Osteoporosis and how it relates to Pelvic Floor Physical Therapy

Donna is a 78-year-old female who recently tripped and bumped into her dining room wall. Unfortunately, she noticed worsening bruising along her ribs the next morning and pain with breathing. She went to her doctor who immediately recommended an x-ray which showed rib fractures. Donna was diagnosed with osteoporosis after further testing. After her fractures healed, Donna’s doctor recommended that she go to physical therapy to increase her strength and improve her balance to reduce her fall risk and likelihood of additional fractures. 

Osteoporosis refers to reduced bone density, specifically as we age. This results in reduced bone strength, increased bone fragility and an increased risk of skeletal fractures. Osteoporosis is typically undiagnosed until a fracture occurs. The most common location of fractures includes the hip, vertebrae (spine) and wrist. This is the reason older people seem to have a higher likelihood of breaking a bone when they fall.1  

Osteoporosis can affect men and women of any age, race or ethnic group; however, the likelihood of osteoporosis typically increases with age especially 1-2 years before menopause. Non-Hispanic white and Asian women are at an increased risk as compared to other populations. Additionally, men and women with more slender, thin-boned builds are at a greater risk.2 

Luckily, physical activity can play a role in the prevention of osteoporosis and reducing its progression once acquired. A systematic review that looked at multiple studies found that “physical activity probably plays a role in the prevention of osteoporosis”. Physical activity had the greatest impact in regard to osteoporosis when performed for greater than 60 minutes, 2-3 times per week for greater than 7 months. This matches the general physical activity guidelines of 2-3 times per week. While there is no one specific exercise program that has been studied and verified as a sure-fire way to prevent osteoporosis, research supports programs that include multiple exercise or resistance exercises as this has a greater effect on lumbar spine bone mineral density.1  

A literature review further supported the findings of this systematic review in which a variety of exercises has the most benefit. According to this review, walking alone has not been found to stop the loss of bone mineral density; however, it may prevent further loss if performed consistently over time. It has been recommended for a general health program to walk for at least 30 minutes per day. Strength training has been found to increase bone density at specific sites, such as the femur (thigh bone) and lumbar spine (low back) with at least 3 sessions per week for a year. Progressive resistance training for lower limbs has been found to be most effective on bone mineral density for the femur neck (part of the thigh bone right outside of the hip joint). Overall, a combination of exercise including weight-bearing activities (like walking), balance training, muscle strengthening, and others are recommended to at least preserve bone density if not increase it over time. Because no two humans are identical, individuals should have an exercise routine tailored to his/her needs as there is no one best exercise routine for those with osteoporosis or for those at risk of developing osteoporosis.3  

When Donna arrived for her first visit, she was surprised that the physical therapist asked if she had any bladder or bowel concerns. “Well, I had 3 kids so of course I pee my pants like everyone else” she replied. The PT explained that there is a higher likelihood of urinary incontinence in those with osteoporosis and that this could be addressed during rehab if she wanted it to be taken into consideration. “Of course! If I don’t have to pee my pants anymore than I’m a happy camper.”  

In fact, a study looked at 6,125 women with osteoporosis and 12,250 women without osteoporosis and found that women with osteoporosis had 1.79 times higher likelihood of stress urinary incontinence regardless of age or fractures.4 Interestingly, some research suggests that low bone quality, meaning poor architecture, has been found to have an increased correlation with urinary incontinence whereas low bone quantity was not found to have a relationship with pelvic floor disorders.5  

The good news is that physical activity, specifically structured exercise, can not only stop the loss of bone density in those with osteoporosis but it can also improve urinary incontinence. A study looked at post-menopausal women aged 55 years and older with osteoporosis (low bone density) and urinary incontinence. One group went through a 3-month physical therapy plan of care at 1 session per week and the other group was provided education regarding physical activity, diet, and medications. At the 12 week and 1 year follow ups, the physical therapy group who had undergone pelvic floor muscle training has significantly less leakage episodes. In fact, the group that only received education had worsening incontinence 1 year later.6  

If you are like Donna and have a diagnosis of osteoporosis, please seek out a physical therapist who can tailor an exercise program that suits your current level of fitness and your goals. If you have osteoporosis and urinary incontinence (or any other pelvic health concerns) please reach out to a pelvic floor physical therapist. Better yet, be proactive about your health and seek out a professional to help implement an exercise program into your current weekly routine to build bone density before aging or menopause. When we implement exercise at a younger age, we are able to more effectively build bone density which protects us in the future when we experience aging and hormonal changes.  

Written by Jordan Schmidt, PT, DPT 

References 

1. Pinheiro, M., Oliveira, J., Bauman, A., Fairhall, N., Kwok, W., & Sherrington, C. (2020). Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. International Journal of Behavioral Nutrition and Physical Activity, 17(1), 

1. U.S. Department of Health and Human Services. (2022, June 28). Osteoporosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved November 29, 2022, from https://www.niams.nih.gov/health-topics/osteoporosis/syndicate  

1. Benedetti, M. G., Furlini, G., Zati, A., & Letizia Mauro, G. (2018). The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients. BioMed research international, 2018, 4840531. https://doi.org/10.1155/2018/4840531 

1. Wei, M., Chou, Y., Yang, Y., Kornelius, E., Wang, Y., & Huang, C. (2020). Osteoporosis and Stress Urinary Incontinence in Women: A National Health Insurance Database Study. International Journal of Environmental Research and Public Health, 17(12), 

1. Meyer, I., Morgan, S., Markland, A., Szychowski, J., & Richter, H. (2020). Pelvic floor disorder symptoms and bone strength in postmenopausal women. International Urogynecology Journal, OnlineFirst, 1-8. 

1. Sran, M., Mercier, J., Wilson, P., Lieblich, P., & Dumoulin, C. (2016). Physical therapy for urinary incontinence in postmenopausal women with osteoporosis or low bone density: a randomized controlled trial. Menopause, 23(3), 286-293.