Correspondence *Hospital for Special Surgery, 535 East 70^th Street, New York, NY 10021, USA

Email LinJ@hss.edu

Introduction

A comprehensive approach to the treatment of osteoporosis is essential to maximize bone density and minimize fracture risk. Although pharmacologic approaches represent the cornerstone of treatment, some patients cannot, or will not, comply with medication regimens. This is particularly true for regimens involving drugs with potential adverse effects, but also occurs in those who cannot afford certain medication options or are in conflict with taking any medications for prolonged time periods. For example, recent press about the possible connection between osteonecrosis of the jaw and the use of bisphosphonates has spurred a lot of skepticism about their use from many patients. Others are concerned about the long-term effects of these anti-osteoporotic therapies in patients, particularly given that there are limited data on the long-term use of these medications.

Nonpharmocologic therapies, such as orthoses, exercise programs, calcium and vitamin D supplementation, fall prevention and kyphoplasty, complement the traditional pharmacologic treatment of osteoporosis and can have a significant role in minimizing fracture risk. Management of osteoporosis should, therefore, involve a comprehensive approach encompassing both pharmacologic and nonpharmacologic treatment. This Review explores the various nonpharmacologic options available.

Orthoses

Orthoses, such as thoracolumbar braces, are often prescribed for osteoporotic patients with vertebral compression fractures. Jewett and cruciform anterior spinal hyperextension (CASH) braces are rigid hyperextension braces¹ traditionally used in patients with acute vertebral compression fracture. Some patients find these rigid braces constricting and opt for other types of brace, since many are now available. Potential alternatives include the posture-training support brace and vest, both with weights, as well as the Spinomed^® (Medi Bayreuth GmbH, Bayreuth, Germany) brace.

Made of a soft material, the posture-training support brace is designed as a mini-backpack that contains 680 g (1.5 pound) weights. Rather than forcibly pulling the patient back, the goal of this brace is to serve as a proprioceptive reminder to the patient to extend their thoracic spine. The posture-training support vest with weights (Figure 1A) is similar in concept, but is designed as a vest, and has a belt that attaches around the waist with fabric hook-and-loop fasteners. Posture-training support has been found to result in pain reduction in patients with acute vertebral compression fracture in one pilot study;² 17 of 23 patients reported "significant" improvement in their symptoms following use of the brace. Another pilot study highlighted a possible association of increased back extensor strength with the use of posture-training support.³ Improved back extensor strength has been postulated to correlate with decreased kyphosis and diminished vertebral fracture risk.^{1, 4}

Figure 1 Orthoses often prescribed for osteoporotic patients.

(A) The posture-training support vest contains 680 g (1.5 pound) weights to remind the patient to extend their thoracic spine. (B) The Spinomed^® brace consists of a back pad and strap system to strengthen the trunk muscle and improve posture. (C) Hip protectors contain padding over the trochanters to help absorb the impact of a fall.

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The Spinomed^® brace is a newer brace that consists of a back pad and a strap system with fabric hook-and-loop fasteners (Figure 1B). Pfeifer et al.⁵ demonstrated that patients who wore the Spinomed^® brace for 6 months experienced increased trunk muscle strength and posture, as well as improved quality of life secondary to pain reduction. The investigators reported multiple positive benefits, including a 73% increase in back extensor strength, 58% increase in abdominal flexor strength, 11% decrease in angle of kyphosis, 25% decrease in body sway, 7% increase in vital capacity, 38% decrease in average pain, 15% increase in well-being, and a 27% decrease in limitations of daily living.

Most hip fractures are a result of a direct fall onto the hip.⁶ Hip protectors are composed of undergarments with padding over the trochanters (Figure 1C). These orthoses help to absorb the impact of a fall and, therefore, reduce the risk of hip fracture. In vitro biomechanical studies have demonstrated the force-attenuation properties of hip protectors.⁷ Several types of hip protectors are currently available, including Safehip^® (Tytex A/S, Ikast, Denmark) and the KPH hip protector (HRA Pharma, Paris, France); most clinical trials have used Safehip^®.

Literature regarding the use of hip protectors has been somewhat contradictory. A recent review analyzed 14 clinical trials and found that there was only a marginally statistically significant reduction in hip fracture in nursing care or residential care settings, and that there was no reduction in hip fracture incidence in community dwelling settings.⁸ Other studies have been more favorable and have identified hip protectors as a cost-effective strategy in reducing hip fractures.^{9, 10} Despite the controversies, the authors feel that hip protectors offer a safe, noninvasive option that has few serious drawbacks and might reduce hip fracture risk.

Although some studies demonstrate acceptable compliance with their use,^{11, 12} noncompliance is known to be one of the main limiting factors in the effectiveness of hip protectors, particularly with regard to long-term adherence.¹³ Factors associated with noncompliance include discomfort on wearing, patients' dislike of their personal appearance with the hip protectors on, and disagreement about their fracture risk.¹⁴ Close follow-up, constant positive feedback, and caregiver education are critical in improving compliance. Educational programs¹⁵ might also help to educate individuals about their risk and improve their compliance.

Exercise programs

Exercise and exercise programs have a key role in the management of the osteoporotic patient and can result in a myriad of positive benefits. Exercise can provide overall increases in strength, flexibility, and balance, with diminished risk of falling. Exercise has also been shown to increase bone mineral density (BMD), with larger changes noted in patients undergoing exercise and pharmacologic treatment than in those undergoing pharmacologic treatment alone. One study by Villareal et al.¹⁶ demonstrated that larger gains in spine BMD were found in patients participating in an exercise program and on hormone replacement therapy than in patients receiving hormone replacement therapy alone. In this trial, larger increases in lumbar spine BMD resulted from a supervised exercise program than from a home exercise program. Additional positive effects of the supervised exercise program included decreased weight, decreased fat mass, and improved muscle strength.

Specific exercise programs geared towards osteoporotic patients have been demonstrated to result in improved balance and gait. In a study involving the combination of a weighted orthosis and a spinal extension exercise program, participants experienced improved balance, gait and strength in plantar flexors, as well as decreased back pain, after only 4 weeks.¹⁷

The osteoporotic patient should participate in regular weight-bearing and thoracic-stabilization exercises. Weight-bearing exercise helps to stimulate osteoblasts to form bone, and thoracic-stabilization exercises, particularly exercises that strengthen the back extensor, can help to improve posture and might reduce the risk of falls. Examples of weight-bearing exercises include walking, running, and impact exercises. All osteoporotic patients should be instructed in appropriate body mechanics and precautions in order to minimize fracture risk. In general, flexion-biased exercises such as abdominal crunches, lifting heavy weights, and excessive twisting and bending should be avoided by patients with osteoporosis.

Appropriate exercise programs for the osteoporotic patient include tai chi, osteoporosis fitness classes, and physical therapy. Some institutions, such as the authors', are incorporating Pilates into classes for osteoporotic patients; future studies are needed to document specific benefits from such an exercise program in this patient population.

Osteoporosis fitness classes are often coordinated by physical therapists. A comprehensive physical therapy program should include strengthening exercises, particularly of the thoracic paraspinal muscles, balance training, body mechanics, and a home exercise program. It has been theorized that strong back extensors might reduce the risk of developing thoracic vertebral compression fractures⁴ and, therefore, the importance of these exercises, as well as weight-bearing exercises, should be emphasized to therapists and patients. Spinal mobility is significantly limited in patients with osteoporotic vertebral fractures and might also be improved with the strengthening of back extensors: one study by Miyakoshi et al.¹⁸ investigated the factors responsible for limited spinal mobility and concluded that spinal mobility is likely to be associated with back extensor strength.

Additional interventions that might prove beneficial include the use of a high frequency, low magnitude mechanical stimulus. Preliminary studies have suggested that such stimuli might help to reduce bone loss.^{19, 20} One study has demonstrated that brief periods (<20 minutes) of these stimuli over a 1-year period resulted in a BMD gain of 0.04% in the femoral neck and a loss of 0.10% in the lumber spine of compliant patients, whereas bone losses of 2.13% and 1.6% in the femoral neck and lumbar spine, respectively, occurred in compliant placebo participants.²⁰

Calcium and vitamin D

Both calcium and vitamin D are essential in the treatment of osteoporosis. Calcium is available in multiple formulations, the most common being calcium citrate and calcium carbonate. Calcium carbonate requires an acidic environment to be activated and, therefore, should be taken with meals and should not be taken by patients who are using antacids or who lack this acidic environment. Vitamin D is essential for the absorption of calcium, and there is increasing recognition of its key role in bone health, as well as in the prevention of other medical conditions. Vitamin D deficiency can result in a failure to attain peak bone mass in adolescence, has a key role in the pathogenesis of osteoporosis in the elderly, and can cause osteomalacia. Vitamin D deficiency in the elderly has been increasingly recognized as an epidemic.²¹

Vitamin D is made by the body, with a cascade triggered by sun exposure. Sun converts 7-dehydrocholesterol in the skin to previtamin D₃, which is then quickly converted to vitamin D₃. Vitamin D₃ is metabolized in the liver to 25-hydroxyvitamin D₃, which, in turn, is metabolized to the biologically active form, 1,25-dihydroxyvitamin D₃, in the kidneys. Most people rely on sun exposure for adequate levels of vitamin D²² and factors such as overcast weather, air pollution, and use of sunscreen can impact on its production (Figure 2). Current recommendations call for 5–10 minutes of exposure of the arms and legs or the hands, arms, and face, 2 or 3 times per week²³ and suggest ingesting at least 800 IU of vitamin D daily, with some groups recommending even higher doses. The serum level of 25-hydroxyvitamin D should be maintained at a minimum of 20 ng/ml and optimally, 30–50 ng/ml.²⁴

Figure 2 Sun exposure allows conversion of 7-dehydrocholesterol to previtamin D₃ in the skin, which is then quickly converted to vitamin D₃ (cholecalciferol).

Vitamin D₃ is metabolized to 25-hydroxyvitamin D₃ in the liver, which, in turn, is converted to 1,25-dihydroxyvitamin D₃ in the kidneys. 1,25-dihydroxyvitamin D₃ is the biologically active form of vitamin D that aids calcium absorption for good bone health.

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Fall prevention

Falls in the elderly represent a significant cause of morbidity and mortality. Each year, falls occur in one third of older adults, and patients with osteoporosis are at highest risk for developing fracture and resulting functional limitations secondary to falls.²⁵ Falls are most often associated with gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, and postural hypotension.²⁶ Additional risk factors for falls and injuries include leg weakness, gait and balance instability, poor vision, cognitive and functional impairment, sedating and psychoactive medications,²⁶ use of diabetes medications, and increased patient-to-nurse ratio.²⁷ Patients at highest risk of falling are those who have fallen in the past year.²⁸ Assessments of gait and balance should be made to help determine fall risk²⁸ and specific strategies implemented to help minimize this risk.

Fall prevention involves environmental modifications, medication review, exercise interventions, gait assessment and treatment, provisions for assistive devices, and attention to concomitant conditions resulting in unsteady gait. In the inpatient setting, additional preventive measures include staff education.²⁹ Environmental modifications can consist of minimizing clutter, altering slippery surfaces, and providing grab bars and other supports in tubs and near toilets. Multiple medications can have a key role in falls. For example, excessive doses of antihypertensives can cause hypotension resulting in lightheadedness and subsequent falls. Medication review should, therefore, be performed on a regular basis, with unnecessary and potentially harmful medications eliminated.

Exercise interventions can include specific balance exercises as well as tai chi, which has been shown to be extremely beneficial in fall risk reduction. Tai chi is a Chinese martial art form that involves a series of slow, rhythmic movements. It has been shown to be extremely effective in significantly reducing fall risk; tai chi was found to reduce the risk of multiple falls by 47.5% in a study performed by the Atlanta Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) Group.³⁰ In this controlled trial, 200 participants were randomly assigned to tai chi, education, or computerized balance training. Intervention length was 15 weeks and primary outcomes, including present and future health, mastery index, perceived quality of sleep, and intrusiveness variables, were measured before and after intervention and at a 4-month follow-up consultation. Tai chi has also been shown to have positive psychologic effects, decrease fear of falling³⁰ and result in improvements in self-perceived health, especially ambulation.³¹

Assistive devices such as properly-fitted canes and walkers should be used to facilitate a more steady gait. Concomitant conditions such as cervical myelopathy, lumbar spinal stenosis, vitamin B₁₂ deficiency, normal pressure hydrocephalus, and Parkinson's disease might all result in abnormal gait and, therefore, increase fall risk.³² These diagnoses should be considered in the differential diagnosis of recurrent falls; such conditions require aggressive, appropriate treatment in order to facilitate gait improvements.

Kyphoplasty

Kyphoplasty is a minimally invasive spine procedure that involves the infiltration of bone cement into a fractured vertebral body after fracture reduction using a balloon tamp. Indications for this procedure include relatively acute, painful compression fractures refractory to conservative treatment. Kyphoplasty can result in diminished pain and reduce kyphosis; multiple studies have shown it to be an effective treatment for painful compression fractures. A large study by Garfin and co-workers,³³ involving 19 medical centers and 155 elderly patients, demonstrated that balloon kyphoplasty resulted in rapid, significant, and sustained improvements in back pain, back function, and quality of life.

Potential complications of kyphoplasty include spinal cord compression, nerve root compression, venous embolism, pulmonary embolism, and recurrent vertebral fracture; however, serious complications are rare. Recurrent vertebral fracture has been estimated at 10% within the first 90 days following this procedure.³⁴ It remains unclear, however, whether these fractures are attributable to kyphoplasty or to the natural history of vertebral fractures. Studies have demonstrated that there are biomechanical changes in the spine following kyphoplasty due to the infiltrated cement; it has been suggested that anterior body shift, rather than stiffness, may be responsible for adjacent body vertebral fractures.³⁵

Conclusions

Nonmedical management of osteoporotic patients has a critical role in a comprehensive treatment plan. Components of this program include the use of orthoses such as spinal braces and hip protectors, exercise programs, calcium and vitamin D, fall prevention, and kyphoplasty. These elements complement pharmacologic interventions, and should be used as part of an interdisciplinary approach to treatment of patients with osteoporosis.

The role of these nonpharmacologic interventions is particularly critical in patients who cannot, or will not, take anti-osteoporotic medications. As considerable debate surrounds the ideal pharmacologic algorithm, it is likely that nonpharmacologic interventions will have a more definitive role in future treatment considerations.

Acknowledgments

Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Subject areas under which this article appears: Therapy | Metabolic bone disease