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Prevention of osteoporotic fracture: from skeletal and non-skeletal perspectives
doi: 10.2478/fzm-2022-0029
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Abstract:
With the global population aging, especially in China, the prevention and management of osteoporotic fragility fractures has become increasingly important. Bone mineral density (BMD) is an important index of osteoporotic fracture risk, which has become aroutine measurement inclinical practice and thus formed the cornerstone in monitoring treatment efficacy of osteoporosis. In the past 30 years, several pharmacologic therapies have been developed to increase BMD and reduce osteoporotic fractures, especially vertebral fractures. However, the management of nonvertebral fractures and hip fractures remains challenging as low BMD is only one of the multi-factors for these conditions. Hip fractures mainly result from a fall and its incidence is higher in the frigid zone due to low temperature affecting neuromuscular function and high latitude with less sunlight, the conditions rendering less active vitamin D conversion, apart from increased falling. In this paper, we focus on two therapeutic strategies targeting both skeletal and non-skeletal factors, that is, Tai Chi (TC) exercise for improving balance and "kidney-tonifying" traditional Chinese medicine (TCM) against muscle atrophy. TC is a mind-body exercise that has the potential as an effective and safe intervention for preventing fall-related fractures in the elderly. This makes it a promising and feasible physical activity for the elderly in frigid zone to prevent osteoporotic fractures. Several TCM formula popular in northeast of China within frigid zone are also introduced. They are reportedly effective in maintaining or improving BMD and muscle strength with the potential of reducing osteoporotic fracture. However, more rationally designed vigorous basic investigations and prospective clinical trials are highly desired to validate and consolidate the preliminary observations in the future.
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Key words:
- osteoporotic fracture /
- sarcopenia /
- Traditional Chinese Medicine /
- Tai Chi exercise
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Table 1. Summary of studies evaluating impact of Tai Chi on BMD, muscle strength and fall in elderly
Study Study Design(Duration) Study Population(Age) Interventions and Sample Size Outcomes Measured Results Qin et al.[36] Case-control study (12 months) Postmenopausal women (50-59 years) Long-term TC practitioners (over 4 years experience)(n=17); Age-matched sedentary controls (n=17) BMD of lumbar spine and proximal femur, and distal tibia Significantly greater BMD in lumbar spine, proximal femur, and tibia in TC vs. control at baseline. Reduced rates of trabecular BMD loss of the ultradistal tibia and of cortical BMD loss of the distaltibial diaphysis in TC. Qin et al.[37] Cross-sectional study Postmenopausal women (55.9 ± 3.1 years) TC: more than 3 h/week (n=48); Age-matched sedentary controls (n=51) BMD of lumbar spine and proximal femur, quadriceps strength, flexibility, balance Significantly greater BMD in lumbar spine and some regions of femur (greater trochanter, Ward's area) in TC vs. control.
Greater quad strength and balance in TC vs. controlChan et al.[42] Age-matched RCT (12 months) Postmenopausal women (54.0 ± 3.5 years) TC: 5 sessions/wk, 45 min (n=67); Age-matched sedentary controls (n=65) BMD of lumbar spine and proximal femur, and of distal tibia Significant retardation of bone loss in both trabecular and cortical compartments of the distal tibia in the TC vs. control.
Four fracture cases, including 3 subjects in the control group and 1 in the TC group.Wayne et al.[44] RCT (9 months) Postmenopausal osteopenic women (45-70 years) TC: 99.5h TC training (n=43);
UC: n=43BMD of the proximal femur and lumbar spine, serum markers of bone resorption and formation, and quality of life. Quiet standing fall-predictive sway parameters and clinical balance tests in a subsample Femoral neck BMD were significantly higher in TC (completed ≥ 75% training) vs. UC. In the Usual Care group, average serum concentrations of CTX and OC increased by 4.3% and 6.3%, respectively, while in the TC group, CTX and OC decreased by-7.1% and -5.1%, respectively. More favorable changes in bone physical domains of quality of life in TC vs. UC. Significantly improved in sway parameters in TC vs. UC. Shen et al.[45] RCT (6 months) Postmenopausal osteopenic women (57.5 ± 6.9 years) Placebo: 500 mg medicinal starch daily (n=44);
GTP: 500 mg of green tea polyphenols (n=47);
Placebo + TC: 1h TC class/week, 500 mg medicinal starch daily (n=42);
GTP + TC: 1h TC class/week, 500 mg of green tea daily (n=38)blood and urine biomarker analyses, and muscle strength At 6 months, significant increases in the change of BALP/TRAP ratio in TC group. Muscle strength significantly improved due to GTP, TC, and GTP + TC interventions at 6 months. Li et al.[53] Controlled Clinical Trial (16 weeks) elderly individuals (aged 60 years, 20 men and 20 women) TC: supervised TC exercise (11 men and 11 women);
Control: general education (9 men and 9 women)maximum concentric strength and dynamic endurance of the knee flexors and the extensors, the maximum concentric strength of the ankle plantar flexors and dorsiflexors, onset latency to sudden perturbations in the rectus femoris, semitendinosus, gastrocnemius, and anterior tibialis muscles Significantly greater muscle strength of the knee flexors in TC group vs. control.
Significantly shorter semitendinosus muscle latency in TC vs. control (P=0.042).Song et al.[55] RCT (4, 8, 12 months) Urban elderly women (years) TC: 40min TC exercise/d (n=35);
Control I: 40min dance/d (n=35);
Control Ⅱ: 40min brisk walking/d (n=35)lower limb skeletal muscle mass, lower limb muscle strength, BMD and balance function At 4 months, most of the study indexes in the control group I and group Ⅱ are improved significantly. The study indexes in three groups show no significant difference.
At 8 months, relevant study indexes of the subjects in the three groups are significantly improved.
The effect in the TC group is more obvious and is better vs. control Ⅱ.
At 12 months, the effect of the TC group is improved significantly vs. control I and Ⅱ (P < 0.05 or P < 0.01).Taylor-Piliae et al.[56] 2-phase RCT (12 months) Healthy adults (69 ± 5.8 years) TC: one 45min TC class/week, encourage daily practice (n=37);
WE: 3 times/week, incorporated endurance, resistance/strength, and flexibility exercises (n=39);
C: healthy aging classes attention-control group (n=56)Physical functioning included balance, strength, flexibility, and cardiorespiratory endurance.
Cognitive functioning included semantic fluency and digit-spantests.At 6 months, WE had greater improvements in upper body flexibility than TC and C. TC had greater improvements in balance and a cognitive-function measure than WE and C. The differential cognitive-function improvements observed in TC were maintained through 12 months. Guo et al.[57] Cross-sectional study Elderly volunteers (64.5 ± 8.48 years) TC: average 9.64 years TC exercise (n=16);
Control: sedentary controls (n=9)static balance test, ankle proprioception test, and concentric and eccentric knee extensor and flexor muscle strength tests TC group performed better than the Control group in balance, proprioception, and muscle strength of lower extremity. BMD, bone mineral density; TC, Tai Chi; UC, usual care; CTX, C-terminal collagen cross-link; OC, osteocalcin; BALP, bone-specific alkaline phosphatase; TRAP: tartrate-resistant acid phosphatase; GTP: green tea polyphenols group; WE: western exercise group; C: control group 
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Table 2. Selected studies on the effects of ginseng, deer antler, epimedium, and baill or its main components in muscle and bone
Herbs Study Population Treatment Function Key finds Panax ginseng extract Kim et al.[108] Fourteen healthy men (22-28 years) Drug: 6 g/d for 8 weeks (n=7)
Control: placebo /d for 8 weeks (n=7)Muscle quality ↑ Ginseng administration significantly increased exercise duration until exhaustion. American ginseng Lin et al.[80] Twelve physically active men (22.4 ± 1.7years) Drug: 1.6 g/d for 4 weeks (n=6)
Control: placebo /d for 4 weeks (n=6)Risk of muscle injury ↓ Ginseng alleviates eccentric exercise-induced muscle damage. Panax ginseng extract Jung et al.[68] Ninety women with osteopenia (> 40 years) H-Drug: 3 g/d for 12 weeks (n=30)
L-Drug: 1 g/d for 12 weeks (n=30)
Control: placebo /d for 12weeks (n=30)Bone formation ↑ Ginseng improved the knee arthritis symptoms with enhancement in the osteocalcin concentration and ratios of bone formation indices like deoxypyridinoline/osteocalcin. Deer Antler Extract Chen et al.[87] Six male BABL/c mice 8.2 mg/day, for 4 weeks Muscle quality ↑ Deer antler extract improves fatigue effect in skeletal muscle by altering the expression of genes related to muscle strength. Fermented deer antler extract Jang et al.[88] Eight male BALB/c mice 500 mg/kg/day, for 4 weeks Muscle quality ↑ Total average duration of swimming time of the deer antler extract group was increased. deer antler Widyowati et al. Six healthy male mice for each group 4, 8, and 12 mg/kg/day, for 4 weeks BMD ↑ Deer antler to increase trabecular bone density and calcium levels in serum. Icariin Wang et al.[97] Eight SD male rats 10 mg/kg/day, for 2 weeks. Risk of muscle injury ↓ Icariin has excellent therapeutic effects on acute blunt muscleinjury in rats by improving immunity. Icariin Zhang et al.[96] Eight Wistar male rats 45 mg/kg/day, for 3 weeks Muscle quality ↑ The exhaustive swimming times of rats in icariin group were significantly prolonged. Epimedium extract Yong et al.[93] Sixty healthy postmenopausal women (57.9 ±8.9 years) Drug: 740 mg/day for 6 weeks (n=30)
Control: placebo /d for 6 weeks (n=30)Bone formation ↑ Rise in prenylflavonoid metabolites was associated with higher levels of the bone anabolic marker BALP. Schisandra chinensis (Turcz.) Baill Cho et al.[105] Eight SD male rats 20 or 100 mg/kg, 14 times over 3 weeks. Muscle quality ↑ Schisandra chinensis (Turcz.) Baill increases the grip strength and muscle fiber size in rats. S. chinensis (Turcz.)extract Kim et al.[103] Seven SD male rats 10 mg/kg/day, for 8 weeks BMD ↑
Muscle quality ↑Baill extract increases the BMD in OVX rats and ameliorates the age-related muscle wasting. The up arrow means increase. The down arrow means decrease. SD, Sprague Dawley; BMD, bone mineral density.
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