Hey everyone.

Welcome to PT Snacks podcast.

This is Kasey your host, and if you're tuning in for the very first time, first of all, welcome.

But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals and bite-size segments of time.

Now, today I am going to attempt to talk about osteoporosis and how we address it as physical therapists in the clinic in a relatively short amount of time, which means I probably won't cover everything that I want to.

But Be sure and reach out if you want Further dive into any particular topic that we discuss today.

Now we are gonna talk about just what exactly osteoporosis is what the research says about what to do about it and then how we can empower our patients who are dealing with this issue.

Before we do that though, if you've been listening to the show for at least three episodes and you found it to be really helpful to you, it would mean the world to me if you would pause and write a brief review wherever you listen to this on the show, because that really makes a big difference in helping the show to grow.

Thank you also for those who have already done so.

I really appreciate you, but diving right back into osteoporosis, let's actually define what this means.

So osteoporosis in a heavy jargon statement is a micro architectural deterioration of bone tissue and low bone mineral density, meaning what our bone mineral was before is decreased.

So we often evaluate it using a scan and in order to classify it according to who, a dxa derived bone marrow density T score of 2.5 or more below the mean is defined as osteoporosis.

If it's between negative one and negative 2.5, then it's classified as osteopenia or low bone mass.

Typically, a lot of these T scores will be standardized by ethnicity and sex but those who have osteoporosis, we know that this can cause a two to threefold increased risk of a fragility fracture, which means that they are at a higher risk with lower bone mineral density.

For that bone to break because it is not as strong as it once was.

Now, here's the thing.

Osteoporosis is known as a silent disease because it often goes undiagnosed until a symptomatic fracture occurs, which means a lot of people may be walking around and have no idea that they have it.

This can be a problem in a lot of different ways, but one of them is cost.

So in the US the cost in 2018 was 57 billion, and it's projected to grow to 95 billion by 2040.

That's a lot of money.

You can find stats in Australia and Britain and probably a lot of other places.

I just chose to pull that one out.

But we do know that more than 200 million people in the world have it.

Which is a lot of people.

So we know that this is something that a lot of our patients may be facing in our clinic, whether they know it or not, and it's our job as physical therapists to make sure that we can help them navigate it, because physical activity can be really scary when you have this diagnosis because a lot of people.

Are afraid that their skeleton's just gonna fall apart.

So we have to make sure that we can help our patients to stay as active as possible, because there's just so many benefits from a system-wide perspective.

Meaning not just our bones, our tissues, our muscles, our tendons, our heart, all of that.

If we keep ourselves as active as possible.

Now there's a lot of first factors that go into it.

Natural aging deficiency of sex hormones that can cause an activation of bone, tissue resorption, decrease osteogenesis, or basically a decrease of the making of new bone cells.

Microarchitecture disorders from external factors like other medications, things like that.

We know that min.

And women can get it, but women tend to have a higher incidence and that incidence also increases with age.

So one in three women over 50 years old have it, and one in five men are thought to have it as well too.

So there's a lot of respecters that play a role.

There can be family history, genetics, ethnicity.

We know this is more common in Caucasian and Asian females especially.

Smoking inactivity, meaning our bodies, our bones respond pretty well to stress.

So when they are not stressed, they probably won't respond.

They probably won't have as high a bone mineral density.

And we also see this in kids who have a very responsive skeletal system, those that tended to participate in sports, especially.

Ones where they're moving in unexpected directions like basketball, soccer, gymnastics tend to have a higher bone mineral density than those that were inactive.

Insufficient sunlight is another risk factor.

More so playing into the role of vitamin D in healthy bones and more so highlighting estrogen.

We see this often a lot more in women because of a greater decrease in estrogen after menopause.

So what can happen is this deficiency can cause an increase in osteoblasts, apoptosis, which means death of our osteoblast, which if you remember osteoblasts are what help us to lay down new bone cells.

It also, this deficiency can cause an inhibition of osteoblast differentiation, which also affects how much of a role osteoblasts are able to play.

Deficiency of estrogen can also cause less inhibition of components that are involved in the maturation process of osteoclast, meaning we can have more osteoclasts.

So all this kinda.

Plays a role in where we may resorb, more bone cells than we lay down.

There's an imbalance within that process, which again leads to lower bone mineral density.

Things like cellular aging, apoptosis, oxidative stress, inflammation can all play a role.

Inflammation can reduce differentiation as well, which can be triggered by estrogen deficiency.

So those are all heavy risk factors and the reason why you need to know that is.

If we are maybe dealing with patients who could potentially have undiagnosed osteoporosis, we might want to take that into account in terms of if we refer them to maybe get it checked out or what exercises that we choose.

Just something that we can think about and we'll talk about exercises in the second half.

But, and as far as the most common fracture sites, it would be in the hip vertebrae or wrist vertebral fractures are associated with a lot of long-term pain in other physical and psychological symptoms.

So really it's ideal if people don't get to that point in the first place.

As well as hip fractures are associated with increased morbidity, so the more that we can decrease.

That as well, the better for our patients and their quality of life.

Now let's talk about how it's treated.

There's a lot of different systematic reviews and really cool evidence that's out there.

I would really encourage you if you're interested in this topic, to take a deeper dive because there's a lot of different programs which can seem a little overwhelming.

But I also think that's a good thing because.

Our patients often aren't just coming to see us because they have osteoporosis.

Even if they know it's there, they might be coming because they have knee arthritis or shoulder pain or low back pain, something that may fit in their overall presentation, but.

Something that you may also need to address.

So that patient may not be ready for a typical high impact bone program, right?

It's good for us to be able to also take into account the patient in front of us, what their fitness level is, their mobility what they enjoy, what they've done before they, have they ever picked up a weight before?

Have they ever have they jumped in the last 40 years?

Things like that so that we can kinda.

Help to bridge a gap between where their current physical function is and where we want them to be.

But as a whole, a lot of these programs are built around.

Trialing resistance training, balance training, because we don't want these patients to fall if they have a higher risk of fragility fractures as well as impact training.

And a lot of the questions that I saw in a lot of these randomized control trials were trying to see if there was a dose response association.

So for some of these studies, they did a one hour session of.

Share stands, squats, step up arm, pullups and even respiratory muscle training with 15 minute walking before and after, and an intensity scaled by the Borg scale.

And they found that there were significant impacts if they did about 60 minutes or more.

Two to three times a week for seven plus months.

So it's not a quick turnaround guys.

But this group in particular was more so focused on prevention training in osteoporosis, not someone who has a preexisting osteoporosis diagnosis.

Now with those who do have a preexisting diagnosis of osteoporosis and do not have active vertebral fractures.

They were grouped into several.

They found that loading that was dynamic, that induced high bone strains or deformation and load that was applied rapidly, really helped people to have a positive effect in terms of either maintaining their bone mass or improving their bone mineral density.

So the key is not static dynamic.

High bone strains applied rapidly.

They also found that they didn't need a lot of loading cycles to elicit a skeletal response as long as the load intensity was adequate because bone cells can desensitize to repetitive loading after time.

Athletic movements like basketball, power lifting, figure skating things that were, random movements had a better result than like lower impact.

And the greatest skeletal benefits from progressive resistance training, they were programs that progressed over time, so they lifted more and more over time.

Progressive overload, right?

The magnitude of their lifting was high, so around 80 to 85% of their one rep max, they were training at least twice a week with larger muscles that were crossing the hip and spine, targeted the paper I'm alluding to.

They found that it may even be better, more so in developing spine bone mineral density.

Now with moderate to high weight bearing impact training.

If these patients did more than two times a week or more than two times impact of their body weight, then.

With progressive, novel and multi-directional movements, those also had an osteogenic effect, meaning it helped improve their bone mineral density, which may have an even better impact in the hip, and it didn't take a lot of impacts, meaning contacts, right?

It was 10 to 50 a day, three times a week.

To have a osteogenic effect, but it may be better with more exposure like four to seven times a week.

All that being said, we do not need our patients to do this for a full hour every single day.

That's way more than 10 to 50 contacts.

Other additional exercises they did be besides impact and progressive assistance training were things that helped to reduce, kyphosis.

For instance, if someone is kyphotic, their center of mass might be more oriented forward, which means they might have a harder time with their balance, which means they could increase their fall risk.

So things like that kind of helped to reduce that.

We're utilized in these programs.

I already mentioned balance training, which can look like a lot of different things.

The other aspect is a lot of these patients were not necessarily doing things that put them into loaded flexion repetitively, we know that with osteoporosis, we don't necessarily want to do a lot of repetitive loaded flexion.

However, here's the caveat, I would say, because I've had a lot of patience with these.

When they hear this, they are scared to do any bending, to go down and tie their shoes or to pick up something from the floor.

We need to teach them how to do these things.

Imagine how debilitating that is in your daily life.

So teaching them to hip hinge properly, they're technically keeping a neutral spine and moving at the hips, And also if they do it once or twice, it's not like we have studies necessarily that measure the absolute strain of an osteo skeleton.

I don't really think that.

The IRB would approve of that.

So sometimes we err on the side of safety, which I think is a good thing, but not to the point where someone has now just resorted to using a grabber for everything they pick up off the floor.

So there's lots of ways to get down to the floor, lunging, hinging, squatting, all that kind of stuff.

Let's build confidence in our patients with those.

Can we.

Now that was a lot of information on things to do.

So let's work on categorizing where to start with our patients, more so by risk factor.

So let's go low risk factors, low risk, moderate risk, and high risk.

So with our low risk patients, when we are deciding what should I do with this patient in front of me, these are individuals that are asymptomatic with normal bone mineral density.

So with them, we can do heavy resistance, we can do high impact sports, balance cardio for other goals, but not necessarily with the goal to build bone mineral density.

That's pretty, pretty much just building out a program on where they are and helping them to prevent it from happening.

With moderate risk.

These are our patients who have low bone mass, so maybe they've been diagnosed with osteopenia.

Our goal with them is to preserve or improve their bone mineral density.

So they're gonna do similar activities to our low risk but they may start with more moderate impact just to make sure that they're tolerating that well.

And we're conditioning from moderate to high intensity resistance and making sure that everything is being done that is pain-free.

And pain-free should probably be across the board, especially if we're treating other things that are going on in our patients.

And then we have high risk.

So these are our patients who have osteoporosis.

They have a previous fracture or multiple risk factors that for developing a fragility fracture.

As I mentioned, we don't know the absolute load of a osteoporotic skeleton without fracturing it.

But there has been some evidence that the progressive weightlifting, the impact can be helpful for our patients.

We just might start them off at a lower threshold and allow their body to condition to that load before we go super heavy with them.

So essentially that's what you wanna do.

See, you should know the risk factors, right?

We're taking a look at their body as a whole, what their family history is, their genetics, their nutrition do they smoke?

Do they have any other risk factors for helping?

For developing osteoporosis.

What's their exercise history like, what have they done in the past?

And then making sure that we can build a bridge from there to ideally things that we know help to build bone mineral density.

Notice I, I didn't really talk about weighted vest walking'cause that just wasn't in what I read.

That's not to say we'll script that.

I will give a nod to whole whole body vibration.

I didn't really take a deep dive into that topic, but it is something that's being evaluated in space medicine for astronauts to help maintain bone mineral density.

From what I've seen, it looks like a good adjunct maybe but not a replacement for the other interventions that I mentioned.

Oh, that was a lot.

I hope that was helpful to you guys.

Obviously we could have taken a deep dive into a lot of other topics, but if you have any questions, feel free to reach out at pt Snacks podcast@gmail.com.

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