bone health 101

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.


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.


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.


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



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



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



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



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



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



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



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

bone health 101

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