Physiotherapy rehabilitation in patients with osteoporosis

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Submission Date: 2020-02-10
Review Date: 2020-02-24
Pubblication Date: 2020-03-09
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Osteoporosis is defined as a systemic disease of the skeleton characterized by reduction and alteration of the qualitative bone mass, accompanied by increased risk of fracture.
According to the Italian Society of Mineral Metabolism and Osteoporosis SIOMMMS (2012) we can distinguish “primitive” post menopausal and senile forms from “secondary” ones determined by many diseases and assumption of drugs. Unlike other rheumatic diseases, osteoporosis is a condition for which preventive measures are really important as well as treatment according to the personal patient’s characteristics and age. Prevention must start early and subsequently adapted to the characteristics of the different life cycles2 .


The WHO World Health Organization defines osteoporosis as a social disease4.

The annual cost in Europe for hospital care is three and a half billion euros per year, and in Italy five hundred million euros. These costs do not include rehabilitation, orthesis and home care.

The aging of the population leads to an increase in the absolute number of fractures: those of the femur are about 1-3% more per year.

Primary osteoporosis prevention: young population

Unlike other rheumatic diseases, osteoporosis is classified as a degenerative disease Società Italiana Reumatologia Reumatismo 51,1  (1999)5, and preventive measures can be put in place at different stages of life. Pharmacological and non-pharmacological prevention must start early and subsequently adapted to the characteristics of the different life cycles.


The guidelines for the diagnosis, prevention and therapy of osteoporosis of the Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases1 highlight how important it is to start exercising at a young age. The programs must include exercises with an impact depending on the frequency, duration, intensity and skeletal weight bearing site 7;8;9;10;11;12;13;14.

The Japanese Guidelines of (2011)state that the most important measure for primary prevention of osteoporosis is appropriate education for each age group.

Primary osteoporosis prevention: adult population

In order to increase bone mass in adults, an essential role is played by practising sports, exercises such as jogging, aerobic gymnastics based on repetitive sequences, oriental disciplines like Tai Chi Chuan. 15

Scientific literature, supported by randomized controlled trials, shows how the practice of regular physical activity, in the premenopausal female population, can increase BMD in different body sites, radio, lumbar spine, femur, heel.

Secondary osteoporosis prevention

The American National Osteoporosis Foundation Physician’s Guidelines (2014), the Physiotherapy Guidelines for the management of osteoporosis by the British Chartered Society of Physiotherapy16, the Guidelines for prevention and treatment of osteoporosis Japan (2011)17,  NOFSA Guideline for the Diagnosis and Management of Osteoporosis South Africa (2010)18, Clinical Guidance on Management of Osteoporosis Malaysian Osteoporosis Society (2012)19, and Guidelines for the diagnosis, prevention and therapy of osteoporosis Italian Society of Osteoporosis, Mineral Metabolism and Skeletal Diseases SIOMMMS (2009)1  represented an important reference to formulate guidelines and organizational strategies about the role of non-pharmacological treatment for the prevention and treatment of Osteoporosis. In 2011, the SIMFER 20 Scientific Society within the Work Commission and Regional Secretariats drafted the Guidelines for rehabilitative treatment in osteoporosis.

International Recommendations and Guidelines

For people with osteoporosis or with an increased risk of falling, rehabilitation must be preventive and / or carried out together with other pharmacological treatments to optimize the quality of life, health and reduce the risk of fracture and / or fracture recurrences21.

The primary objective of the program is to meet the patient’s needs, agreeing with him/her on a path that considers the pathology-related physical aspects, together with specific risk factors 22;23;24;25.

Physiotherapy and rehabilitation assessment

The physiotherapy and rehabilitation assessment of the person with secondary osteoporosis, in the post menopausal, senile and osteopenic age, is strictly necessary to modulate a rehabilitative path that is suitable and compatible with the needs of the person from a biopsychosocial perspective.

Contextual factors must also be considered according to the criteria of the International Classification of Functions, Disabilities and Health ICF26.

The objectives are numerous and very articulated in terms of time schedules, methods and strategies. In particular, there are two types of intervention: on the person and the environment where he/she lives 27;28.

Rehabilitation and physiotherapy project in senile, secondary, postmenopausal osteoporosis and in osteopenic people in good health

In people with osteopenia it is important to maintain or increase BMD and reduce fast loss in the immediate postmenopausal period.

Indexed studies indicate in senile, secondary, post menopausal osteoporosis and in osteopenic people in good health, a rehabilitation program that includes physical activity based on axial pressure and dynamic loading exercises on high impact bones. Dynamic load, axial pressure and selective tendon muscle activation allow correct skeletal muscle dynamics, responsible for the orientation of the lines of force, sensitive to mechanical information 29;30;31.

Aerobic exercises are effective in reducing the loss of bone density in the spine and wrist. Examples are jogging, running, dancing and playing with the ball 32;33.

If the exercises employ the upper limbs, the load is on the wrist. The exercises proposed in Howe’s Cochrane aim at the stimulation of bone growth and the conservation of bone mass. The selected bone structures are the most used in everyday life, in particular exercises in loading schemes and resistance movements with the use of weights are suggested.

The authors concluded stating that several reasons can explain why effectiveness varies for site specific exercises: muscle insertions, different weights, stretches or type of contraction, duration and nature of the exercise34;35;36;37;38;39;40;41;42.

Women after menopause with an increased risk of falling

In the prevention of osteoporosis, the risks of falling must be considered. About 40% of people over 65 fall every year.

Risk factors for falling have been identified in the literature such as: hyposthenia, sarcopenia, obesity, loss of coordination, hyperkyphosis, reduction of walking speed, history of falls without fractures, fear of falling and reduction of functionality 44;24.

Rehabilitative and physiotherapeutic objectives

Rehabilitation and physiotherapy goals for people with increased risk of falling include, bone density loss decrease, the prevention of fractures and falls, a program to inform and educate the person to adopt correct rules of life.

The modification of the environment, as a fall risk factor, is part of the objectives for this type of patient.

Rehabilitation and physiotherapy program

To demonstrate efficacy, the rehabilitation and physiotherapy program for fall prevention must be customized considering the general health conditions and  a careful analysis and evaluation of the individual 45.

Osteoporosis tertiary prevention: women after osteoporotic menopause with a history of fractures

RobynSpeerin in Moving from evidence to practice: models of care for the prevention and management of musculoskeletal conditions highlight the high cost represented by the incidence of osteoporosis fractures due to population aging47.

There is a close relationship between osteoporosis and the risk of fracture. Women over the age of 60 are more exposed to danger. The most frequent fracture is that at the vertebral level, followed by that of the femur and radius; there is a familiarity especially with regard to hip fracture. A sedentary lifestyle, associated with postural dimorphisms, is the basis for muscle mass loss, defined as ’sarcopenia’ in the elderly, and it is a cause for falls.

Older people and in particular those institutionalized with coexisting and manifest central neurological deficits are particularly exposed to the risk of fracture, due to problems related to balance and coordination; for this reason it is useful to use hip protectors as prevention48;49.

Physiotherapy and rehabilitation assessment

A careful evaluation requires a patient history including the greatest amount of information regarding past pathologies, analysis of district and global pain, work activities, lifestyles.

Finally, the patient must be evaluated with a postural analysis that includes the verification of the body axes both in flexed and extended position, loading and unloading conditions, in monopodalic support, balance and walking test.

Vertebral articularity is measured by using the Schober50 test.

For general mobility the Timed Up and Go Test is used51.

The treadmill or cycle ergometer evaluates the aerobic capacity which must be at 60% of the maximum heart rate.

The Physical Performance Test (PPT) 52is an evaluation comprising a series of 7-9 functional tests.

The evaluation of pain is very complex, to understand its different aspects and correctly evaluate its characteristics, all its components such as nociception, perception, suffering, behavioral reaction must be taken into consideration. Pain measurement must include, in addition to somatic components, also the perceptive, affective and behavioral components which are part of the person’s attitude.

Rehabilitative and physiotherapeutic objectives

A physiotherapy and rehabilitation program should aim to reduce pain, counteract the risk of falling and therefore fracturing, improving balance and coordination by increasing strength, flexibility and aerobic capacity, posture and proprioceptive afferents of the spine and lower limbs. Therefore, it is useful to strengthen the extensor musculature of the spine, and / or to reduce muscle-tendon retractions. Breathing and correction of wrong motor patterns are as well important. If necessary, it is essential to identify support, equipment and adaptation or mobility guardians and educate the person to correct rules of life to avoid the risk of falls.


Non-pharmacological treatment with rehabilitation and physiotherapy plays an important role in the prevention of osteoporosis. In elderly people with fractures in the spine of the upper and lower limbs, rehabilitation not only affects the pain or recovery of the patient’s gestures, but involves more complex aspects, connected to the affective-relational sphere, self-esteem and self-respect, the dignity of the person in relation to the external environment.


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