bone mass and muscle mass (22).

You must avoid and treat common risk factors for falls, balance disorders, visual disturbances, use of
sedatives excess slippery floors, walking on ice, etc.

Exercise acts on bone metabolism both directly and indirectly through hormonal mechanisms (23)
.The force exerted on bone mechanical causes endogenous signals that interfere with bone remodeling,
the main cells involved in this is osteocytes (24) by prostaglandin E2 means which act as an autocrine
factor (25) .Anyway, the action of prostaglandins on bone tissue is controversial. Their administration
on cultured osteoblast increases activity and their number (26), but it is proved and their catabolic
effects,by stimulation of osteoclasts (27). These different effects are due to the different subtypes of
receptors. The indirect effect is due to local cytokine production and release of growth factors by
osteocytes (28) .In addition, exercise is a trigger for a response hypothalamic -pituitary adrenal and
hypothalamic -pituitary -gonadic (29) and stimulates the secretion GH, with bone anabolic effects
directly, or indirectly through IGF-1 (30) .While the physical effort is increased the secretion of
thyroid hormones and cortisol (31) and reduced secretion of sexoid hormones (32), while the secretion
PTH seems not to be affected (33).

In conclusion, exercise properly conducted gradually, preferably under the guidance of a

physiotherapist is recommended and beneficial to most patients with osteoporosis (34).

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Corresponding author
Pavel Oana Roxana
Departament of Endocrinology
UMF Craiova
e-mail:oana_roxana_pavel@yahoo.com
phone:+40727764549