Safe exercise and osteoporosis

Safe exercise and osteoporosis

Thursday 5th October, Galgorm Manor,

Ballymena

Osteoporosis Team Lagan Valley Hospital

The team

Dr Rosemary Kelly – Consultant in Care for the Elderly Lorraine McConnell - Osteoporosis Nurse

Ronan Scullion – Physiotherapist

Joined today by Sarah Leyland – Osteoporosis Nurse Consultant

Aims of the workshop

Give simple guidance on which exercises are useful and which are not for people with Osteopenia/Osteoporosis

Aim of the workshop

Case scenarios

Practical session

Audience participation

Problems in Osteopenic/ Osteoporotic Patient group

• Stiffness

• Postural issues

• Weakness – both skeletal and muscular

• Falls

• Fractures

• Pain

• General advice – “What should I do/not do?”

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Healthy bone Osteoporotic bone

Osteoporosis is a silent condition until break

Osteoporosis is silent. It is not painful

It is the fracture that is painful

Osteoporosis in the absence of fractures gives no symptoms

Common sites of fracture

Spine

Neck of femur

Wrist

DefinitionWhich bones get osteoporosis?

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Vertebral compression fractures (multiple and severe)

• Back pain – acute and chronic

• Height loss and curvature

• Activities of daily living affected; eating, breathing and mobility

© IOF developed with Prof. Dieter Felsenberg for Stop the Stoop campaign

Prevention of osteoporosis

Things you cannot fix

non modifiable risk factors

Age, gender, family history

Modifiable risk factors

WEIGHT

Women with very low body weight have twice the rate of fractures

Modifiable risk factors

SMOKING

Women – greater risk of hip fractureBone density declines by a further 2% per decade in smokersMen – lower BMD at hip

Modifiable risk factors

DIETLink with pre-menopausal intake and BMDCurrent calcium intake weakly associated with BMD

Modifiable risk factors

EXERCISEPositive correlation between BMD and activity levels in young femalesAlso seen in females 50-75years

Ronan Scullion

Physiotherapist

What is exercise? • Physical activity defined as -

any bodily movement produced by skeletal muscles that requires energy expenditure

• Physical activity benefits - reduce risk of cardiovascular diseases, diabetes, colon and breast cancer, and depression; adequate levels of physical activity decrease the risk of hip or vertebral fracture and help control weight

• Exercise is -planned/structured physical activity with an ultimate goal

Why Exercise?• Bone is our body’s scaffolding and adapts to different stresses – muscular pull

and loading stress

• Muscle pulls on bone in order to produce movement - being a living tissue, bone adapts to the muscular pull by growing

• It does this all the time – therefore, any increase in muscle activity will result in increases in bone strength

• Likewise when bone bears weight it adapts to this loading; increased load - within reason - results in increased bone density

• Exercise can also promote muscle strengthening and joint mobility/stability

Types of Exercise • Weight-bearing – any exercise in which you support your own

body weight; can be low/high impact - needs to be selected based on the individual and their diagnosis

• Muscle strengthening – can be directed to improve specific area of strength or balance/joint support e.g. spinal

• Postural exercises

• Mobility exercises – joint specific e.g. spinal; post-fracture

• Balance re-education

Aims of Exercise – address the individuals problems• Relieve stiffness

• Improve posture

• Increase muscle/bone strength

• Reduce risk of a fall/improve balance

• Prevent fractures/manage post-fracture

• Reduce or control pain

• Increase general fitness/improve mental health

Getting started• Must be exercise i.e. planned and structured

• Regular to get best benefits – 30 minutes a day, 5 times per week – 2 days per week should include muscle strengthening

• Important to start slowly and build up – warm up

• Be specific – meet the individuals goals, within the scope of their ability/diagnosis/PMHx

• Benefits outweigh risks – fractures/falls

Specifics – low risk • Whilst swimming and cycling will improve mobility, strength and

cardiovascular health, they are non-weight bearing exercises so will not build bone density

• Aim brisk walking, stair climbing, jumping, skipping, weight programs – exercise classes that incorporate high impact weight-bearing, flexibility and balance/co-ordination exercises

• Pain management – hydrotherapy, mobility/strengthening exercises

• Posture - sitting, standing, lying; Pilates, Tai-Chi, Yoga; regularly break up prolonged postures

Low risk - avoid• High impact exercises at beginning

• Trunk flexion – toe touching

• Trunk twisting, especially when holding weight e.g. kettlebells, some simple ADL’s

• Lifting

• Activities that may increase falls risk e.g. horse riding

Specifics – medium risk• Similar to low risk with focus on strength training with body weight

• Weight-bearing aerobic exercises – side-stepping, knee lifting, hip abductions, dancing

• Flexibility exercises

• Focus on balance and gait re-education

Medium risk - avoid• High impact, fast-moving exercises – jumping,

running, skipping

• Exercises in which you bend forward and twist – toe touches, sit-ups

Specifics – high risk• Focus is on reducing risk of fall/management post-

fracture

• Balance exercises – narrow base, single leg, heel toe walk; Tai-Chi

• Strengthening – hip/ankle specific

• Hydrotherapy – pain management, mobility, strengthening

Pitfalls • Bending – e.g. toe touches; increased risk of vertebral fractures due to

uneven vertebrae loading

• Twisting – particularly when holding weight; risk of spinal fractures/falls

• Combined flexion, rotation and side flexion

• Trampolining, walking poles, technology – no evidence

• Manual therapy - increased risk of vertebral fractures

• Lumbar jackets - increased fracture risk

• Exercise programme needs to be specific to the individual – respect their baseline, diagnosis, PMHx

Useful resources• NHS Choices – “Are you at risk of falling?”

http://www.nhs.uk/Livewell/healthy-bones/Pages/falls-risk-assessment-tool.aspx

• Age UK – “Staying Steady”

http://www.ageuk.org.uk/Documents/EN-GB/Information-guides/AgeUKIG14_staying_steady_inf.pdf?dtrk=true

• Age UK/CSP – “Get Up and Go”

http://www.csp.org.uk/publications/get-go-guide-staying-steady

• National Osteoporosis Society – “Exercise and Osteoporosis”

https://nos.org.uk/media/98591/exercise-osteo-october-2016.pdf

Ongoing research….

• Sarah Leyland (Nurse Consultant)

Case scenarios

Sr McConnell

Case 1

45 year old

Pre menopausal

Osteopenia on Xray

Has never been to a gym before

Has a desk job

Types of exercise

High impact Low impact Muscle strength

dancing Elliptical machine

Lift weights

hiking Low impact aerobics

jogging Stair step machine

Elastic exercise bands

running Fast walking on a treadmill

Stair climbing Fast walking outside

Weight machine

Tennis

Standing

Case scenario 2

56 year old

Plays golf

DXA T score -3.5

No vertebral fractures on Xray

Types of exercise

High impact Low impact Muscle strength

dancing Elliptical machine

Lift weights

hiking Low impact aerobics

jogging Stair step machine

Elastic exercise bands

running Fast walking on a treadmill

Stair climbing Fast walking outside

Weight machine

Tennis

Standing

Case scenario 3

82 year old

Lives alone at home

3 thoracic vertebra fractured on x-ray

T score -2.8

Types of exercise

High impact Low impact Muscle strength

dancing Elliptical machine

Lift weights

hiking Low impact aerobics

jogging Stair step machine

Elastic exercise bands

running Fast walking on a treadmill

Stair climbing Fast walking outside

Weight machine

Tennis

Standing

Case scenario 4

78 year old man keen gardener

Vertebral osteoporosis

Can he go on holiday

What exercise can he do

Types of exercise

High impact Low impact Muscle strength

dancing Elliptical machine

Lift weights

hiking Low impact aerobics

jogging Stair step machine

Elastic exercise bands

running Fast walking on a treadmill

Stair climbing Fast walking outside

Weight machine

Tennis

Standing

Guest speaker – Sarah Leyland Discuss common queries to helpline

Discuss ongoing development of protocols – Strong, Steady, Safe

A new focus at the charity…

Sarah Leyland Nurse Consultant September 2017

STRONG, STRAIGHT

STEADY

Will exercise strengthen my bones ? What do I need for my hip, my spine, my wrists?

What types, how often, for how long and how ‘intense’? (Will walking strengthen my spinal bones?) If I have osteoporosis on a scan will this exercise be safe or cause fractures? Can I jump and jog? What if I osteopenia?

Can I carry on with normal daily activities and movements such as bending down?What about golf, Pilates, yoga or horse riding – will they cause me to fracture?

Common helpline questions

Lack of certainty (HP and people with fractures or at risk)

Lack of evidence

No consistent messages consensus – confusion for people especially those with a ‘diagnosis’ or fractures

Are fit/well people doing enough or the right type of exercise ?

Are those with spinal fractures getting exercise advice to help with pain and posture?

Are people frightened into less or no activity?

Are those who are less mobile or well getting help to get started?

Exercise and physical activitythe issues

STRONG, STRAIGHT STEADYSTRONG - exercise and physical activity that will strengthen bones safelySTRAIGHT- moving, lifting and living safely with osteoporosis- help with pain and posture after spinal fracturesSTEADY - balance and muscle strength to stop you falling

A new project at the charity..

What do we want to produce?

Recommendations and information resources for people/patients in different formats

Consensus statement for health professionals

On safe, effective exercise and physical activity to prevent fragility fractures in those at risk

Guidance for physios and exercise professionals from Chartered Society of Physiotherapists (CSP)to include all physiotherapy interventions for spinal fractures

Training modules for HPs

Stamp of approval for HPs

completing module

Community or hospital based

exercise classes

Tool kit for HPs to set up exercise sessions

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Your questions ?

Conclusions

We all need to exercise .

Ida Keeling at 97 becomes oldest American female sprinter -

Conclusion

Dr Kelly

Questions