O stcoporotic fractures frequently affect the spine, in addition to the hips and extremities. While calcium intake and diet arc very important for prevention, and hormone status is a major factor, physical activity and exercise have been shown to provide significant protection from osteoporosis' and fractures due to falls.2 The most common fractures due to osteoporosis arc vertebral fractures and, yet, less than a third of all vertebral fractures are clinically diagnosed.' Our radiographs help us identify those patients who are at risk of fracture, and we can then provide lifestyle recommendations that decrease that risk. Properly tailored exercises will help to prevent the spinal complications of osteoporosis, such as increased kyphosis, vertebral wedging, and frank compression fractures. General Exercise Recommendations Exercise is a form of repetitive loading that facilitates os-tcoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption.4 Even the moderate amount of exercise that is recommended for general wellncss (a minimum of 30 minutes, on most days) is helpful in preventing osteoporosis.5 Based on Wolff's Law, bone density and strength are a function of the magnitude and direction of the mechanical stresses that act on bone. Assuming the availability of necessary nutrients, stimulus to the osteoblasts will result in a net gain in bone mass. Aerobic training: In order to create sufficient stimulus to increase bone density, aerobic exercise activities should be done weightbearing and have some repetitive impact. Unfortunately, women who participate in a regular swimming program have no significant difference in bone mass from women who don't exercise.6 Bone mineral density can be increased by walking, but it needs to be done at a brisk pace—getting close to the anaerobic threshold.7 Strolling is better than sitting, but to actually build bone mass, a brisk pace should be maintained while walking. Because this additional stress can highlight underlying biomechanical imbalances, caution is needed when recommending brisk walking to elderly patients. Good-quality shoes are important, and stabilizing orthotics with additional support and shock absorption may be necessary. Strength training: Weight training in a submaximal controlled, supervised situation can preserve8 and even increase9 bone deposition. Avoiding exercise is the worst approach to an aging patient with osteoporosis. Strength training recommendations should be an integral part of chiropractic treatment for older and osteoporotic patients. Patient education must emphasize the dangers of lifting in flexion, and of performing flexion exercises, since placing an anterior load on the vertebral bodies is a potentially harmful activity. Exercise tubing is an excellent tool for strength training of the elderly, since the risks of injury are minimized, and there is no need for a spotter or expensive equipment. Specific Spinal Exercise Recommendations Spinal osteoporosis is often associated with an increase in the thoracic kyphosis. This ky-photic posture develops from many decades of flexed activities, and may be compounded by poor posture habits and tendencies to "slump". Elderly patients should be shown corrective exercises that arc specific for the postural imbalances they have developed. When the torso is carried flexed forward, the patient will need to retrain the extensor muscles of the spine with isotonic resistance exercises. This is most effective when done in an upright, weightbearing position. The hyperkyphosis of post-menopausal women is directly correlated with weakness of their back extensor muscles,10 and increasing the strength of the back extensor muscles with resistance exercises has been shown to decrease the extent of the associated kyphosis." Conclusion A well-designed exercise program can improve posture, help reduce bone loss, and prevent fractures, while also reducing symptoms. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly during daily activities. For some elderly patients, orthotic support will be necessary to reduce excessive impact and ensure correct alignment of the lower extremities during weightbearing exercises such as walking. We understand now how important it is to provide exercise recommendations to prevent hyperkyphosis and spinal compression fractures in our elderly patients. See references on page 62 John K. Hvland, D.C., M.P.H. D.A.C.B.R., D.A.B.C.O., C.S.C.S., C.H.E.S., is board-certified in two chiropractic specialties, and is also certified as a Strength and Conditioning Specialist and a Health Education Specialist. He has 20 years of clinical practice; for eight vears he specialized in chiropractic rehahiiitation. He is currently a Research Associate at Parker College of Chiropractic, and an Adjunct Professor of Clinical Sciences at the University of Bridgeport's College of Chiropractic. You can contact him at drjkhvlanddaimsn.com. ifcTW REFERENCES REHABILITATION-Pg.56 Exercise for Spinal Osteoporosis by John K. Hyland, D.C., M.P.H., D.A.C.B.R. Chien MY, Wu YT, Hsu At, et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmeno- pausal women. Calcil Tissue Int 2000:67:443-8. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice pro gramme of home based exercise to prevent falls in el derly women. BrMedJ 1997:315:1065-9. 3 Ross PD. Clinical consequences of vertebral fractures. /»mJMed1997;103:30S43S. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med 1987:8:331-5. US Dept. of Health and Human Services. Physical activ ity and health: a report of the surgeon general. Atlanta: 1996. Orwoll ES, Ferar J, Oviatt SK, et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med 1989:149:2197-200. Hatori M, Hasegawa A, Adachi H, et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Inl 1993:52:411-4. Nelson ME, Fiatarone MA, Morganti CM, et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA 1994:272:1909-14. Kerr D, Ackland T, Maslen B, et al. Resistance train ing over 2 years increases bone mass in calcium- replete postmenopausal women. J Bone Miner Res 2001:16:175-81. lO.Sinaki M, Itoi E, Rogers JW, et al. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil 1996;75:370-4. 11.Itoi E, Sinaki M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo C/inProc 1994:69:1054-9.
