Bone quality: a combined and integrated approach to prevent and treat osteoporosis.

G. Ronconi¹, P.E. Ferrara¹ and G. Maccauro²

¹UOC of Physical Medicine and Rehabilitation, Hospital Foundation “Agostino Gemelli”, IRCCS, Catholic University of Sacred Heart, Rome, Italy

²Orthopedic and Traumatology Institute, Catholic University of the Sacred Heart, Rome, Italy

To the Editor,

            Osteoporosis is a systemic bone disease that affects millions of people around the world and is mostly observed in the female postmenopausal population. The World Health Organization (WHO) describes osteoporosis as a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and increased risk of fractures of the hip, spine, and wrist (1), and the evaluation is based on Bone Mineral Density [BMD that lies 2.5 standard deviations or more below the average value for young healthy women (a T-score of <-2.5 SD)] with dual energy X-ray absorbtiometry (DXA), considered the gold standard diagnostic instrument (1). Osteoporosis treatment requires a multidisciplinary approach to reduce potential fractures. Preventing risk factors, such as physical inactivity, low weight, tobacco smoking, high alcohol consumption, tendency to fall, impaired vision, low exposure to sunlight, and use of corticosteroids, is possible. Pharmacologic treatment is well studied in the relative literature. Calcium and vitamin D reduce the risk of hip and other fractures, except vertebral, in elderly women. Bisphosphonates reduce the number of fractures, mainly vertebral fractures, in postmenopausal women with osteoporosis. Estrogen has also been shown to reduce the number of fractures, but its applicability is limited due to the increased risk of side effects. Selective estrogen-receptor modulators (SERM) have been shown to reduce the risk of vertebral fractures. Teriparatide increases bone mass primarily through remodelling of older or damaged bone and abundant replacement with new mineralizing bone. Denosumab, a fully human monoclonal antibody targeted against the receptor activator of nuclear factor kappa B ligand, is an alternative osteoporosis treatment indicated in presence of increased risk of fractures (2). Non-pharmacologic approaches have been suggested for the management of women with osteoporosis, and physical activities have been considered important for maintaining healthy bone. Weight-bearing training, such as jumping, aerobic exercise, endurance training, and weight lifting, probably have the greatest effects on bone density associated with balance and flexibility training to reduce the risk of falls. Mechanical vibrations is a non-pharmacological intervention to stimulate muscular response and increase bone mineral density in postmenopausal women. The literature related to this topic is controversial and heterogeneous regarding its effects (3, 4). Whole body vibration treatments in elderly women can reduce BMD decline. The interaction of mechanical vibration with the structures of the body would induce the process of bone formation . It has been demonstrated that the fluid flow in canaliculi and bone lacunae may be increased due to the loading frequency. The mechanotransduction may be influenced by the mechanical loading adequate to increase fluid flow in bone and by the effects of forces from muscle contraction applied to bone during physical activity. Several biomarkers are used in clinical studies to evaluate bone metabolism and its relationship to exercises effects, such as osteocalcin, parathyroid hormone, bone alkaline phosphatase, calciferol, N-terminal propeptide of type I procollagen (P1NP) and C-terminal cross-linking telopeptide of type I collagen. Currently, various anabolic and anti-resorptive physical therapies have been employed in an attempt to retain healthy bone mass and strength (5, 6). Pulsed electromagnetic fields (PEMFs), first applied in treating patients with delayed fracture healing and nonunions, may turn out to be another potential and effective therapy for post-menopausal osteoporosis. PEMFs can enhance osteoblastogenesis and inhibit osteoclastogenesis, thus contributing to an increase in bone mass and strength. However, accurate mechanisms of the positive effects of PEMFs on osteoporosis remain to be further elucidated (7).

1. US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 319(24):2521-31. doi: 10.1001/jama.2018.7498.
2. Osteoporosis – prevention, diagnosis and treatment: A Systematic Review Swedish Council on Health Technology Assessment.
3. Daly RM. Exercise and nutritional approaches to prevent frail bones, falls and fractures: an update. Climacteric 2017 119-124; 20(2):8. doi: 10.1080/13697137.2017.1286890.
4. Zhao R, Zhang M, Zhang Q. The effectiveness of combined exercise interventions for preventing postmenopausal bone loss: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2017; 47(4):241-51. doi: 10.2519/jospt.2017.6969.
5. Fratini A, Bonci T, Bull AM. Whole body vibration treatments in postmenopausal women can improve bone mineral density: results of a stimulus focussed meta-analysis. PLoS One 2016; 11(12):e0166774..
6. Dionello CF, Sá-Caputo D, Pereira HV, et al. Effects of whole body vibration exercises on bone mineral density of women with postmenopausal J Musculoskelet Neuronal Interact 2016; 16(3):193-203.
7. Zhu S, He H, Zhang C, Wang H, Gao C, Yu X, He C. Effects of pulsed electromagnetic fields on postmenopausal osteoporosis Bioelectromagnetics 2017; 38(6):406-424. doi: 10.1002/bem.22065.