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Bone Health
101Chuck Ottavio PT
Disclaimer
The information in this presentation is not intended to be
a substitute for a medical consultation or for one‐on‐one care by a physician or a physical
therapist.
A A musculoskeletal musculoskeletal disorder with disorder with
compromised bone compromised bone strength that predisposes strength that predisposes an individual to increased an individual to increased
fracture riskfracture riskNIH Consensus Development Panel NIH Consensus Development Panel onon
Osteoporosis Prevention, Osteoporosis Prevention, DiagnosisDiagnosis, and Therapy. , and Therapy. JAMA 2001: 285:785JAMA 2001: 285:785‐‐795795
Milner, Colin. Making Bone HealthA Priority. The Journal on Active Aging.May June 2002.
OSTEOPOROTICBONE
NORMALBONE
•Bone Density•Bone Quality
•Architecture•Mineralization•Micro damage accumulation
BONE BONE STRENGTHSTRENGTH
True or False
1. Most people don’t need to worry about osteoporosis.
http://nof.org/articles/4c
False
The total number of people
estimated
to have low bone mass
in the US is
52 millionhttp://nof.org/articles/4c
One in two women and up to one in four men over the age of 50 will break a bone due to
osteoporosis
By 2020, half of all Americans over age 50 are expected to have low bone density or
osteoporosis
OsteoporosisOsteoporosisis more prevalent than:
•coronary heart disease(12.5 million)•heart attack (1.1 million)•diabetes (17 million)
(Ref: Surgeon General’s Report 2004)
OsteoporosisOsteoporosisis more common
thanbreast, uterine, and
ovarian cancer combined
True or False
2. Osteoporosis is only a problem for older Caucasian women.
Falsehttp://nof.org/articles/4c
OsteoporosisOsteoporosisis a pediatric condition is a pediatric condition
that manifests in that manifests in adulthood adulthood
Osteoporosis affects all populations:
•Women •Men •Young adults •Elderly
•• The amount of bone we The amount of bone we accumulate as a young adult accumulate as a young adult (generally age 30(generally age 30‐‐35)35)
•• About 90About 90‐‐98% is accumulated by 98% is accumulated by age 18age 18‐‐2020
Peak Bone Mass
• Heredity accounts for up to 75%• The remaining 25% is the result of:
– Physical activity– Nutrition – Hormonal status– Ethnicity – Lifestyle factors
Determinants of Peak Bone Mass
http://http://www.niams.nih.gov/Health_Info/Bone/Owww.niams.nih.gov/Health_Info/Bone/Osteoporosis/bone_mass.asp#asteoporosis/bone_mass.asp#a
Accessed October 21, 2011Accessed October 21, 2011
True or False
3. Osteoporosis is not serious.
False
http://nof.org/articles/4c
The Human CostDownward Spiral
70‐80 % of vertebral compression factors are silent
Neurological ConsiderationsSpinal Nerves Spinal Cord
True or False
4. If you drink a lot of milk and exercise, you are not at risk for osteoporosis.
Falsehttp://nof.org/articles/4c
OsteoporosisOsteoporosisKnows NONO boundaries
regardingAge,
Gender, Lifestyle or, Ethnicity
Some people are more at risk
than others but no one istotallyimmune
Risk Factorsfor
Osteoporosis
• Female• Family History• Post‐Menopausal – Natural or Surgical• Advanced Age• Caucasian or Asian• Delayed Puberty/Irregular Menstrual Cycles• Early Menopause• Men over age 75• Nulliparous‐having had no children• Small Boned
Non‐Modifiable Risk Factors
• Smoking• High Alcohol Intake• Caffeine (more than 2‐5 cups/day)• Sedentary Lifestyle/Over‐Exerciser• Men‐Low Testosterone• High Protein Diet (Meat)• Low Calcium Diet• Eating Disorders
Modifiable Risk Factors
Diseases and Conditions• AIDS/HIV• Ankylosing spondylitis• Blood and bone marrow
disorders• Breast cancer• Chronic obstructive
pulmonary disease (COPD), including emphysema
• Cushing’s syndrome• Inflammatory bowel
disease, including Crohn’s disease and ulcerative colitis
• Depression• Diabetes • Eating disorders, especially
anorexia nervosa• Female athlete triad
(includes loss of menstrual periods, an eating disorder and excessive exercise)
• Gastrectomy• Gastrointestinal bypass
procedures• Hyperparathyroidism• Hyperthyroidism• Kidney disease that is
chronic and long lasting
NOTE (from NOF)This list may not include all diseases and conditions that may cause
bone loss.
Diseases and Conditions Continued• Liver disease that is
severe, including biliary cirrhosis
• Lupus• Lymphoma and
leukemia• Malabsorption
syndromes, including celiac disease
• Multiple myeloma• Multiple sclerosis• Organ transplants• Parkinson’s disease
• Polio and post-polio syndrome
• Poor diet, including malnutrition
• Premature menopause• Prostate cancer• Rheumatoid arthritis• Scoliosis• Spinal cord injuries• Stroke • Thalassemia• Thyrotoxicosis• Weight loss
Medications• Aluminum-containing antacids• Antiseizure medicines (only some) such as Dilantin®
or Phenobarbital• Aromatase inhibitors such as Arimidex®, Aromasin®
and Femara®• Cancer chemotherapeutic drugs• Cyclosporine A and FK506 (Tacrolimus)• Gonadotropin releasing hormone (GnRH) such as
Lupron® and Zoladex®• Heparin• Lithium• Medroxyprogesterone acetate for contraception
(Depo-Provera®)• Methotrexate
Medications Continued
NOTEThis list may not include all medicines that may cause bone loss.
• Proton pump inhibitors (PPIs) such as Nexium®, Prevacid®and Prilosec®
• Selective serotonin reuptake inhibitors (SSRIs) such as Lexapro®, Prozac® and Zoloft®
• Steroids (glucocorticoids) such as cortisone and prednisone
• Tamoxifen® (premenopausal use)
• Anti-rejection drugs in organ-transplant patients
• Thiazolidinediones such as Actos® and Avandia®
• Thyroid hormones in excess
True or False
5. People with osteoporosis can feel their bones getting weaker.
Falsehttp://nof.org/articles/4c
FIRST SIGNS
•Fracture‐minimal trauma(e.g., Colles Fracture, Compression Fracture, Rib Fracture)
•Any fall from standing body height is a fracture of minimal trauma•Hyper‐Kyphosis •Loss of body height•Transparent skin•Periodontal disease•Back Pain•Protruding Abdomen
Vertebral Body
International Osteoporosis Foundation 2005Report of the Surgeon General on Bone Health Oct 2004
11www.nih.gov accessed November 30, 2011
• Bones of spine usually first to show signs of osteoporosis
• Only 20‐30% of all compression fractures are symptomatic
• 1 in 5 women will sustain a 2nd vertebral fracture within one year
RISK FOR FRACTURE
• History of Previous Fracture – Fracture Predicts Fracture
• Vision Problems• Deconditioning/Hypokinesis• Balance Problems• Tall Slim Build• Hip Fracture Immediate Family‐especially of the mother
• Inability to get out of a chair unaided• Being on one’s feet less than 4 hours per day
CLINICAL CONSEQUENCES OF SPINE FRACTURES
SYMPTOMS SIGNS FUNCTION FUTURE RISKSBack Pain (acute/chronic)Sleep DisturbanceAnxietyDepressionDecreased Self EsteemFear of future: Falls and FracturesReduced Quality of LifeEarly Satiety
Height LossKyphosisDecreased Lumbar LordosisProtuberant AbdomenReduced Lung FunctionWeight Loss
Impaired ADL’sDifficulty Fitting ClothesDifficulty Bending LiftingDescending Stairs Cooking
Increased Risk of FractureIncreased Risk of Death
Source: Papaioannou et al. 2002. Reprinted from The American Journal of Medicine, Diagnosis and management of vertebral fractures in elderly adults.113(3):220‐228
Bone Health and OsteoporosisA Report of the Surgeon General October 2004
True or False
6. An osteoporosis test is painful and exposes you to a lot of radiation.
Falsehttp://nof.org/articles/4c
Tests for Osteoporosis
X‐Ray NOT a test for osteoporosis
Diagnostic• Bone Mineral Density Test (BMD/DXA (DEXA)Scan)
• Lateral Vertebral Assessment
Screening Tools• Wrist Scan• QUS• Accudexa
Bone Mineral Density Test• Gold Standard• AP View Lumbar
Spine and Hip• Only Non‐Invasive
Test
World Health Organization
T Score• Compares a person’s bone density to a young adult reference point
• 1 to ‐1Normal Bone
• ‐1 to ‐2.5Osteopenia
• ‐2.5 & Below Osteoporosis• Below ‐2.5 in presence of fracture Severe Osteoporosis
• Compares person being tested with other persons his/her own age
• Used for:–Pre-Menopausal Women–Men <50 years old–Children
*World Health Organization
Z Score
When we return we will When we return we will begin to discuss treatment begin to discuss treatment
and exerciseand exercise
Muscle imbalance, Muscle imbalance, combined with loss of combined with loss of body height, can be a body height, can be a
contributor to back pain, contributor to back pain, postural instability, postural instability, balance deficit and balance deficit and
somatic complaints so somatic complaints so common in the elderly.common in the elderly.
Patterns of Postural ChangePatterns of Postural Change
Anatomy of the Human BodyHenry Gray, F.R.S.
27th Edition Lea & Febiger; Philadelphia, PA
Muscular ConsiderationsLower Abdominals Erector Spinae (ALL)
Pelvic Floor
The Lower Core
Richardson, Jull & Lee
Multifidus Rotatores
Hip Joint
• Stretch Hip Flexors (primarily) & Rotators
• Strengthen Gluteus Medius
Stretch and Strengthen
IS THE
KEY
Function FollowsForm
SEATED SEATED POSTUREPOSTURE
From THE CHAIR
by Galen CranzW.W. Norton & Co. NY, NY
From the local comics
Slouch Line Stretch
• http://www.drsarasolomon.com/wp‐content/uploads/2013/05/slouch‐overcorrect.jpg
• Imagine a line that stretches from your breast bone to your belly button
• Attempt to elongate the line
• Develop a cueing system to remind yourself to check your posture throughout the day
• When you find yourself hunched over, stretch the slouch line
• Do not fit every body type• Usually bilateral movement• Too much weight = compensatory incorrect movement
• Incomplete range of motion
Problems with Exercise Machines
• Most Exercise/Fitness/Activity Programs are one size fits all– ONE SIZE DOES NOT FIT ALL – Does not consider other medical and special conditions of the elderly
– Exacerbates patters of postural change– Increases risk of injury
Need for Change
Senior Classes
•• Seated position with poor body alignmentSeated position with poor body alignment
•• Taught by untrained personnelTaught by untrained personnel
•• Mostly flexion exercisesMostly flexion exercises
•• Weightlifting with no stabilizationWeightlifting with no stabilization
•• Strong and/or tight muscles get Strong and/or tight muscles get stronger stronger and and tightertighter
•• Weak and/or elongated muscles Weak and/or elongated muscles •• get weaker and more elongatedget weaker and more elongated
Guidelines for Exercise
Based on Reversing the
Patterns of Postural Change
General Considerations
• Strengthening/stabilization – Exercises precede flexibility
• Emphasize body mechanics throughout the program
• Return to re‐alignment routine when complications arise
• Flow sheet to track progress
Nachemson, A. The Load on Lumbar Disks in Different Positions of the Body. From the Department of Orthopaedic Surgery, University of Gothenburg, Gothenburg, Sweden
•• On The BackOn The Back--SupineSupine•• Side LyingSide Lying•• On The AbdomenOn The Abdomen--ProneProne•• Hands/KneesHands/Knees•• KneelingKneeling•• StandingStanding•• SittingSitting
Complete Exercise from Least to Most Compression
Consider the Forces of Gravity
GLADYSGLADYS
• Maintain Trunk Stability During Movement of Extremities
• Need for Back Supports—teach “Perch Posture”
• Exercise to Prevent, Arrest and/or Reverse Patterns of Postural Change
• Encourage standing—go beyond what you THINK you can do
Guidelines for Senior Classes
Kerr, D, Exercise effects on bone mass in postmenopausal women Kerr, D, Exercise effects on bone mass in postmenopausal women are siteare site‐‐specific and loadspecific and load‐‐dependent. J Bone Min Res 1996dependent. J Bone Min Res 1996
Guidelines Continued
• Warm Up‐‐Use Treadmill rather than Stationary Bicycle
• Stretch tight areas• Strengthen weak areas• More weight– fewer repetitions• During exercise, stabilize the back with core
control, positioning and/or support in optimal alignment
• Active Isolated Stretching seems ideally suited for older people
More Guidelines • Precede Weightlifting and Weight Training• With Flexibility Exercises(STRETCHING)• “If you haven’t got time to warm‐up, you haven’t got
time to work‐out”””••• “““Less Is More & More Is LessLess Is More & More Is LessLess Is More & More Is Less”””••• Complete Fewer ExercisesComplete Fewer ExercisesComplete Fewer Exercises••• Make Make Make Exercises Exercises Exercises CountCountCount••• Err on the Side of Err on the Side of Err on the Side of CautionCautionCaution••• When When When in doubt, donin doubt, donin doubt, don’’’ttt!!!••• Avoid hunching over during exercisesAvoid hunching over during exercisesAvoid hunching over during exercises••• “““Bottom LineBottom LineBottom Line”””––– Prevention of the NEXT fracturePrevention of the NEXT fracturePrevention of the NEXT fracture
People seem to be getting a message that any exercise is ok as long as they are up and moving.
This is NOT a good message.
Many activities contain risky and contraindicated movements and also can contribute to more postural and alignment problems.
YOGAYOGA
QI GONGQI GONG
TT’’AI CHIAI CHI
AEROBICSAEROBICS
WEIGHTSWEIGHTS
PILATESPILATES
GOLFGOLF TENNISTENNIS BOWLINGBOWLING
STAIR STEPPERSTAIR STEPPER
POOL CLASSES and SWIMMINGPOOL CLASSES and SWIMMING
CARDIOCARDIO
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
CONSIDERATIONCONSIDERATIONSS
FOR FOR ACTIVITIES ACTIVITIES
ANDANDEXERCISEEXERCISE
GENERALGENERALGUIDELINESGUIDELINES
• Pick something you LIKE to do• Look back to your childhood-
what gave you the most pleasure when you were young
• See if you can duplicate that feeling – bring PLAY back into your life
• Vary the forces on your bones• In any activity, maintain upper
body alignment, especially the back, as much as possible
• Cross-train
HAPPYBONES!
CONSIDERATIONCONSIDERATIONSS
FOR FOR ACTIVITIES ACTIVITIES
ANDANDEXERCISEEXERCISE
GENERALGENERALGUIDELINESGUIDELINES
• Be aware of upper body alignment as you make activity more complex
• Maintain stability and optimal spinal alignment as much as possible
• Do exercise program to strengthen back and hip stabilizers and to offset the repetitive-use patterns of the activity
• Exercise to Prevent, Arrest or Reverse Patterns of Postural Change
QI GONGQI GONG
TT’’AI CHIAI CHI
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
• Generally speaking, T’ai Chi is considered to be one of the most safe activities one can do
• Movements are slow and controlled
• Studies have shown improvement in balance in persons who do T’ai Chi
• Qi Gong is similar to T’ai Chi –more “free-flowing”
YOGAYOGA PILATESPILATES
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
• Both Yoga and Pilates contain many movements that would put people with low bone mass at risk for injury
• Important to modify movement for safety and to train with a teacher who is familiar and/or trained in the special needs of persons with osteoporosis
AEROBICSAEROBICS STAIR STAIR STEPPERSTEPPER
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
RUNNINGRUNNING
• Need for “Cardio” for cardiopulmonary system health
• Weightbearing and site specificity vary
• Consider odd-impact and random movement
• Maintain upper body alignment and be sure to add variety and site specific exercise to program
ElliptiGOElliptiGO
WALKINGWALKING
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
ADVANTAGES OF POLES•Promote a more upright posture•Weightbearing for upper extremities•Raises cardiac output•Promotes an image of ability rather than disability•Can do forward, backward, sideward with poles
POLE
WALKING
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
GYM & FITNESS CENTERGYM & FITNESS CENTER
• Before lifting any weight, make sure you can maintain trunk stability without weight
• More Weight – Fewer Reps is more osteogenic
• As you add weight, make certain you can maintain good form and stability
• Free weights are superior to machines because they add elements of balance and coordination not available with machines
POOL CLASSES POOL CLASSES SWIMMINGSWIMMING
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE
• You can use the resistance of the water for greater muscle contraction
• However, exercise in the pool has little weight-bearing effect and it is recommended that, for bone health, a person work towards exercising also out of the pool
• For better posture, emphasize side stroke and back stroke and not just the freestyle that people usually do
• Water walking-forward, backward, sideward – exercise to prevent, arrest, reverse POPC
GOLFGOLF
TENNISTENNIS
BOWLINGBOWLING
CONSIDERATIONSCONSIDERATIONSFOR FOR
ACTIVITIES ACTIVITIES ANDAND
EXERCISEEXERCISE• The “big-three” in terms
of stress to the spine• Consider getting training
for better technique• Do site-specific exercise
to strengthen back and reduce risk of injury
• Consider wearing Spinomed IV to help protect and strengthen back during activity
Seated Rows Emphasize Scapular
Retraction
Overhead PressOverhead Press
Good Exercises for Bone HealthGood Exercises for Bone Health
Shoulder FlexionShoulder Flexion
Shoulder AbductionShoulder Abduction
DEFINITELY AVOIDDEFINITELY AVOIDAbdominal Crunches or Sit-Ups
Abdominal Roll Ups
Abdominal MachineBrings Ribcage towards Pelvis
Single or Double Knee to Chest
Toe Touches Seated or Standing
Avoid or Use CautionAvoid or Use Caution
Part of Part of a a comprehensive comprehensive approach approach to the to the
management management of of patients patients with osteoporosis andwith osteoporosis and//or or compression fracture compression fracture
Bracing
PURPOSES OF BRACINGPURPOSES OF BRACING•Support and protection•Control of motion•Prevent fracture•Allow weight-bearing activities
Bracing usually associated with weakeningof the body part it is designed to protect
SPINOMED
Spinal Orthosis for OsteoporosisSpinomed IV
• Ordered by Physician• Fit by Orthotist – orthotist should make sure patient understands how to don/doff Spinomed before leaving the office; may need modifications in future; Physical Therapist can also become fitters
• Physician, Orthotist, Physical Therapist, & Patient work together forultimate best fit and satisfaction
• Covered by Medicare
The Spinomed®
Spinal Orthosis for Osteoporosis
After TreatmentNo Brace
After TreatmentClam Shell
After TreatmentSpinomed
Modalities and Special Modalities and Special Treatment Treatment in Physical Therapyin Physical Therapy
ActiveActive--Isolated Isolated StretchingStretching
MassageMassage
Myofascial Myofascial ReleaseReleaseSpecific StretchesSpecific Stretches
Arm Pull Arm Pull Diaphragm and Diaphragm and
Thoracic ReleasesThoracic ReleasesCervical TractionCervical Traction
Moist HeatMoist HeatIceIce
Ice MassageIce Massage
Electrical Electrical StimulationStimulation
UltrasoundUltrasound
Emotional Stages of OsteoporosisDENIAL
"No way ‐ can't be!" “They’ve got my report mixed up with someone else’s”ANGER
"Darn! I am so angry: I did everything right and I get OSTEOPOROSIS anyway?!??!!!"
NEGOTIATING/BARGAINING"So ... it's not so bad (osteopenia, borderline) .. and, if I elongate A LOT, I can still do those forward bends, sidebends and twists right? Maybe I
just won't round quite so much...."DEPRESSION
"I am so down about this ... I have this condition for the rest of my life. I just won't move at all cause I could break a bone"
ACCEPTANCE"Ok, I have osteoporosis. But I'm going to find a way to do yoga and
exercise because I love it ...Just have to find a way to do it safely”
TAKE TAKE ACTION ACTION NOW!NOW!!!
Best way to diffuse the worldBest way to diffuse the world’’ss
Osteoporosis Osteoporosis ttime ime bbombomb
is tois to
WHATWHATISIS
YOURYOURNEXTNEXTSTEP?STEP?
Better Bone HealthBetter Bone Health••ItIt’’s s Never Too Never Too LateLate••Stop Stop Focusing on T ScoreFocusing on T Score••Think Bone Quality InsteadThink Bone Quality Instead••Eat Healthy FoodEat Healthy Food••Get Restful Sleep & RelaxationGet Restful Sleep & Relaxation••Avoid Toxins as Much as PossibleAvoid Toxins as Much as Possible••Diminish Negativity of ThoughtDiminish Negativity of Thought••Engage in Engage in Weight Bearing Exercise Weight Bearing Exercise DailyDaily••Stay Stay Well Hydrated Well Hydrated (Weigh yourself. (Weigh yourself. Divide by Divide by ½½. Use that # as the # of ounces you . Use that # as the # of ounces you should should drink daily. Divide that # by 8 to get # of 8 oz glasses per drink daily. Divide that # by 8 to get # of 8 oz glasses per day.)day.)
©The Meeks Institute 2011
REMEMBERREMEMBER……..
ItIt’’s not thes not theAGEAGE
ItIt’’s thes theMILEAGEMILEAGE
ItIt’’s Never Too Early s Never Too Early or Too Late or Too Late
to do something about to do something about
BONE BONE HEALTHHEALTH
Further information
• National Osteoporosis Foundation:
http://nof.org/
• Chuck Ottavio, PT• Orthopedic Physical Therapy of Northern Virginia
• 703‐354‐1230
**These slides were modified from the work of Sara Meeks PT, MS, GCS