As a Physical Therapist you are in an ideal position to write an exercise prescription for osteoporosis. Today I am going to address the following question: Do we safely and effectively challenge our clients enough to prevent bone loss?
Exercise Prescription for Osteoporosis
I discuss some of the latest research on exercise and aging, and share my treatment options for my own clients and what I observe from Physical Therapists who have taken my course, Working with Osteoporosis and Osteopenia.
Today’s Reading Material is at the bottom of this page.
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“Working with Osteoporosis and Osteopenia has inspired me to become more involved in the area of Osteoporosis. Margaret is extremely knowledgeable about Osteoporosis and an excellent instructor. She demonstrates the important role of Physiotherapy in the prevention of fractures and promotion of overall health and well-being.” — Sherri Hayes, Physiotherapist, Active Body Physical Therapy, LaSalle ON
Hi, welcome back to MelioGuide. Today we’re going to demystify exercise prescription as it relates to bone health. We’re going to start with the recommendations put forth by the American College of Sports Medicine in regards to adults. The recommendations are that adults do some form of cardiovascular exercise, 3 to 5 times a week, for 30 to 60 minutes.
Strength Training Routine
And so for our strength training, the recommendations are two to three times a week, covering a broad spectrum of muscle groups. So looking at a 45-minute routine with a number of different muscle groups in the bodies because we know that un
less you work on the muscles that are attached to those bones, those bones are not going to get stronger.
Intensity of Strength Training
Now the intensity is what’s new for most of the therapists that I’ve been teaching. The intensity needs to be in the range of 80% of 1 rep max. So one rep max means if you’re going to take a healthy, young individual and load them up, and load them up, and see what is the most weight that they can take one time, they would be strength training at 80% of that weight.
Now you and I know, with the clients that we see that have multiple co-morbidities, or that are more frail, or have not been exercising at some time, we don’t push somebody to 80%, 1 rep max, at least not at the beginning. And so with my clientele, it may take up to six months before they’re working as hard as they need to to stimulate bone.
But exercise is a lifetime pursuit, and so giving them that time that they need to build up the mitochondrial elements of the cell, to build up the microcapillaries, and to have them eventually lift to the level that they need to lift to build bone is the wise thing to do. And so we’ll talk more in terms of the prescription put forth in the MelioGuide.
Do We Push our Clients hard Enough?
So in regards to pushing your clients, there is an interesting talk at the World Physical Therapy Conference in Vancouver several years ago, and they were looking at bone health in the stroke population.
And one of the resounding messages that they’re giving was we’re not pushing our clients hard enough post-stroke recovery. So we look at the neural facilitation, but we need to be more aggressive in terms of building muscle, which then stimulates the bone to build as well. Because in strokes, as in many co-morbidities, there is a lost of bone when there’s a lost of activity.
Recent Study: Journal of Strength and Conditioning
There’s a recent study in the Journal of Strength and Conditioning that looked at healthy individuals. And they took female population, one group was in the 25-age bracket, and the other was in the 65-age bracket. And they put them on very similar strength training programs, and they looked at their potential for improving strength.
And there was virtually no difference whether the individuals, women, were 25 or 65. So with your healthier clients, you can definitely push a 65-year-old as hard as you would push a 25-year-old, and giving them opportunities to build that stamina that they can build, and you should not use age as a discriminating factor.
Exercise Options for Osteoporosis
So what are some of the exercise options for individuals with low-bone density, osteoporosis or osteopenia? Well, at Chapters, if you go and you scour the shelves at Chapters, there are a lot of exercise books in relation to bone health, but most of these books are written by nutritionists or doctors. And the Chapter that’s included on exercises was really put in there as an afterthought.
And I have a little story to share, but there was a book signing, and I won’t declare which book it was, but it had to do with bone health. And because one of my clients happen to know the author, the M.D. who had signed off on this book, he said, “Oh, you really should go and meet her. Very neat individual.” So when I did go and meet her at the book signing, I brought up my concerns in regards to the exercise chapter in the book because one of the exercises had individuals actually standing on exercise balls without any guidance whatsoever, but just standing on exercise balls.
And I said, “That’s a rather risky thing to do, blatantly putting anybody, whether they’re a high fracture risk or not, to have them standing on balls.” And her response to me was, “Oh, I actually never looked at the chapter on exercise.” And so oftentimes, these books are written to sell and, again, they’re wanting to round out the books so they’ll throw in something on exercise, but there isn’t an exercise expert that’s involved in creating that book. And that’s where MelioGuide differs.
And so MelioGuide, I like to think that, although we’re never an expert and learning every day, and I learn from my clients every day, that my knowledge of physical therapy and my knowledge as a certified strength and conditioning specialist has allowed me to put together what I think is a very safe exercise program.
Four Tiered Exercise Program
It’s not a one size fits all, it’s a four tiered exercise program. So we start at a beginner level, individuals can move up to active, to more athletic, and then to an elite level of program. And throughout the program, we don’t focus just on strength or just on balance or just on cardio, but all the facets of fitness are addressed.
So we have a section addressing specifically strength exercises, balance exercises, flexibility exercises, that although we know flexibility is not an imperative component in terms of bone health itself, it’s imperative that someone be flexible enough to be able to move with good body mechanics. And so how to stretch safely is very important because how we move throughout the day and activities of daily living has a very strong focus in the program as well. But how we move and how we teach somebody to move is incredibly important in the exercise programs so that there is the carryover to keep the spine state.
Dr Sinaki Mayo Clinic Osteoporosis Study
When it comes to exercise, a lot of you, I hope many of you, are now familiar with Doctor Sinaki’s study that was produced in 1984, looking at the contraindication of flexion exercises in the program for individuals with osteoporosis. And that recommendation…we saw through her studies that doing flexion exercises led to significant increase in fracture rates. And doing extension exercises where you’re stimulating the back extensor muscles led to a significant reduction in fracture rates.
But it wasn’t until recently that we really understood more why that occurred. It was very exciting for me to be able to speak to one of the Swiss researchers at the October 2010 American Society for Bone and Mineral Research Conference that was held in Toronto. And he had looked at the morphology of the lumbar spine, specifically one lumbar vertebrae. And he found that the trabeculae was less dense in the anterior part of the vertebral body.
So that made a lot more sense in terms of why, when individuals do repeated flexion exercises, why does the anterior vertebral body give way and compress when someone already has weakened bone? So that was very interesting. The blog that we wrote in regards to that interview that I had with that individual and his research findings can be found at the link below.
Study by Charles Turner
I strongly encourage you to read the paper written by Charles Turner, and the link is below as well, on where he looked at bone strength. And in his paper, he describes bone strength as it relates to mechanical loading or the accretion or strengthening of bone through mechanical loading. Because we know that with exercise, we can get a small increase in bone-mineral density, especially in the post-menopausal years, unlike a drug that can have significant increase in bone-mineral density, but it’s the type of bone and the quality of the bone that I’m most concerned about and my clients are concerned about.
So with mechanical loading, he found that even just a 5% to 8% bone mineral density change led to a 60% increase in bone strength, and it led to 100% decrease in fracture rates. So that to me was very significant. So even small gains in bone-mineral density, we know through mechanical loading, through exercise, can lead to significant improvement in bone strength. And so the link to that article is below as well.
My Motivation for Creating MelioGuide
One of my motivations when creating MelioGuide was that if you go to any of the osteoporosis websites, or you will ask anybody who has been recently diagnosed with osteoporosis what the recommendations in regards to exercise they’ve been given is, and they all say, “Well, I’ve read and my doctors told me I really need to do strength training and weight bearing.”
But that’s the entire guidance that they get. And God knows I’ve seen so many unsafe strength training exercises, and not all weight bearing exercises are created equal. And so MelioGuide provides individuals with a very safe, strength training programs. And in regards to weight bearing, this is where cardiovascular exercises fall into place. And we’ll provide guidance in terms of high recommendations, moderate recommendations and low-level recommendations in terms of bone building.
Many of my clients, when they call me up, “I have already done a lot of search on osteoporosis,” and they have great questions when it comes exercise. They also have really good questions in regards to nutrition and drugs. And so although as exercise specialists, we are not nutritionists and we are not pharmacists, but we should have some basic understanding of the drug therapies that are used with low bone density and osteoporosis. And we should have some basic understanding of the recommendations for calcium, for vitamin D because our clients will ask your advice, and you do need to have an opinion.
And so I’ll give you a little overview on nutrition and pharmacotherapy tomorrow. Looking forward to see you then.
Today’s Reading Material
Here are the articles and research reports I encourage you to review after viewing today’s lesson:
See you tomorrow.
Physical Therapist, Certified Strength & Conditioning Specialist
Physical Therapy Continuing Education
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Enjoyed the program and looking forward to reading the references. You probably aren’t aware though, that the video cuts off before the end just when you were mentioning the Melioguide approach to weight-bearing e ercise.
Hi Betty: Thanks for catching that. I have fixed the video and reposted (with the transcript).
every day i learn a new thing about OP
I’m not a PT but I do have osteoporosis and I’m so glad I found Melioguide. I’m working through the Active Level in Exercise for Better Bones — it’s just right the amount of physical challenge for me — but I truly appreciate these insights into the ‘why’ of what’s involved. Also, as someone who knew just enough to seriously question whether SAFETY was properly addressed in more-or-less standard, popularized exercise programs, I now have a level of confidence in the exercises I do. For me, that enhances my discipline and drive. It’s a win-win. Thank you!
Richard Martin says