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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