Lora Giangregorio, PhDCaitlin McArthur, MScPT

Collaborators: Cheung, AM, Heinonen A, McGill S, Laprade J, Ashe MC, Shipp K, Wark JD, MacIntyre NJ, Keller H, Jain R, Papaioannou A, Osteoporosis Canada

TOO FIT TO FRACTURE

TRUE or FALSE?

I do activities to increase muscle strength, such as lifting weights or working with resistance exercise bands, twice a week or more.

I do activities that challenge my balance, such as Tai Chi, dynamic balance activities or “standing still” balance challenges on most days of the week. I do moderate or vigorous intensity aerobic physical activity for at least 30 minutes on 5 or more days per week, in bouts of 10 minutes or more.

I do exercises to improve my posture daily. I pay attention to my posture during daily activities, to avoid excessive twisting or forward bending.

I progressively increase the intensity of the exercises I do over time, so that they are always challenging me.

Fractures occur when…

BONE STRENGTH

APPLIED LOAD

▪ Falls▪ Spine loads▪ Shock absorption

Cheung AM, et al. JAMA. 2008;299:1468-70.

▪ Bone structure▪ Bone material

FALLS AND FRACTURES HAPPEN TO OLD LADIES, NOT ME

• 1 in 3 aged 65 or older falls each year• Leading cause of fatal and nonfatal injuries• Death rate 40% higher in men (age controlled)• Men more likely to die from a hip fracture

Tromp et al, 2001, CDC WISQARS

• Meds review• Eye exams,

colour/contrast• Remove rugs,

use grab bars & railings, good lighting

• Chronic disease management

• Exercise!http://www.parentgiving.com/elder-care/preventing-falls-five-dangers-seniors/

Normal Bone

Porous Bone

WHAT IS OSTEOPOROSIS?

NIH Definition:

“…a skeletal disorder characterized by compromised bone strength

predisposing a person to an increased risk of fracture. Bone

strength reflects the integration of 2 main features: bone density and

bone quality.”

COMMON FRACTURE SITES

Most common type of fracture

in women < 75yrs

Usually undiagnosed

unless pain or height loss

↑ Mortality↓ Mobility and independence

Pics: http://en.wikipedia.org/wiki/Vertebral_columnhttp://upload.wikimedia.org/wikipedia/commons/3/30/Gray82.png

Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

PHYSICAL CONSEQUENCES OF SPINE FRACTURES

4 cm

3 F-B’s

8 cm12 cm

2 FB’s

Height loss

A. Height LossB. Wall-Occiput DistanceC. Rib-Pelvis Distance

WHY SHOULD I EXERCISE?

Reduces risk of : Cardiovascular disease, thromboembolic stroke, hypertension, type 2 diabetes mellitus, osteoporosis, obesity, colon cancer, breast cancer, anxiety, depression, falls and injuries from falls, functional limitations

Substantial role as therapy for: Substantial role: coronary heart disease, hypertension, peripheral vascular disease, type 2 diabetes, obesity, elevated cholesterol, osteoporosis, osteoarthritis, and chronic obstructive pulmonary disease.

A role as therapy for: depression and anxiety disorders, dementia, pain, congestive heart failure, syncope, stroke, prophylaxis of venous thromboembolism, back pain, and constipation.

Nelson, M. E., Rejeski, W. J., Blair, S. N., Duncan, P. W., Judge, J. O., King, A. C., ... Castaneda-Sceppa, C. (2007). Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation, 116(9), 1094-1105.

Expert consensus and best evidence support:1. Strength training ≥ 2x/wk2. Balance training daily3. Exercises for back extensor muscles daily4. ≥ 30min/day aerobic physical activity 5. Spine sparing strategies like hip hinge and step-

to-turn can ↓ spine loads → how to move, rather than how not to move

11

RECOMMENDATIONS– EXERCISE AND PHYSICAL ACTIVITY

Giangregorio LM, et al Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int. 2014 Dec 16. [Epub ahead of print]

- Start with a few strength exercises 2x/wk, 1 balance challenge daily

- Add in aerobic physical activity in 10 min bouts- Attend a class that includes strength and balance

training

WOW! THAT SOUNDS LIKE ALOT

Consult Bone Fit trained individual - www.bonefit.ca

Involves using muscles to generate force against resistance

Use: Free weights, weight-training machines, exercise bands, lifting body weight against gravity (e.g., push-up on wall or counter, squat exercise)

STRENGTH TRAINING

At least twice a week

One exercise for each major muscle group:• Lower legs• upper legs• Chest• Back• Shoulders• Arms where you do 8-12 repetitions.

- Squats or sit-to-stand exercises or lunges - legs and buttock muscles

- Heel raises - lower legs- Wall/counter pushups – chest, triceps- Bow and arrow “pulls” with exercise band

- upper back and biceps- Diagonal shoulder raises with exercise

band - shoulders and upper back.

FIRST-TIMERS FAB FIVE

Find exercises with a continuum of progression!

EXAMPLE: SIT TO STANDS OR SQUATSLEGS AND BUTTOCK MUSCLES PROGRESSION

Don’t forget your hip hinge!

Supported sit to stand Unsupported sit to stand Strong legs squat

Target Standing Seated SupineChest/triceps: • wall/counter pushup

• theraband press• theraband press • theraband press

Back/biceps: • standing lat pull• bow and arrow pull

• Seated lat pull• bow and arrow pull

• bow and arrow pull

Shoulders: • diagonal shoulder raise• upright row• bilateral shoulder raise

• diagonal shoulder raise• upright row• bilateral shoulder raise

• diagonal shoulder raise

- Challenge your balance daily!- Can do without wavering for > 5 seconds but <

30 seconds- Can be done in one place, or moving around- Progressively ↑ the challenge is important

BALANCE TRAINING

Find a class in your community that includes balance exercises, or get help selecting the right exercises for you.

Example strategies to design balance exercisesReducing Base of Support in Static Stance:

∙ Feet together→ stand on one foot∙ Standing on heels or toes only

Shifting Weight, Moving to Limits of Stability∙ Shifting weight between heels and toes

“Moving around” balance exercises:∙ Walking on toes or heels only∙ Figure 8s∙ Sit-to-stand or squat∙ Walking backwards

Fun Balance Challenges:∙ Tai Chi∙ Dancing

EXAMPLE: SEMI-TANDEM TO TANDEMSTATIC BALANCE PROGRESSION

Semi-tandem with support

Semi-tandem without support

Tandem with support

Tandem without support

≥ 150 min moderate-to-vigorous physical activity a week or ≥ 30 min/day

Move every 30 min!

Weight-bearing aerobic physical activity, like walking or dancing

Those with vertebral fracture should aim for moderate intensity only

AEROBIC PHYSICAL ACTIVITY

If you are at high risk of fracture, unfamiliar with exercise, or have other health problems, start at a low intensity and progress to moderate intensity.

0 - Nothing at all1 - Very light2 - Fairly light3 4 - Somewhat hard5 - Hard67 - Very hard8910 - Very, very hard

Borg, G.V. (1982) Psychological basis of perceived exertion. Medicine and Science in Sports and Exercise, 14, 377-381.

www.bonefit.ca

- 5-10 min per day lie flat on firm mattress or floor- Legs straight, or if uncomfortable, bent or resting on pillow under knees- Only use a pillow if your head does not reach floor- Imagine your collar bones are wings, and spread your wings without pulling

your shoulders back

What is “spine sparing”?

Recommend that patient modify activities that apply rapid, repetitive, weighted or end-range flexion (forward bending) or twisting torque to the spine.

How?

• Hip hinge

• Step-to-turn

• Avoid lifting from or lowering to the floor

• Slow, controlled twist, not to end of range of motion

• Support trunk when flexing

• Hold weight close to body, not overhead

If you are at moderate risk of fracture….- History of activity and strong desire to continue - Can you modify?

- Spine sparing! Loads: lying on back < standing < sitting

- High-impact sports, high fall risk, contact → do low impact, slow pace

- Be aware of your health and abilities – get help if needed!

https://www.flickr.com/photos/yogamama-co-uk/3794097473/

NOYES

If you are at high risk of fracture, have problems with walking or balance or have a “humped” spine….

- Alignment and spine sparing more important than intensity

- Moderate intensity aerobic physical activity only

- May need trained instructor for classes, physical or occupational therapist re: ADLs

- Get help beyond light ADLs, avoid sitting long periods

- Lying on your back “unloads” the spine, promotes extension, pain relief

RESOURCES

Too Fit To Fracture landing page, includes videos, webcast: http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/

TRUE or FALSE?

I do activities to increase muscle strength, such as lifting weights or working with resistance exercise bands, twice a week or more.

I do activities that challenge my balance, such as Tai Chi, dynamic balance activities or “standing still” balance challenges on most days of the week. I do moderate or vigorous intensity aerobic physical activity for at least 30 minutes on 5 or more days per week, in bouts of 10 minutes or more.

I do exercises to improve my posture daily. I pay attention to my posture during daily activities, to avoid excessive twisting or forward bending.

I progressively increase the intensity of the exercises I do over time, so that they are always challenging me.

- What are you going to do?- How are you going to do it?- Where are you going to do it?- When are you going to do it? What is the trigger?

PICK ONE NEW GOAL

Too Fit To Fracture TeamAlexandra PapaioannouAngela CheungAri HeinonenJohn WarkKathy ShippMaureen AsheNorma MacIntyreStuart McGillHeather Keller

Osteoporosis Canada Ravi Jain Judi LapradeResearch teamCaitlin McArthurJenna GibbsChristina ZiebartRuchit PatelRebecca Clarke

@l_giangregorio

http://www.facebook.com/toofit.tofractureLora.giangregorio@uwaterloo.ca