Ask anyone on the street what one should do for osteoporosis and the typical answer is weight-bearing exercises - and they would be partially right. Weight-bearing, or loading, activities have been shown to increase bone density.(1) But that’s not the whole story. Different exercises have different strain magnitudes, strain rates, and strain frequencies - all of which impact bone density.

• Strain Magnitude - the force or impact of the exercise. Exercises such as gymnastics and weightlifting have a high strain magnitude.
• Strain Rate - the rate of impact of the exercise. Exercises such as jumping or plyometrics have a high strain rate.
• Strain Frequency - the frequency of impact during the exercise session. Exercises such as running have a high strain frequency.

When considering weight-bearing exercises for a home exercise program, the million-dollar question is, “How much weight-bearing is enough to stimulate bone growth, and how much is too much to compromise bone at risk for a fracture?” We know that there are incidents of individuals fracturing from just their body weight upon standing. Recently patients have been asking about heel drops and stomping, and whether they should do them. One size does not fit all.

An alternative is to focus on odd impact loading. A study by Nikander et a (2) targeted female athletes in a variety of sports classified by the type of loading they apparently produce at the hip region; that is, high-impact loading (volleyball, hurdling), odd-impact loading (squash-playing, soccer, speed-skating, step aerobics), high magnitude loading (weightlifting), low-impact loading (orienteering, cross-country skiing), and non-impact loading (swimming, cycling). The results showed that high impact and odd impact loading sports were associated with the highest bone mineral density.

Marques et al found that odd impact has the potential for preserving bone mass density as does high impact in older women in their 2011 study (3). Activities such as side stepping, figure eights, backward walking, and walking in square patterns help “surprise the bones” due to the different angles of muscular pull on the hip. The benefit, according to Nikander, is that we can get the same osteogenic benefits with less force, moderate versus high impact. This type of bone training would offer a feasible basis for targeted exercise-based prevention of hip fragility.

I tell my osteoporosis patients that if they walk or run the same route, the same distance, and the same speed that they are not maximizing the osteogenic benefits of weight bearing. Providing variety to the bones creates increased bone mass in the femoral neck and lumbar spine.(4)

Dancing is another great activity that combines forward, side, backward, and diagonal motions to movement. In addition, it adds music to make the “weight-bearing exercises” more fun. Due to balance and fall risk, many senior exercise classes offer Chair exercise to music. Unfortunately sitting is the most compressive position for the spine and is particularly problematic with osteoporosis patients. Also, the hips do not get any weight-bearing benefit. Whenever safely possible, have patients stand; you can position two kitchen chairs on either side, much like parallel bars, to hold on to while they “dance.”

Providing creativity in weight-bearing activities using odd impact allows not only for fun and stimulation and offers more “bang for the buck!”

Build on your knowledge of osteoporosis management by joining Deb Gulbrandson and Frank Ciuba in their upcoming short course Osteoporosis Management scheduled for January 25! Not only will you gain a deeper understanding of the scope of the problems, and specific tests for patients with osteoporosis, but you will also learn skills for evaluating patients as well as appropriate safe exercises for an Osteoporosis program. 

Resources:

1. Mosekilde L. Age-related changes in bone mass, structure, and strength--effects of loading. Z Rheumatol (2000); 59 Suppl 1:1-9.
2. Nikander et al. Targeted exercises against hip fragility. Osteoporosis International (2009)
3. Marques et al. Exercise effects on bone mineral density in older adults: a meta-analysis of randomized controlled trials. Epub 2011 Sep 16
4. Weidauer L. et al. Odd-impact loading results in increased cortical area and moments of inertia in collegiate athletes. Eur J Appl Physiol (2014)
5. Benedetti MG, Furlini G, Zati A, Letizia Mauro G. The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients. Biomed Res Int. 2018 Dec 23;2018:4840531. doi: 10.1155/2018/4840531. PMID: 30671455; PMCID: PMC6323511.

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.

An interview with Frank Ciuba.

Frank Ciuba, co-instructor of Osteoporosis Management< alongside Deb Gulbrandson, explains that practitioners need the information provided in their course. "This course is the latest up-to-date research compiled by my partner Deb Gulbrandson and myself in the management of osteoporosis for clinicians." He shares that similar to learning about the pelvic floor, "when physical therapists go to school they get only a small amount of what osteoporosis is and very little on how to treat a patient."

Frank explains that he became interested in teaching osteoporosis management when he learned "that one in four men statistically will get osteoporosis or an osteoporosis-related fracture in their lifetime and they're really not being identified." Osteoporosis Management provides an exercise-oriented approach to treating these patients and it covers specific tests for evaluation, appropriate safe exercises and dosing, basic nutrition, and ideas for marketing your osteoporosis program.

In pelvic health rehabilitation, it's seen that osteoporosis-related kyphosis (curvature of the spine) can affect pelvic organ prolapse, breathing, and digestion. Patients who go through the osteoporosis management program with Frank and Deb, are shown that they reduce the likelihood of compression fracture by 80%.

This course, Osteoporosis Management, is not just for practitioners working with osteoporosis or osteopenia patients. Frank lists the types of patients he's been able to help. "I've used this on high school backpack syndrome, whiplash injuries, adhesive capsulitis, spinal stenosis, low back pain, lumbar strain, even some hip pathologies." He concludes with "We just need to get the word out to more individuals that this a program that can help them. Not only in the short term, but in the long term. This is a program for life."