Interesting case report about a 55 year old man who experienced the onset of back pain while jogging. He discovered that he had osteoporosis and underwent a vertebroplasty to repair the fracture. He was painfree within one week post surgery.
Category Archives: Osteoporosis
Atypical Subtrochanteric Fractures with Long-Term use of Bisphosphonates (Fosamax, Actonel, Boniva, Reclast)
Last week, Good Morning America hosted a segment on spontaneous fractures with long-term use of bisphosphonates commonly used to treat osteoporosis. They implicated that these drugs taken for 7-8 years actually make bones more brittle. Here is a link to the story. But please read the following article about the FDA Task force as well. Good Morning America Story…
The FDA and the American Society of Bone and Mineral Research Subtrochanteric Femoral Fracture Task Force (read about the task force here) are convening to investigate this topic. At present these types of fractures are extremely rare and all fractures of this type are under investigation by medical specialists in this field.
When considering drug therapies for bone health, one must consider the risks and benefits. When we know that the risk for someone breaking a bone due to osteoporosis past the age of 50 is 1 out of every 2, sometimes the risks of these rare types of fracture is worth it. I am not advocating the use of drugs, I am just stating that this should be a conversation and a mutual decision by patient and physician.
On a side note, it is currently recommended that patients take a “drug holiday” occasionally when on a bisphosphonate type of drug.
We will keep looking at the research as it comes forward to make informed decisions. So, for now, let’s keep exercising, practicing balance, working on leg strength and spinal extensor strength to aid in fracture prevention and overall health and function!
Read this 2010 case report of a Pilates student who experienced a spontaneous diaphragmatic rupture while doing Pilates. Published in the American Journal of Emergency Medicine by Yang, et al.
I’ve seen a few articles about the effect of strontium supplements on osteoporosis. What do you think?
|Response from Gayle Nicholas Scott, PharmD, BCPS, ELS
Assistant Professor, Eastern Virginia Medical School, Norfolk, Virginia; Clinical Pharmacist, Chesapeake Regional Medical Center, Chesapeake, Virginia
Strontium is located on the periodic table in the alkali earth metal group, the same group that includes calcium. Strontium is used for a variety of indications ranging from an ingredient in toothpaste for sensitive teeth (Sensodyne®, GlaxoSmithKline, Research Triangle Park, North Carolina) to strontium-89 (Metastron™, GE Healthcare, Waukesha, Wisconsin) for metastatic bone pain. Strontium is widely promoted for treatment of osteoporosis. In Europe, strontium ranelate is available as a prescription drug. In the United States, strontium is a dietary supplement available as the carbonate, chloride, citrate, gluconate, and sulfate salts. The US Food and Drug Administration (FDA) granted strontium malonate investigational new drug (IND) status.
Most drugs for osteoporosis inhibit bone resorption. Available antiresorptive agents include bisphosphonates (alendronate, risedronate, ibandronate, and zoledronic acid), estrogen, selective estrogen modulators (raloxifene), and calcitonin. Parathyroid hormone (teriparatide) and fluoride stimulate bone formation. Strontium ranelate is unique in that it appears to act by both of these mechanisms.
Strontium ranelate is comprised of 2 atoms of strontium and the organic acid ranelic acid. Product information about strontium ranelate on the Website of the European Medicines Agency, the European Union equivalent of the FDA, explains the choice of the ranelate salt with “the organic part permit[s] the best compromise in terms of molecular weight, pharmacokinetics and acceptability of the medicinal product.” The bioavailability of strontium ranelate ranges from 19% to 27%; food and calcium products reduce its already low bioavailability by 60%-70%.
The safety and efficacy of strontium ranelate for osteoporosis have been investigated in 4 randomized, double-blind, placebo-controlled trials. Three trials evaluated strontium ranelate 0.5-2 g/day for osteoporosis treatment,[2-4] and 1 study evaluated 125 mg-1 g/day for osteoporosis prevention. For treatment, strontium ranelate 2 g/day for 3 years reduced vertebral fractures by 37% (relative risk [RR] 0.63; 95% confidence interval [CI] 0.56, 0.71) and nonvertebral fractures by 14% (RR 0.86; 95% CI 0.75, 0.98). Lower doses were superior to placebo, but reduction in vertebral fractures and increase in bone mineral density were greater with 2 g/day. A recent study of women with osteoporosis taking strontium ranelate 2 g daily for 8 years showed sustained increases in bone mineral density. In all studies, patients took supplemental calcium and vitamin D.
Diarrhea is the most common adverse effect associated with strontium ranelate, usually occurring with higher doses. Data suggest that patients receiving strontium 2 g/day for 3-4 years have a higher risk for vascular side effects (eg, blood clots) and nervous system side effects (eg, seizures).
All research published in peer-reviewed journals is on strontium ranelate. A phase 2 study on strontium malonate has been published as a meeting abstract. No credible research is available on other strontium salts, and the bioavailability and effectiveness of these products are unknown.
For patients concerned about osteoporosis prevention, emphasize the importance of weight-bearing exercises and adequate calcium and vitamin D intake. For patients with diagnosed osteoporosis, FDA-approved treatments are indicated. Tell patients that dietary supplements containing strontium are unproven and should be avoided.
Keep your skeleton strong and fracture-free by serving that calcium supplement with a salad on the side.
Salad? Yep, salad. A 4-year study found that older adults with the highest intakes of carotenoids — think tomatoes, carrots, and leafy greens for major sources — retained more bone mineral density than folks eating fewer fruits and veggies.
Antioxidant Bone Protection
Fruits and vegetables are bursting with antioxidants called carotenoids — including compounds like lycopene, beta carotene, lutein, and zeaxanthin, to name a few. Don’t bother trying to pronounce them. Just know that veggie-stacked salads will probably provide your daily needs and then some.
How They Work
Carotenoids may protect bones by stymieing the oxidative stress thought to play a role in age-related weakening of bones. Carotenoids may also act synergistically with vitamin D to boost bone-cell growth. Still need more reasons to eat extra fruits and veggies?
Inverse association of carotenoid intakes with 4-y change in bone mineral density in elderly men and women: the Framingham Osteoporosis Study. Sahni, S. et al., American Journal of Clinical Nutrition 2009 Jan;89(1):416-424.
Proton pump inhibitors (PPIs) treat GERD and ulcers by limiting the production of caustic gastric acids. The problem: Gastric acids are a vital component of digestion. Blocking them may interfere with the absorption of calcium, which is essential for maintaining strong bones. By limiting calcium absorption, PPIs may put you at greater risk for developing osteoporosis. If you have osteoporosis, taking a PPI may increase your fracture risk. Here’s what you need to know …
Read more: http://www.johnshopkinshealthalerts.com/alerts/back_pain_osteoporosis/JohnsHopkinsHealthAlertsBackPainOsteoporosis_3279-1.html?ET=johnshopkins_blog:e35877:221674a:&st=email&st=email&st=email&s=EBH_100115_013
|My colleagues, Dawn-Marie Ickes, Gabrielle Shrier and Allyson Cabot are presenting their study at the APTA CSM Scientific Meeting this year:
Pilates-Based Exercise for Fall Risk Reduction in Older Adults: A Pilot Study
|Falls are a common cause of morbidity and mortality in older adults. Impairments in balance, strength, range of motion, and functional mobility can lead to increased fall risk. Pilates is a form of exercise designed to improve core strength, flexibility, and functional mobility, making it an exceptional form of exercise for individuals at risk for falls. The purpose of this study was to investigate the effects of a Pilates-based exercise intervention in improving balance and reducing fall risk with a population of adults over 65 who are known fallers or at risk for falls.8 subjects (5 males, 3 females; mean age 78.6 years) participated in the study. Inclusion criteria included a self-reported history of two or more falls or one injurious fall in the past year or a Timed Up and Go (TUG) test of >13.5 seconds suggesting risk for falling. Six subjects completed the intervention and post-testing.
Subjects attended 10 sessions of a 45-minute Pilates-based exercise program once a week at Core Conditioning in Studio City, CA. Pilates training utilized the Balanced Body® Pilates Studio Reformer® under the supervision of a physical therapist who is a Gold Certified PMA Pilates Instructor with 9 years of experience using this methodology. Participant to instructor ratio was 4:1 with all subjects working on Reformers concurrently in a group class format. Each subject performed 10 specific exercises, 10 repetitions each, using varying resistance of 2-4 springs progressed according to each participant’s ability.
The following outcomes measures improved significantly at the p<0.05 level: TUG scores significantly decreased from 14.8 to 11.1 seconds suggesting reduced fall risk; SOT composite scores significantly increased from 55.7 to 64.2/100 suggesting increased postural stability; BBS scores significantly increased from 44.8 to 51.8/56 suggesting improved static and dynamic balance; Right ankle dorsiflexion AROM significantly increased from 5.2° to 10.3°
Pilates-based exercise using the Reformer performed once per week resulted in significant improvements in static and dynamic balance, ankle range of motion, functional mobility, and reduced fall risk in eight adults over age 65 who were at risk for falling.
This pilot study suggests that rehabilitation focusing on Pilates exercise using the Reformer only once a week is an excellent intervention to improve balance and decrease fall risk in older adults. Future randomized-controlled studies should be performed to further validate these findings.
An article just came out last month in the NY Times on “The
Best Exercises for Healthy Bones”. It was interesting to
say the least. The writer suggested that hopping was the
best exercise to build bone but gave no context or
guidelines to incorporate hopping or jumping safely into
an exercise program! I decided to pull together the best
information from the top researchers in the field of bone
and exercise. I like to look at the groups who have been
doing this kind of research for a long time. I was at a bone
symposium last week and was able to ask Beth Lambright,
the Oregon State University exercise teacher of all the
main studies during the past 15 years if jumping rope or
mini-trampolines build bone. The answer was “No, you
need 4-8x body weight impact to stimulate bone. For
children this means jumping off a 24″ box and for adults
this means jumping off an 8″ step. They progress from 4″
to 6″ to 8” very slowly and prepare the knees and hips
with step-ups, heel raises, squats, lunges and faux jumps
before jumping off the steps. So what else will give us
1. Walking does not build bone and should not be
considered an osteoporosis exercise. (However, walking is
great for your heart if you keep up a good pace.)
Palombaro KM. “Effects of walking-only interventions on
bone mineral density at various skeletal sites: a metaanalysis.”
J Geriatr Phys Ther. 2005;28(3):102-7.
2. Weighted vests with lunges, squats, step ups, side
lunges and small jumps 3 x per week builds bone in the
hip according to Christine Snow’s bone research lab at
Oregon State University.
(Long-term Exercise Using Weighted Vests Prevents Hip
Bone Loss in Postmenopausal Women by Christine M.
Snow, Janet M. Shaw, Kerri M. Winters, and Kara A. Witzke
Journal of Gerontology: 2000, Vol. 55A, No. 9, M489-
M491) They are continuing their long-term studies and the
latest one should be published next month!
3. Sinaki has the best long-term research on exercise for
building bone and fracture prevention in the spine
(Sinaki, M., et al. 1986.”Relationship between bone
mineral density of spine and strength of back extensors in
healthy postmenopausal women.” Mayo Clinic
Proceedings, 61 (2), 116-22.)
(Sinaki, M., et al. 1996. “Can strong back extensors
prevent vertebral fractures in women with osteoporosis?”
Mayo Clinic Proceedings, 71 (10), 951-56.)
(Sinaki, M, et al. 2002. “Stronger back muscles reduce the
incidence of vertebral fractures: A prospective 10 year
follow-up of postmenopausal women.” Bone, 30 (6), 836-
(Sinaki, M”The role of physical activity in bone health: a
new hypothesis to reduce risk of vertebral fracture.” Phys
Med Rehabil Clin N Am. 2007 Aug;18(3):593- 608)
4. Loren Fishman has some ongoing research on Yoga for
osteoporosis and is getting some increases in BMD with
(Yoga for Osteoporosis: A Pilot Study by Loren M.
Fishman, MD. Topics in Geriatric Rehabilitation. Vol. 25,
No. 3, pp. 244-250: 2009)
Main Points for Exercising Your Bones:
- Hip Bone Building: Jumping is best. (If your T- score is below a -3.0 do not jump!) Prepare for jumping by doing forward and side lunges, squats, step ups, heel raises and standing balance exercises. Consider using a weighted vest up to 10% of your body weight. Mini-trampolines are a good warm-up or for cardiovascular work but they do not build bone.
- Spine Bone Building: Prone (face down) Back Extension Exercises are best.
- Walking briskly on uneven terrain up and down hills is great for your heart but should not be considered a bone building exercise.
- Yoga and Pilates in general are not considered bone building exercises YET! They may be effective programs to increase variety and pleasure with exercise and are a good body awareness fracture prevention and preparation for the bone loading exercises necessary to stimulate bone formation!
Regarding the difference between osteoporosis and osteopenia: Basically we must assume that if the person has osteopenia of the lumbar spine that they may very likely have osteoporosis of the thoracic spine. 1)The thoracic spine is more oriented to kyphosis and anterior loading of the vertebral bodies, 2)The vertebrae get smaller as we go up the vertebral column and 3) The most popular fracture site of the spine is at T6-T7 and T8. We also have no way of determining whether or not the disease is progressing as we are working with our clients. There is no way we can determine how much force it would take to cause a fracture in the spine. The statistics are clear; 1 in every 2 women over age 50 will have an osteoporotic fracture in their lifetime. Then after the 1st vertebral fracture the risk of having another one within 1 year is 500%!! We need to be very vigilant about preventing the 1st fracture. It’s not a good idea to “experiment” with clients when the research is very clear. A physical therapist is guilty of malpractice if they put a patient who has known osteoporosis in spine flexion.(Carole Lewis, PT) I am in support of “evidence-based” practice in PT and Fitness. I want to give my clients/patients SAFE exercises that WORK! Unfortunately with so many flexion exercises in our beloved Pilates method we are forced to be creative and compliant. Yes, we WILL narrow their options for movement somewhat but my clients from age 20-84 are completely happy with their exercise programs and feel very confident about their guidelines and exercises! They don’t want to have any/anymore fractures! I know very few people on the planet these days that need to increase their degree of thoracic flexion!
There is an article that explains all of the reasons for avoiding flexion, Modifying Pilates for Osteoporosis, published April 2005 in the IDEA Fitness Journal. It is downloadable on the Osteoporosis News page of this TheraPilates website.