Osteoporosis

Neil - Doctor of PhysiotherapyBlog, Exercise, Health, Osteoporosis, Physiotherapy0 Comments

Over the past couple of weeks, I’ve shared a number of articles about physical activity and exercise(s) specifically in relation to older adults.

Listening to an episode of the Senior Rehab Podcast with Margaret Martin from March 14 last year (2016) ‘How to fight osteoporosis & build stronger bodies’ (here), Margaret told podcast host Dustin Jones, “anything that brings the spine into flexion” was a risk of spinal fracture for anyone with osteoporosis. I was driving at the time and nearly choked on my breakfast shake.

In a short twitter thread with Justin and Neil Maltby that followed, I was introduced to Dr Lora Giangregorio (PhD) from the Department of Kinesiology at the University of Waterloo in Canada. Dr Giangregorio subsequently sent me some articles and a 2014 consensus statement written with Prof Stuart McGill and published in Osteoporosis International.

On Twitter, I questioned if avoiding all flexion was an appropriate solution and what the implication may be for developing kinesiophobia (the fear of moving, specifically bending forward) and function. Dr Giangregorio suggested that hyperextension (bending backwards) was also associated with fracture too, and that exercise prescription in this higher-risk population needed a sensible approach without demonising forward or backward bending, as avoiding either is simply impossible and likely problematic with potential deconditioning. “We need to listen and build confidence and control.”

While an increased thoracic curve indeed alters loading, this article (here) concluded, “thoracic kyphosis measurements alone are not sufficient to characterize the impact of spinal curvature on vertebral loading”

This article here from 2010 concluded “the [large number of] factors and activities that cause VFxs [vertebral fractures] remain ill defined”.

The same research group this year published another paper here which broadens our understanding of ‘why’, from a loading mechanics perspective, why certain parts of the spine are more susceptible to fracture, but still we have no causative association between movement or activities. We cannot say that forward bending is a higher risk of fracture as we have no data to support that.

Just yesterday, I shared a recent comment made my Greg Lehman:
“I think the injury debate just comes down to how well do we adapt to the stresses we place on our body. If you think that structures have good adaptability and that pain is a reasonable guide in the moment then you might make the choice to expose movements that stress certain tissues.”

Today, this video was ‘liked’ by Sigurd Mikkelsen on Facebook and popped up on my newsfeed; a 78yr old lady with a kyphotic back performing a heavy deadlift – apparently 103kg!! I wonder what the experts who tell us that older people shouldn’t be bending forward with more than a few kilos would say to this lady?

The physical activity and exercise recommendations for adults with osteoporosis from Giangregorio and McGill et al has exercises recommendations with an emphasis on three things – (1) strength, (2) balance and (3) alignment.

“All of the recommendations evolved from an amalgamation of expert responses – they were not based on a review of evidence.” If the expert responses were similar to those from Margaret, I would strongly disagree with them. I suggest the young lady in the video may disagree too. It goes without saying that if an elderly woman has multiple fractures (or a history of them), pain, or an excessively kyphotic back, then she isn’t going to be doing the same exercises as the lady in this video. Nobody in their right mind would even be considering it. The ‘experts’ actually recommend that this population lift no more than 2.3-4.6kg!!

In the podcast, Margaret suggested that a ‘deadlift’ was not functional. There are many people, including myself, who consider the deadlift pattern to reflect the general way in which someone would pick an object up from the floor. The consensus document considers the ‘hip hinge’ (that’s the deadlift pattern) a ‘spine-sparing’ technique during activities of daily living or leisure. Sitting down onto a toilet seat is more hip-hinge and deadlift than ‘squat’.
There is no evidence that suggests bending forward (flexion) causes or is a risk for fracture. In fact, the consensus states “It was noted that there is no adequately powered evidence regarding the benefits and harms of exercise to enable the development of specific recommendations for all potential case presentations of individuals with osteoporosis that all clinicians will be able to interpret and apply.”

“Clinical reasoning is required to tailor exercise/activity recommendations or goals to patient characteristics, such as comorbid conditions (e.g., physical, psychological, social), fall risk, and individual ability.”

The consensus recommends exercise should have an emphasis on three outcomes; the deadlift (picking up a load from the floor) meets two of those: increase strength, specifically as stated in the consensus of the spinal extensors, and balance.

I agree with this statement: “Progressive overload over time is necessary to improve muscle strength or endurance”
Interesting, the exercise the ‘expert panel’ proposed to increase the strength and endurance of the spinal extensors was to lie on the ground and “gently push the shoulders into the ground”. How is lying on the floor working the spinal extensors? How is pushing the ‘shoulders’ backwards working the spinal extensors? How can their suggestion of ‘progressive overload’ be applied to this? How is this going to help someone with anything standing upright? The mind boggles!

I disagree with this statement: “Lifting weighted objects from or lowering them to the floor should be avoided – lifting or lowering objects should be performed from/to knee height or higher.”

That recommendation is absurd and unhelpful. You try going a day without bending past your knees, or lifting no more than 4.6kg. Consider how much a load of wet washing weighs and how someone would typically get that washing hung up on a line to dry. I guess these experts aren’t ever expecting grandma to hold her grandchildren either.

“Do not lift more than 5 lbs” only works if a patient knows how to move safely with that 5 lbs (2.3 kg).”

Everything about that sentence screams hypervigilance, frailty, kinesiophobia and deconditioning. Suggesting that an elderly person must be consciously mindful of performing every movement is simply not a workable solution. That’s like expecting a 3yr old child to behave like an adult; it’s not going to happen, regardless of any instruction they may be given. If you’ve ever raised a toddler, you’ll know what I mean.

With older adults, I apply the ‘mum test’; what would I have mum doing?

If my mum, who will be 70 next year, was diagnosed with osteoporosis I would be increasing her strength training program quick smart, and she wouldn’t be lying on the floor to do it either!

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