Physical Therapy for Osteoporosis

A little more about me. My career journey started in St. John’s, Newfoundland. Although I am a McGill graduate, I went over to St. John’s did rotations in ICU, NICU, and neuro rehab. Then across the country into young adult long term care.

Life brought me to middle of Canada in Toronto in peds, ortho, pulmonary rehab, and then onwards to five years in the area of health, fitness and safety in a large corporation.Then went down and worked in California for nine years where I went back into a hospital setting in spinal cord rehab, burns, inpatient, outpatient ortho, neuro, and then finally brought the family back to Canada in Ottawa, which is where we are currently located and where my clinic is located and the head office for MelioGuide.com.

So one thing in reflecting on my career is that I came to realize is that the one common denominator of all my clients is that they had a skeletal system. So often when I was addressing their stroke or was addressing the range of motion in the burn client I wasn’t always considering their skeletal system.

And so that’s the purpose of today’s talk is for you, regardless of the setting that you are working in, is to give a deeper consideration to your client’s health and that deeper consideration is their bones.

Bone Physiology

I’m not going to spend a lot of time looking at bone physiology but the one thing I do want you to think about is our bones undergo a constant modelling and remodelling and if my big toe was a good representation of my skeleton at 50, my big toe would take ten years to totally regenerate.

Fortunately, it’s only going to take about a year. It’s about six months old since my injury in this photo but the osteoblasts and osteoclasts are always working to make adaptations to our skeleton based on the stresses of the skeleton.In our youth there’s a whole vibrant time of going modelling which then starts to enter a more remodelling phase.

In today’s talk I’m really wanting the message to get across of the different stages of life. In thinking of those different stages and keep getting the idea that would stick in your mind. With my menopause I went back and thought what movie sticks in my mind. Eat, Pray, Love sticks in my mind.

Nutrition

Let’s look at bone health with that same concept. Eat, Move and Greed. The nutrition that we take into our body. What we do in terms of skeletal movement and challenges to our bones. Then what is happening to our hormones and as physical therapists we are more in control of asking somebody what their menstrual cycle is like. If their sexual urges are more natural. We are going to be looking more at the estrogen/testosterone.

There are many other hormones that impact bone health but primarily as physical therapists those are the ones that we should at the very least be paying attention to.

In today’s talk we look at bone health from utero to university, from kids to careers and visit big chunks of time in our life that the next one is post menopause to post-op.

We’re going to look at these as stages of bone health through my eyes because these are clients that I got to see. Let me share with you some of their case histories. Their photos are obviously not truly them except for some of the clients but to protect their health.

Let’s start with the first picture of bone health, from utero to university.

Two Clients: Molly and Kim

Two clients that I want to bring up, Molly, who was presented to me with upper back pain and Kim, who came to see me because of knee and hip pain, mostly in her sport which was basketball. Both these young ladies were in their late teens when I first saw them. Their findings on first observation was that Molly was on a vegan diet.

I’m not going to go into the positives and negatives of each because this will take an hour long talk but know that each one of the things that I’m bringing up is because these things have either a positive or negative impact on bone health.

Kim was on a low protein diet, no omega 3. Both of these diets have challenges when it comes to bone health. Molly was working with a personal trainer which technically should have been a positive thing except the type of exercises that she was being given that were inappropriate.

Kim was doing daily basketball practice and she had games on weekend which is great for your bones except that there was a disproportionate amount of energy output for her energy input. She was just having way too much breaking down, not enough anti-inflammatories in her diet to support the level of intensity that she was training at.

Molly had irregular menstrual periods. Kim was on Depro Provera birth control which causes cessation of menstrual periods. If you have a female who is entering a female athlete triad type scenario you don’t actually know if their body weight is problematic for their cycle and whether or not their entering in amenorrhoea as well, as the drugs have other issues.

Molly presented in a teen with a cephalic posture that was not able to be corrected so it’s quite concerning and Kim had good spinal alignment but with high level sports movements. She had poor hip and knee alignment.

I had some serious concerns with Molly. I did send her back to her doctors and ask for a spinal x-ray before seeing her again. Sure enough the x-ray came back with fractures at T6, 7, and 8. She went on to have a bone mineral density which showed severe osteoporosis and yes, she was still in her teens. Then went on within two weeks time to have vertebroplasties done at T6, 7, and 8.

Let’s look at the bone health from utero to university for Molly and for Kim. Molly’s mother wears religious coverings significant in meanings in regards to vitamin D. Kim’s mom is a physical therapist, outdoorsy, a little more ability to absorb the Vitamin D. Molly was premature, whereas Kim was a full term baby. Very different in terms of the health of the bone even years later.

Molly had benign hypotonia whereas Kim had normal growth and development. Because of the hypotonia Molly had very limited outdoor playing. No sports. She didn’t actually start walking until the age of two and had sustained an ankle fracture when she had started walking. Kim was very active in very many sports.

Molly didn’t start her period until she was 14 whereas Kim started at a younger age, at 11. Given the number of years within a woman’s lifespan that they’ve had their periods is going to positively impact bone health.

The last thing Molly had a fracture at her elbow and at the patella from falling on ice. So simple which is still considered a puglian fracture when she was 15. Kim because of the concern, as I mentioned earlier, in regards to the female athlete triad and although she had a lot of good bone health leading up to her late teens, she was starting to have some negative changes and had a hairline fracture at 17.

What was the intervention for both of these young ladies? Molly, as I mentioned, did have vertebroplasty.

Following her vertebroplasty she did work with a nutritionist. The exercise intervention was very much around not modifying her daily activities, isometrics and gradually we introduced more weight bearing and strength training.

An important component for Molly was the education to gain weight, to maintain her weight, to maintain her normal periods so that she’d have not only the nutrition, the eat. Not only the move, the exercise but also the greed. The hormones working in her favour for optimizing her bone health.

Kim was really quick in terms of modifying. I was comfortable in looking at her protein requirements, her omega 3 requirements. She upped those.

She modified some of the exercises we were giving to her. We worked on hip and knee alignment and she’s done great. She’s made the provincial team and one other recommendation for her bone health was to make a consideration about the birth control of choice that she made so that it would not negatively affect her bone health.

Here’s a great example of two young women where as a standard physical therapist we would see them, take care of their issues but not always regard the bone health. In order to allow these two young ladies to enter the next phase of life with as much bone in their bank as possible, I think we need to make clear definitions.

We are musculo-skeletal specialists and we need to look at those skeletons. Let’s move on into the next phase of life where eat, move and greed is very important from kids to careers.

A really busy time in a woman’s life where whatever they choose to eat. They are really often making meals on the run and they’re not only making them for themselves but for their family. The movement is very limited to activities with kids or activities when you’re running to or from work. Then greed the effect of pregnancy and lactation on hormones and then obviously the effect on bones.

I’m going to introduce to you Simone who is a client that I thought wow, she’s a client who has really got it together. She’s got a well balanced diet. She was exercising 60-90 minutes a day. She had regular menstrual periods. Birth control was taken care of by her husband who had had a vasectomy. But she came to see me with vertebral compression fractures, when I first saw her.

The vertebral compression fractures were as a result of tobogganing with her kids. Wow, then you start looking back. What is it that is missed in this ladies bone health? Let’s go back in her bone remodelling.
She had three fractures as a child. Obviously, no one noticed that as a red flag so there was no intervention done other than taking care of the fractures, healing and things went on.

She was undiagnosed until her late 40’s that she had had celiac. So many years really her life of not absorbing all of her nutrients.

She had had three children which wasn’t an issue except that she had them later on in life and she had had them fairly close together. She had not only the years she was pregnant but she also nursed each of them for two years.

She had a long period of time and then she didn’t have a lot of time before going into menopause. These are things that affect bone modelling. Her activity it was great that she was active so much but most of her activity was around swimming which we know it isn’t as weight bearing as it could be and walking her dog or her dog walking her and that was a really brisk pace.

We know we need a brisk pace in order to affect bone health, at least at the level of the hip.

Last thing, an important thing, as a primary school teacher Simone was always bending forward. A lot more weight bearing on the interior vertebral body of the vertebrae and we know in the interior vertebral body there are less trabeculae than in the posterior vertebral body so there’s already possibly some micro-fracturing occurring but was just stressed to a much higher level with the tobogganing an caused a vertebral fracture.

My intervention initially with Simone was pain management, teaching her body mechanics both for safety and for pain management. Then we went on to gait retraining and exercise hoping that she will have enough time to rebuild her bone back. She’s going to have to have some intervention. Possibly some HRT (Hormone Replacement Therapy).

Things she’ll have to discuss with her doctor but bringing her into the next phase of life, the post menopause to post operative period because now we know that just with strictly loss of estrogen this is a significant time where people actually start thinking about low bone health, low bone density, osteoporosis because of the decrease in estrogen.

It’s also a time in people’s lives in their 50s, things start to break down and we haven’t been optimizing our healthy choices and so medications get introduced and core morbidities happen.

There are many medications that have a lot of influence on bones. The Depro provera I mentioned. Glucocorticosteroids, medication for anti-seizures, medication chemo therapy meds. There’s a long list of medication that can have a negative impact on our bones.

Just to put any other assault to our body that affects movements, so strokes, Parkinson’s, COPD, so many things that will affect the ability to stress our bones that then obviously will then lead to lower bone density.

Food intake, most people get older, they’re not preparing foods for their family anymore. They’re just making small meals. They might not be ingesting as much protein, calcium, the nutrients, they’re not out in the sun as much so their vitamin D absorption as well as their aging skin doesn’t absorb as much vitamin D.

The weight bearing and strength training if it has not been part of their life before a lot of people don’t start taking it on. But, it’s such an important thing to do especially as we enter this last phase of life.

Lastly, in this stage, we most of us as physical therapists are thinking fall prevention, great but we need to be considering at a deeper level all the other things that we brought up.

If you haven’t met Babs before, Babs is somebody who I feature a lot on my website and in my blogs and she’s a dynamic 97 year old. We’ve worked a lot through strength training, flexibility, balance.

With Babs she was a unique case study where I got to work with her twice a week. We worked on agility training. Similar to what you do with football players and the progression was just phenomenal. When we started to introduce this to local hospitals, and giving them services around Ottawa and Montreal. The therapists that have been using this on a daily basis have just found it really exciting and finding really good results with their clients and fun to do for them as well.

I encourage you to think about your bone health, whether your clients are in the stages in utero to university, kids to careers, or post menopause to post-op, learn a little bit more. Come and take my free course; melioguide.com.

Come to this page with hundreds of articles that you can search for in the search box. Click on the free course and encourage you as a musculo-skeletal specialist to take into consideration the skeleton of your patients. Thank you very much for tuning into MelioGuide today. It was a pleasure sharing this with you.