Male Osteoporosis and Weight Bearing
Male osteoporosis is underdiagnosed and undertreated but there is increased attention to this public health problem. In a recently published Endocrine Society Clinical Practice Guideline, increased testing is recommended for males over the age of 70 years and for males 50-69 years old who have risk factors (1). Treatment recommendations included sufficient calcium, vitamin D and weight bearing exercise. The evidence of the benefits of weight bearing on males with osteoporosis is growing but remains fair from conclusive.
The research on weight bearing exercise for males in relationship to bone is diverse because of the range of weight bearing activities. There is a continuum from high impact dynamic exercises, such as running and jumping, to low impact activities, such as walking and further, to reduced weight bearing, such as biking and swimming.
The large amount of evidence indicates that activity intensity was a key factor with greater bone mineral density (BMD) resulting in males performing more intense activities, such as strenuous sports and boxing (2, 3, 4,5). In contrast, some researchers reported no effect on BMD with exercise programs aimed at skill, coordination, strength or rehabilitation post-hip fracture. deJong et al found no change in BMD in frail elderly persons in the eighth and ninth decades of life who exercised twice weekly for 17 weeks. Similarly, Binder et al, also reported no increase in BMD in older adults who had sustained hip fractures and underwent 6 months of rehabilitation. Villareal conducted a randomized controlled trial of community dwelling men and women all over the age of 78 years of age (8). The subjects exercised 2-3 times weekly which included resistive exercises as well as endurance exercises for a total of 9 months. They found trends for significant increases in BMD at the total hip (.08) and trochanter sites (.07). increase in bone mineral density.
In later study, Villareal et al conducted a randomized controlled trial for one year and found that the exercise group increased total hip bone mineral density by 1.5% in the exercise group(9). The training intervention, 3 sessions per week of approximately 90 minutes duration, involved aerobic exercises, resistance training, and exercises to improve flexibility and balance. It included walking on a treadmill, stationary bicycle, and stair climbing. Blumenthal and associates exercised 101 males with the mean age of 67 years with a warm-up period followed by brisk walking, jogging, and arm ergometry for 15 minutes and 30 minutes of resisted bicycle (9). After 14 months, they found a mean increase in at the distal radius of 19%. Kukuljan et al conducted an 18 month trial with males between the ages of 50 and 79 years of age and demonstrated improved lumbar spine and femoral neck BMD following their program which consisted of aggressive resistive training along with weight bearing impact activities 3 days weekly(10). Weight bearing activities included jumping, bench stepping, jumping off benches landing with one or both feet.
Gomez-Cabello et al conducted a systematic review of the effects of training on bone mass in older adults which included males and females. They concluded that aerobic activities, such as walking, have less beneficial effect on bone mineral density than strength training and multi-component training activities. Borschmann and associates conducted a systematic review to determine the skeletal effects of physical activity in persons who had a stroke at least one year earlier. They found a number of studies that demonstrated a small effect with physical activity maintaining or improving bone density on the paretic side compared to control subjects. There is evidence exercise performed in the pre and early pubertal age, may have more benefits because of the bone remodeling and this appears to be maintained at advanced age (Karlsson and Rosengren). Leisure time activity may also have a positive linear trend in bone mineral density in adulthood (Morseth 2010).
The benefits of bicycling are many but they do not appear to have beneficial effects on bone mineral density. Nichols and associates found the bone mineral density of the lumbar spine and the total hip was significantly lower in master cyclists compared to age-matched controls and young adult cyclists. Similarly, Sabo et al found the bone mineral density of the lumbar spine in endurance cyclists was lower than the controls.
In conclusion, weight bearing activities for males have benefits on bone and intensity as well as duration are key training factors. Evidence suggests that starting at a young age is better than at an older age but older individuals can also benefit if the training intensity is sufficiently intense.
Male Osteoporosis and Strength Training
Male osteoporosis is underdiagnosed and undertreated but there is increased attention to this public health problem. In a recently published Endocrine Society Clinical Practice Guideline, increased testing is recommended for males over the age of 70 years and for males 50-69 years old who have risk factors . Treatment recommendations included sufficient calcium, vitamin D and weight bearing exercise. The evidence of the benefits of exercise on bone mineral density on males with osteoporosis is growing but remains far from conclusive.
The research on strength training for males in relationship to bone is diverse because of the variety of strength training exercises. They range between progressive resistive exercise with weights or machines to low load, high repetition resistance and to vibration exercise.
Although some research indicates that resistance exercise does not increase bone mineral density (BMD), but these studies may not have had sufficient intensity [2, 3, 4]. A lifetime of weightlifting and impact activities, such as boxing, demonstrates beneficial effects on BMD . In a review article Cheung and Giangregorio, summarize their findings that older persons engaging in strength training activity and high force dynamic exercise can enhance their BMD . “Males with the greatest muscle power had the greatest bone strength”. Several small studies found beneficial effects of high impact or resistance training on the BMD in some, but not all, sites that were tested [7, 8, 9]. Daly et al studied high intensity resistance training for 12 months in older overweight adults with Type 2 diabetes ages 60-80 years and reported the resistance training group maintained their BMD and bone mineral content whereas the non-exercising group lost BMD . Braith et al measured BMD for the total body, femoral neck, and lumbar vertebrae in 16 male heart transplant recipients. They found resistance exercise for 6 months offset the BMD loss which was found 2 months after transplantation . The control group did not recover any of the losses. Chilibeck et al studied 29 older men age 71 who performed resistance training for 12 weeks . They found creatine supplementation enhanced BMD. Yarasheski and colleagues used daily growth hormone along with resistance training for 16 weeks 4 times a week in healthy males, aged 67 years . They found BMD of the proximal femur significantly increased but BMD was not increased at the spine or the femoral neck. Kukuljan et al studied 180 men between the ages of 50 and 79 years of age . They exercised 3 times weekly with progressive resistive exercise and weight bearing impact activities. After 18 months, there was a 1.9% gain in areal BMD at the femoral neck and lumbar spine trabecular bone mineral density also showed a 2.2% increase. Maddalozzo and Snow reported that high intensity standing free weight exercise program conducted approximately 75 minutes for 3 times weekly for 24 weeks significantly increased the BMD in the spine of men, mean age 54.6 years. Moderate intensity exercise training produced no bone effect.
Colletti et al studied 12 young men between 19 and 40 years, who had engaged in resistance training for at least one year and found significant increases in BMD of the lumbar spine, greater trochanter, and the femoral neck but not at the mid-radius . The Canadian Multicentre Osteoporosis Study included 2,855 community dwelling males who were at least 25 years of age and older . They used a self-reported physical activity questionnaire at the start of the study and 5 years later. They quantified physical activity based on metabolic equivalent (MET) and included work history as well as sporting and leisure time activity. Physical activity was associated with a small increase in total hip BMD. Higher physical activity was defined as greater than 2,455 MET min/day. Kelley, Kelley and VuTran conducted a meta-analysis to investigate the association of exercise and BMD in males. They concluded that site specific exercise may improve or maintain BMD at the femur, lumbar spine, and os calcis in older men, although they stated that the variety of exercises will not allow them to form any firm conclusions. A positive relationship between physical activity and BMD has been reported for boys ages 15 and 16 years of age as well as active men, ages 21-42 years who demonstrated a 9% higher BMD at the hip when compared to persons who are less active .
In conclusion, there is clear evidence that resistance training and high impact activities can enhance BMD [7, 8, 9, 12, 14]. There are benefits to starting this early in life [16, 19] yet benefits can also be found in older adults [6, 11, 17].
Type 2 diabetes (adult onset) is a major international health problem which degrades quality of life and is the 7th leading cause of death. Exercise is one of the major interventions for the treatment of diabetes. However, it requires time, energy, and commitment and what is the correct exercise? Medication is a crucial and effective treatment for diabetes and should be directed by your physician. The third major component of diabetes care is lifestyle and nutritional counseling.
A recent study of primary care clinics showed that the average time spent discussing exercise with diabetic patients is only 22 seconds (J Am Board Fam Med 2011;24:26-32). This is most likely an insufficient amount of time to motivate a patient to start an exercise program. Also, exercise is very sophisticated and includes aerobic, anaerobic, isotonic, eccentric, concentric, static, dynamic, balance, fitness, flexibility, and numerous other types of exercise activities. Additionally, each patient is unique in that some have osteoarthritis, back pain, neck pain, cardiovascular or cardiopulmonary disease, neurologic conditions, and possible nerve damage due to the diabetes that maylead to visual, sensory, or muscular changes.
The American Diabetes Association reports almost 26 million Americans have diabetes and another 79 million have pre-diabetes. Diabetes across the world has more than doubled since 1980 and now tallies at 347 million. Proper exercise is an important component of the self-management lifestyle changes necessary for controlling diabetes.
Researchers have recently shown (Arch Inter Med 2011;171:1951-1953) sedentary people with Type 2 diabetes can improve their quality of life through a structured supervised exercise program. This was measured on the Rand, Short Form-36 Health Survey,( SF-36). The exercise group trained twice weekly for 150 minutes per week (75 minutes per training session). The exercise included aerobic and anaerobic exercise. Additionally, each of the persons received structured individualized counseling. A controlled group was included which received counseling alone.
After 12 months, the exercise group improved in all but one of the quality of life measurements. In contrast, the controlled group was worse in all measurement areas.
Further evidence about the benefits of exercise intervention for persons with diabetes was provided in a systematic review published in a recent issue of the Journal of the American Medical Association (JAMA 2011;305:1790-1799). These researchers studied the mean plasma glucose concentration (blood sugar levels) and reported that structured exercise training involving aerobic exercise, anaerobic exercise and both combined, showed favorable improvements in blood sugar concentrations. In their studies people who exercised more than 150 minutes per week had greater decline in blood sugar concentration but even persons who exercised 150 minutes or less also showed benefits.
Exercise is a key component in diabetes management along with dietary and pharmacological interventions.
Kauffman Physical Therapy is keenly interested in starting a guided exercise program for all patients with Type 2 adult onset diabetes. Our exercise programs will emphasize aerobic and anaerobic exercise and will be tailored to each individual person.
Vertebral Compression Fractures are significant health problems across the world. There are estimated to be about 700,000 fractures in the US each year, some of them are silent and painless but others are painful and may lead to adverse postural changes and even early death . Low bone mass is a significant factor. Our research suggests that these fractures may be associated with vestibular dysfunction and may increase the risk of falls. Physical therapy can offset some of the detrimental effects and facilitate recovery and enhance quality of life.
Gait is the type or style of walking and it can be abnormal for a variety of causes such as nerve injury, amputations, fractures or diseases like multiple sclerosis, Parkinson's Disease or cerebral palsy. As we age, a host of changes can lead to an abnormality of gait and increase the risk of falls. Our research has shown that persons over the age of 65 years have an underlying factor in the their risky style of walking and that is vestibular dysfunction. This is one of our balance control systems and involves the semi-circular canels in our ears. This system becomes less effective as we age and contributes to unsteady gait.
Life expectancy for women is decreasing since 1997 in 850 counties in the US according to research published in the journal, Population Health Metrics. The authors were uncertain as to the cause but they attributed the change to smoking, obesity, high blood pressure and other behaviors/conditions that lead to early deaths.