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Physical Therapist's Guide to Osteopenia (Low Bone Mass)

Osteopenia, now called low bone mass, is a term used to describe lower-than-normal bone density or thickness. Approximately 44 million adults in the United States have osteopenia.The condition is different than osteoporosis, which is a disease where normal bone structure becomes thinned out and porous.

Low bone mass can occur at any age, but noticeable and significant bone loss is most likely to occur in women during the 5 to 7 years following menopause. This group is also more likely to experience a bone fracture than someone with normal bone mass.

What is Osteopenia?

Low bone mass is a condition that develops when a person:

  • May naturally have less-dense bones due to factors such as body size, genetics, or gender.
  • Has gradually lost bone mass over time due to lack of exercise and poor diet.
  • Has begun to experience perimenopause, symptoms that signal the onset of menopause or who is in menopause.
  • Has rapidly lost bone mass due to an illness or use of medication.

How Does it Feel?

There are no specific symptoms oflow bone mass. You may have the condition and not know it. It is important to recognize your risk factors to prevent bone fracture. You should discuss any concerns with your health care provider and physical therapist.

How Is It Diagnosed?

Low bone mass is diagnosed through a quick and painless specialized scan ordered by a physician. If you are seeing a physical therapist for rehabilitation, the therapist may confer with your physician when detecting a possible need for bone testing.

The results of the scan are reported using T- and Z-scores.

The T-score compares your score to that of healthy 30-year-old women. A T-score between -1 and -2.49 means that you have low bone mass. Those who have a T-score of -2.5 and lower have osteoporosis.

If you have a T score of -1 or less, you have a greater risk of experiencing a fracture. A person with a T-score of -2 has lower bone density than a person with -1.

The Z-score compares your bone mineral density to the average of people who are of the same age, sex,weight,and race as you. A Z-score of -2 or lower might mean that something other than normal bone loss due to age is occurring. Your doctor will likely explore other health issues that might be causing the bone loss.

Other methods of screening bone density include x-ray, ultrasound, and CT scan.If you have risk factors that include certain diseases, short- or long-term use of steroids, or a recent bone fracture, a DXA scan may be prescribed.

How Can a Physical Therapist Help?

A physical therapist can help you prevent and treat low bone mass at any age by prescribing the specific amount and type of exercise that best builds and maintains strong bones.

When you see your physical therapist, the therapist will review your health history, including your medical, family, medication, exercise, dietary, and hormonal history. Your physical therapist will also conduct a complete physical therapy examination and identify your risk factors for low bone density.

It is important to exercise throughout life, and especially when you have been diagnosed with low bone mass in order to build and maintain healthy bones. Exercise can help to build bone or slow the loss of bone.

Your physical therapist is likely to prescribe 2 types of exercise that are best to build strong bones:

Weight-bearing Exercises

  • Dancing
  • Walking at a quick pace (122-160 steps per minute or 2.6 steps per second)
  • Jumping, stomping, heel drops
  • Running at least a 10-minute mile
  • Racket sports

Resistance Exercises

  • Weightlifting
  • Use of resistance bands
  • Gravity-resistance exercises (pushups, yoga, stair climbing, etc.)

Your physical therapist will design an individual exercise program for you based on your particular needs. Your physical therapist will test you to see how much resistance is needed and is safe for your specific bone density as well asother physical issues that you may have. Treatment starts at the level you can tolerate. Once you learn how to perform your program, your physical therapist may add more strenuous activity with physical effort to encourage your bones to grow stronger.

Your exercise prescription will include guidelines for weightbearing and resistance training for the hips, spine, shoulders, and wrists. The therapist will prescribe guidelines for the intensity, frequency, and progression of your exercises.

Exercise is only 1component of healthy bones. Your physical therapist will encourage you to pursue a healthy and varied diet, including foods rich in calcium, to reach the amount recommended according to your age and health status. Your physical therapist may recommend that you meet with a dietitian to learn about the many foods that contribute to bone health. Sometimes, medication or hormone replacement therapy may be recommended. Your physician will help guide you to find the best combination of exercise, diet, and medication to treat your condition.

Can this Injury or Condition be Prevented?

Risk factors that you can avoid in order to lower your chances of developing low bone mass include:

  • Cigarette smoking
  • Excessive alcohol intake (greater than 1 drink per day for women, 2 per day for men)
  • Poor diet
  • Low calcium and Vitamin D levels
  • Sedentary or low level activity—less than 5,000 steps per day

Real Life Experiences

Allison is a 49-year-old woman in good health. Allison stays active and walks daily. She also occasionally takes a yoga class. Over the past few months, however, she has noticed that when she coughs, she experiences a bit of urinary incontinence. She decides to call her physical therapist.

At her first physical therapy visit, Allison’s physical therapist performs an assessment that includes a medical review for health issues and risk factors, and takes her exercise history. Allison's physical therapist conducts a physical assessment. She notes that Allison has a slight increase in the rounding of her upper back. She also assesses the muscle strength of Allison's trunk and pelvis as well as that of her hips and lower extremities. She measures her joint motions for her neck, trunk, arms, and legs. She watches how Allison moves and lifts objects.

Although Allison is not a postmenopausal woman, the typical picture of someone with low bone mass, her physical therapist notes that Allison may be at risk for having low bone mass because of the risk factors uncovered during the health assessment. She has a family history of osteoporosis, late onset of menstruation, and low body weight. The physical therapist also notes that although Allison is active and does exercise quite a bit, it is not the best form of activity to help maintain her bone density.She contacts Allison's primary care physician; he orders a DXA scan.

Allison's DXA scan report indicates that she has low bone mass. Her physical therapist designs a plan to treat her incontinence, and adds a separate exercise treatment program to help increase her bone mass.

Her physical therapist shares resources with Allison on where to find good dietary information and learn more about necessary calcium and Vitamin D supplementation.

Allison commits to a regular weight-lifting program, beginning with the amount of weight recommended by her physical therapist, and rigorous aerobic exercise.

Allison discovers that she actually enjoys working with weights, and really likes the idea of getting stronger. She attends sessions with her physical therapist to ensure she is performing her exercises properly, and to learn how to safely increase her exercise program. She continues to practice her exercises daily at home and at her community gym.

Allison returns 1 month later to see her physical therapist, who shares the good news that she sees measured improvements in Allison's strength and endurance. Allison continues to work with her physical therapist to treat her incontinence, which is a separate condition.

Allison's course of physical therapy to improve her bone mass ends with the understanding that she will continue to work out at her community gym, and will follow up with her physician to monitor her bone-density levels in the future.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat low bone mass. However, you may want to consider:

  • A physical therapist who is experienced in treating people with women’s health, geriatric, or orthopedic conditions. Some physical therapists have a practice with a focus on women’s health, geriatrics, orthopedics, and osteopenia/osteoporosis.
  • A physical therapist who is a board-certified clinical specialist in women’s health, geriatric, or orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

  • Get recommendations from family and friends or from other health care providers.
  • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have osteopenia or osteoporosis. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.

Further Reading

The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

The following articles provide some of the best scientific evidence related to physical therapy treatment of low bone mass. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

Watts NB. Improving osteoporosis outcomes in primary care. National Osteoporosis Foundation. Published 2009. Accessed May 22, 2014.

Going SB, Farr JN. Exercise and bone macro-architecture: is childhood a window of opportunity for osteoporosis prevention? Int J Body Compos Res. 2010;8:1–9. Free Article.

Winters-Stone KM, Snow CM. Site-specific response of bone to exercise in premenopausal women. Bone. 2006;39(6):1203–1209. Article Summary in PubMed.

Saraví FD, Sayegh F. Bone mineral density and body composition of adult premenopausal women with three levels of physical activity. JOsteoporos.2013;2013:953271. Free Article.

Rowlands A, SchunaJM Jr, Stiles VH, Tudor-Locke C. Cadence, peak vertical acceleration and peak loading rate during ambulatory activities: implications for activity prescription for bone health. J Phys Act Health.2013 October 31 [Epub ahead of print]. Article Summary in PubMed.

Bielemann RM, Martinez-Mesa J, Gigante DP. Physical activity during life course and bone mass: a systematic review of methods and findings from cohort studies with young adults. BMC MusculoskeletDisord. 2013;14:77. Free Article.

US Department of Heath and Human Services, National Institutes of Health. Bone mineral density in childhood study (BMDCS).  Updated November 30, 2012. Accessed September 7, 2009.

Cosman F, De Beur SJ, leBoff MS, Lewiecki EM, Tanner B, Randall S, Sindsay R. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014; Aug 15 (Epub ahead of print). Accessed September 15, 2014.

*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.

Authored by Mary Saloka Morrison, PT, DScPT, MHS. Reviewed by the editorial board.

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