The role of physiotherapy in the prevention and treatment of osteoporosis

The Effect of a Comprehensive Corrective Exercise Program on Kyphosis Angle and Balance in Kyphotic Adolescents

This study aimed to investigate the effects of a comprehensive corrective exercise program on the kyphosis angle and balance in kyphotic adolescents. A total of 62 male adolescents (between the ages of 10 and 18, mean BMI 21.7 kg/m2) with a thoracic kyphosis (TK) angle of ≥ 50° were divided into three groups using the simple randomization method: CCEP (comprehensive corrective exercise program), TEP (thoracic exercise program) and control group. The CCEP program consisted of corrective exercises plus postural perception training (PPT). Exercise programs were applied for 40−50 min, 3 days a week for 12 weeks. The kyphosis angle was measured using a flexible ruler, and balance was assessed using the Romberg index obtained from pedobarography. After training, a highly significant reduction in the kyphosis angle was observed in the CCEP and TEP groups (p < 0.001). Comparison among the groups showed a greater reduction in the kyphosis angle in the CCEP group (p < 0.020). Postural perception improved in the CCEP group versus other groups (p < 0.001). Improvement of the Romberg index (balance) was found only in the CCEP group upon within-group comparison (p < 0.001), with no difference among the groups (p > 0.05). The use of postural perception in combination with corrective exercise programs for thoracic kyphosis represents a comprehensive approach, and PPT can increase the effectiveness of the intervention.

A randomized controlled study of the effect of functional exercises on postural kyphosis: Schroth-based three-dimensional exercises versus postural corrective exercises

PURPOSE

To compare the effects of postural corrective and Schroth-based three-dimensional exercises on thoracic kyphosis angle (TKA), lumbar lordosis angle (LLA), balance and quality of life (QoL) in individuals with postural kyphosis.

METHODS

This was a single-blind randomized controlled clinical trial with a total of 63 subjects (57 women, 6 men) with TKA of ≥40°. Subjects were separated into three groups: postural corrective exercise group (PCEG), Schroth-based three-dimensional exercise group (SBEG) and control group (CG). Participants in the exercise groups participated in the exercise program twice a week for eight weeks under the supervision of a physiotherapist: CG performed no exercise but was generally informed. The primary outcome variable was TKA. Secondary outcome variables were LLA, balance and QoL.

RESULTS

After the functional exercise programs, TKA (mean change for PCEG, SBEG: -9.71, -14.76, p < 0.001), static postural stability index overall (-0.22, -0.40, p < 0.05), and QoL (-0.41, -0.37, p < 0.001) significantly improved in both training groups compared with CG. The LLA (-3.95, p = 0.003) was significantly lower in the SBEG group than in CG.

CONCLUSION

This study demonstrated that Schroth-based three-dimensional exercises are an effective treatment for individuals with postural kyphosis and have a large effect size that improves TKA, LLA, balance and QoL. Clinical trial registration number: NCT03706495 Implications for rehabilitationEight weeks of postural corrective or Schroth-based three-dimensional functional exercise programs are effective in addressing thoracic kyphosis angle (TKA), balance, and quality of life in individuals with postural kyphosis.An eight-week Schroth-based three-dimensional exercise program was more effective than postural corrective exercises in improving TKA, lumbar lordosis angle, and balance for patients with postural kyphosis.Schroth-based three-dimensional exercise programs could promote balance and spinal health in young adults with thoracic kyphosis.

Comparison of physical function according to the lumbar movement method of stabilizing a patient with chronic low back pain

[Purpose] The purpose of this study was to examine the changes caused by lumbar stabilization exercises in chronic low back pain patients. [Subjects and Methods] Swiss ball exercise regimen group and sling exercise regimen group exercised for 30 minutes a day, 5 days a week, for 12 weeks. The control group was to continue performing their usual daily living activities. [Results] We obtained significant results in both the Swiss ball and sling exercise groups, but not in the control group. The best effect was obtained in the sling exercise group. [Conclusion] The Oswestry Low Back Pain Disability Index and visual pain scale scores of the patients with low back pain decreased in both the Swiss ball exercise group and the sling exercise group, and these patients experienced an increase in waist isometric muscular strength after 12 weeks of exercise compared with those doing no exercise (the control group).

The generation of loads in excess of the osteogenic threshold by physical movement

This study investigates the use of physical movement to cause joint and bone loads that stimulate bone growth in order to reduce the adverse effects of osteoporosis. It has been established that stresses in bones in excess of the osteogenic threshold will stimulate bone growth; however, protocols for the generation of these stresses had not been established. Two trial movements were examined in the study: the plié and a movement requiring the subject to move a leg sequentially to 45° displaced positions - the star excursion balance test. Using inverse dynamics and an optimisation approach, the loads in the muscles crossing the hip and knee joints and the corresponding joint contact forces were calculated. It was found that the osteogenic threshold was exceeded in both these trials identifying them as suitable exercises in the maintenance of bone health. In the order of increasing bone load at the hip, and hence increasing bone growth stimulation, are the following demi plié, star excursion balance test with maximum reach criterion, grande plié and star excursion balance test with maximum speed criterion. In the order of increasing bone load at the knee are demi plié, grande plié, star excursion balance test with maximum reach criterion and star excursion balance test with maximum speed criterion. However, due to the high loads encountered, these exercises are not recommended for subjects with advanced osteoporosis although the boundary between therapeutic bone loading leading to increase in bone mineral density and loads capable of causing fracture is unclear.

Exercise for improving outcomes after osteoporotic vertebral fracture

BACKGROUND

Vertebral fractures are associated with increased morbidity (e.g., pain, reduced quality of life), and mortality. Therapeutic exercise is a non-pharmacologic conservative treatment that is often recommended for patients with vertebral fractures to reduce pain and restore functional movement.

OBJECTIVES

Our objectives were to evaluate the benefits and harms of exercise interventions of four weeks or greater (alone or as part of a physical therapyintervention) versus non-exercise/non-active physical therapy intervention, no intervention or placebo on the incidence of future fractures and adverse events among adults with a history of osteoporotic vertebral fracture(s). We were also examined the effects of exercise on the following secondary outcomes: falls, pain, posture,physical function, balance,mobility, muscle function,quality of life and bone mineral density of the lumbar spine or hip measured using dual-energy X-ray absorptiometry (DXA).We also reported exercise adherence.

SEARCH METHODS

We searched the following databases: The Cochrane Library ( Issue 11 of 12, November 2011), MEDLINE (2005 to 2011), EMBASE (1988 to November 23, 2011), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to November 23, 2011), AMED (1985 to November 2011), and PEDro (Physiotherapy Evidence Database, www.pedro.fhs.usyd.edu.au/index.html, 1929 to November 23, 2011. Ongoing and recently completed trials were identified by searching the World Health Organization International Clinical Trials Registry Platform (to December 2009). Conference proceedings were searched via ISI and SCOPUS, and targeted searches of proceedings of the American Congress of Rehabilitation Medicine and American Society for Bone and Mineral Research. Search terms or MeSH headings included terms such as vertebral fracture AND exercise OR physical therapy.

SELECTION CRITERIA

We considered all randomized controlled trials and quasi-randomized trials comparing exercise or active physical therapy interventions with placebo/non-exercise/non-active physical therapy interventions or no intervention implemented in individuals with a history of vertebral fracture and evaluating the outcomes of interest.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using a pre-tested data abstraction form. Disagreements were resolved by consensus, or third party adjudication. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate each study. Studies were grouped according to duration of follow-up (i.e., a) four to 12 weeks; b) 16 to 24 weeks; and c) 52 weeks); a study could be represented in more than one group depending on the number of follow-up assessments. For continuous data, we report mean differences (MDs) of the change or percentage change from baseline. Data from two studies were pooled for one outcome using a fixed-effect model.

MAIN RESULTS

Seven trials (488 participants, four male participants) were included. Substantial variability across the seven trials prevented any meaningful pooling of data for most outcomes. No trials assessed the effect of exercise on incident fractures, adverse events or incident falls. Individual trials reported that exercise could improve pain, performance on the Timed Up and Go test, walking speed, back extensor strength, trunk muscle endurance, and quality of life. However, the findings should be interpreted with caution given that there were also reports of no significant difference between exercise and control groups for pain, Timed Up and Go test performance, trunk extensor muscle strength and quality of life. Pooled analyses from two studies revealed a significant between-group difference in favour of exercise for Timed Up and Go performance (MD -1.13 seconds, 95% confidence interval (CI) -1.85 to -0.42, P = 0.002). Individual studies also reported no significant between-group differences for posture or bone mineral density. Adherence to exercise varied across studies. The risk of bias across all studies was variable; low risk across most domains in four studies, and unclear or high risk in most domains for three studies.

AUTHORS' CONCLUSIONS

No definitive conclusions can be made regarding the benefits of exercise for individuals with vertebral fracture. Although individual trials did report benefits for some pain, physical function and quality of life outcomes, the findings should be interpreted with caution given that findings were inconsistent and the quality of evidence was very low. The small number of trials and variability across trials limited our ability to pool outcomes or make conclusions. Evidence regarding the effects of exercise after vertebral fracture, particularly for men, is scarce. A high-quality randomized trial is needed to inform exercise prescription for individuals with vertebral fractures.

Bone health and type 2 diabetes mellitus: a systematic review

PURPOSE

To systematically review the literature related to bone health in older adults with type 2 diabetes mellitus (T2DM).

METHODS

We conducted a systematic review of the literature from January 2005 until February 2010, using keywords related to T2DM and bone-health imaging technology in older adults (aged ≥60 years) to search PubMed, OVID MEDLINE, Ageline, CINAHL, Embase, and PsycINFO.

RESULTS

We found a total of 13 studies that met the inclusion criteria for this review. The majority of the studies used dual X-ray absorptiometry (DXA) and showed either higher or similar areal bone mineral density (aBMD) for older adults with T2DM relative to healthy controls. Studies using more advanced imaging suggested that there may be differences in bone geometry between older adults with and without T2DM.

CONCLUSIONS

Older adults with T2DM have similar or higher aBMD at the hip relative to older adults without T2DM, despite previous literature reporting an increased risk of low-trauma fractures. Recent studies with advanced imaging have suggested that there may be differences in bone geometry between older adults with T2DM and those without. Health professionals, especially physiotherapists, should be aware of the increased risk and include assessment of fall risk factors and exercise prescription for fall prevention for older adults with T2DM.

The Effects of Treadmill Exercise Training on Hip Bone Density and Tibial Bone Geometry in Stroke Survivors: A Pilot Study

Background. Individuals with stroke often sustain bone loss on the hemiparetic side and are prone to fragility fractures. Exercise training may be a viable way to promote bone mineral density (BMD) and geometry in this population. Objective. This was a pilot study to evaluate the effects of a 6-month treadmill exercise program on hip BMD and tibial bone geometry in chronic stroke survivors. Methods. Twenty-one individuals with chronic stroke, with a mean age of 64.5 years and mean poststroke duration of 8.3 years participated in the study. The treatment group underwent a treadmill gait exercise program (two 1-hour sessions per week for 6 months), whereas the control group participated in their usual self-selected activities in the community. The primary outcomes were hip BMD and bone geometry of the midshaft tibia on the paretic side, whereas the secondary outcomes were gait velocity, endurance, leg muscle strength, balance self-efficacy, and physical activity level. Mann-Whitney U tests were used to compare the change in all outcome variables between the 2 groups after treatment. Results. Significant between-group differences in change scores of tibial cortical thickness ( P = .016), endurance ( P = .029), leg muscle strength on the paretic side ( P < .001) and nonparetic side ( P < .001), balance self-efficacy ( P = .016), and physical activity level ( P = .023) were found. Conclusion . The treadmill exercise program induced a modest improvement in tibial bone geometry in individuals with chronic stroke. Further studies are required to explore the optimal training protocol for promoting favorable changes in bone parameters following stroke.

An assessment of the osteogenic index of therapeutic exercises for stroke patients: relationship to severity of leg motor impairment

SUMMARY

Exercise may be a viable way to promote bone health in stroke survivors. This study used the osteogenic index to evaluate the osteogenic potential of selected exercises for stroke survivors. The results show that brisk walking and stepping may be good skeletal loading exercises for this population.

INTRODUCTION

Exercise may induce positive effects on bone health in stroke patients. The purpose of this study was to evaluate the osteogenic potential of selected exercises for stroke survivors.

METHODS

Sixty stroke patients were categorized into group 1 (moderate to severe leg motor impairment) and group 2 (mild to moderate impairment). Each subject performed five exercises in random order: walking at self-selected speed, walking at maximal speed, stepping onto a 6-in. riser, sit-to-stand, and jumping. The peak ground reaction force (GRF) on the hemiparetic side and the number of loading cycles achieved in 1 min were determined. The osteogenic index (OI) was computed for each exercise, based on the formula: OI = Peak GRF (in body weight) x In (number of loading cycles + 1). Two-way analysis of variance was used to compare the OI among the five exercises between the two groups.

RESULTS

For group 1, stepping had significantly higher OI than other exercises (p < 0.001). For group 2, both walking at maximal speed and stepping had significantly higher OI than other exercises (p < 0.001).

CONCLUSIONS

Stepping had the highest OI for those with more severe leg motor impairment. Both stepping and brisk walking had superior OI for those with mild leg motor impairment.

Thoracic kyphosis affects spinal loads and trunk muscle force

BACKGROUND AND PURPOSE

Patients with increased thoracic curvature often come to physical therapists for management of spinal pain and disorders. Although treatment approaches are aimed at normalizing or minimizing progression of kyphosis, the biomechanical rationales remain unsubstantiated.

SUBJECTS

Forty-four subjects (mean age [+/-SD]=62.3+/-7.1 years) were dichotomized into high kyphosis and low kyphosis groups.

METHODS

Lateral standing radiographs and photographs were captured and then digitized. These data were input into biomechanical models to estimate net segmental loading from T2-L5 as well as trunk muscle forces.

RESULTS

The high kyphosis group demonstrated significantly greater normalized flexion moments and net compression and shear forces. Trunk muscle forces also were significantly greater in the high kyphosis group. A strong relationship existed between thoracic curvature and net segmental loads (r =.85-.93) and between thoracic curvature and muscle forces (r =.70-.82).

DISCUSSION AND CONCLUSION

This study provides biomechanical evidence that increases in thoracic kyphosis are associated with significantly higher multisegmental spinal loads and trunk muscle forces in upright stance. These factors are likely to accelerate degenerative processes in spinal motion segments and contribute to the development of dysfunction and pain.

Postural taping decreases thoracic kyphosis but does not influence trunk muscle electromyographic activity or balance in women with osteoporosis

BACKGROUND

Greater thoracic kyphosis is associated with increased biomechanical loading of the spine which is potentially problematic in individuals with osteoporotic vertebral fractures. Conservative interventions that reduce thoracic kyphosis warrant further investigation. This study aimed to investigate the effects of therapeutic postural taping on thoracic posture. Secondary aims explored the effects of taping on trunk muscle activity and balance.

METHODS

Fifteen women with osteoporotic vertebral fractures participated in this within-participant design study. Three taping conditions were randomly applied: therapeutic taping, control taping and no taping. Angle of thoracic kyphosis was measured after each condition. Force plate-derived balance parameters and trunk muscle electromyographic activity (EMG) were recorded during three static standing tasks of 40s duration.

RESULTS

There was a significant main effect of postural taping on thoracic kyphosis (p=0.026), with a greater reduction in thoracic kyphosis after taping compared with both control tape and no tape. There were no effects of taping on EMG or balance parameters.

CONCLUSIONS

The results of this study demonstrate that the application of postural therapeutic tape in a population with osteoporotic vertebral fractures induced an immediate reduction in thoracic kyphosis. Further research is needed to investigate the underlying mechanisms associated with this decrease in kyphosis.

Postural Health in Women: The Role of Physiotherapy

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Physiotherapy and osteoporosis: practice behaviors and clinicians’ perceptions—a survey

Physiotherapists typically use a variety of modes to treat their clients, including manual therapy. The literature cautions against the use of manual therapy in individuals with osteoporosis, (Musculoskeletal Manipulation: Evaluation of the Scientific Evidence, Charles C Thomas Publisher, Springfield, IL; Common Vertebral Joint Problems, 2nd Edition, Churchill Livingstone, New York; Maitland's Vertebral Manipulation, 6th Edition, Butterworth-Heinemann, Boston; Br. J. Sports Med. 37 (2003) 195-196) yet clinical experience (Br. J. Sports Med. 37 (2003) 195-196) and published cases (J. Manip. Physiol. Ther. 15(7) (1992) 450-454) suggest that these techniques are still being used by at least some clinicians. The purpose of this study was to measure the most common treatment modes used by a random sample of physiotherapists practicing in the province of British Columbia (BC) in the treatment of individuals with osteoporosis. To assess whether physiotherapists in BC have concerns about the use of manual therapy in individuals with osteoporosis, particularly whether physiotherapists have concerns about fracture as a complication of treatment. This cross-sectional study of 171 physiotherapists in BC used a questionnaire developed by the physiotherapist in the Osteoporosis Program at the BC Women's Health Centre (a part of the Children's & Women's Health Centre of BC). The response rate (67/171) was 39%. Ninety-seven per cent of respondents reported using strength exercises and postural reeducation, while 45% reported using manual therapy in this population. Ninety-one per cent of respondents reported having concerns about the use of manual therapy. Vertebral fracture and rib fracture were the most commonly reported concerns. These findings suggest that most physiotherapists practicing in BC, Canada use evidence-based methods (i.e. strength training) when treating individuals with osteoporosis, a large number use manual therapy, and most have concerns about its use. Physiotherapists are most concerned about fractures, in particular vertebral fracture, but injury to other musculoskeletal tissues is also of concern. Studies of safety and effectiveness of manual therapy in this population are needed to guide clinical practice.

The effect of scapula taping on electromyographic activity and musical performance in professional violinists

Taping the scapula has been suggested as a method of improving both scapula position and muscular efficiency of the shoulder girdle. These factors have been linked to neck and arm problems in violinists. The purpose of this study was to evaluate the effects of taping the scapulae of violinists into a position that prevented excessive elevation and protraction whilst playing. Eight professional violinists played three different musical excerpts with and without scapula taping applied in random order. Electromyographic activity was recorded from the upper trapezii, the scapula retractors and the right sternocleidomastoid muscles. Performances were recorded onto videotape and audiocassette, and self-report data collected for later analysis. Compared with the control condition, scapula taping increased electromyographic activity in the left upper trapezius muscle during playing by 49% as an overall effect, with a 60% increase in the most physically demanding piece played. Lower music quality was detected in the same piece by raters blinded to performance conditions. Taping also had significant negative effects on subjects' reports of concentration and comfort. Short-term application of scapula taping did not enhance selected scapula stabilising muscles during playing and was not well tolerated by professional violinists.