What We Do for Osteoporosis, and Why:
Due to the nature of osteoporosis, increasing and maintaining bone mass is vitally important. Absolute Physical Therapy helps our patients progress and become confident in their exercise program to continue independently in the home or fitness center once their therapy is complete.
Maximal Strength Training
In a study that I recently commented on in my blog, researchers were striving to determine which type of strength training is most beneficial for patients with osteoporosis. Current guidelines recommend weight-bearing activities, preferably strength training for improving skeletal health in patients with osteoporosis but the most beneficial exercise is not established. Maximal strength training (MST) is known to improve 1-repetition maximum (1RM) and rate of force development (RFD), which are considered as important co-variables for skeletal health.
Researchers suggested that squat exercise MST might serve as an effective intervention for patients with low bone mass. The squat exercises were done 3 times per week for 12 weeks and the result was an increase in hip (femoral neck) bone mineral content of 4.9% (that’s a lot in osteoporosis studies), and an increase in lumbar spine bone mineral content of 2.9%. The strength had improved 154%. They did the reps which was explosively with the subjects exploding upwards with the weights as fast as they could. They called this “Maximal Strength Training” (MST) which is a new term for me but sounds identical to Compensatory Acceleration Training (CAT) coined by Fred Hatfield back in the 80’s. Some say tomato and some say potato but either way I expect the exploding with the weights throughout the concentric (upward) motion is a better way to train. When I was doing Olympic Weightlifting at NAU, pretty much all our reps were explosive. So it’s cool to see explosive training with weights being applied to and helping elderly women with osteoporosis. It goes to show, yet again, that the best techniques for physical therapy come out of the weight room rather than the classroom.
Check out my blog to read more about Maximal Strength Training and Increased Bone Mineral Content
Fast Weight Lifting
A 2005 study investigated if power training is more effective than strength training for maintaining bone in postmenopausal women. The study directly separated out concentric speed (the lifting part) of weight lifting (as fast as possible in the power training group) vs lifting the weight over 4 seconds in the strength training group. The power group maintained BMD over a year, while the regular strength training group lost some bone mineral density. Set and repetition range was not given (which would have been nice of them to mention) but training intensity was said to be 70-90% of their 1 repetition max (1 RM) for 12 weeks, interspersed with a 4-5 week recovery period training at 50% of their 1 RM. The exercises were machine based; leg presses, leg curls, bench press, rowing, leg adduction and abduction, abdominal flexion, back extension, lat pulldown, hyperextension, leg extensions, shoulder raises and hip extensions.
Even with the slow 4 second eccentric phase the power training group was able to maintain bone mineral density in pre-trained postmenopausal women, while the slow strength training group was not. Being as this was a 2005 study, it likely helped researchers towards the more recent program performed on osteoporotic women using “Maximal Strength Training” which led to substantial increases in bone mineral density in just 12 weeks. It’s also why I am skeptical of use of yoga, particularly given the potential for injury in women with osteopenia and osteoporosis.
Check out my blog to read more about Weight Lifting in Postmenopausal Women
Those with mild to advanced osteoporosis can be started on exercise programs designed to increase strength and balance to lessen the risk for falls, as well as to increase bone mineral density.
At Absolute Physical Therapy we are constantly reading research. Using the most current research we create a program that is optimal for increasing bone strength and function while taking into account the patient’s current abilities.
For patients with osteoporosis, I think the best course of action is to:
1. Complete fast repetitions of weight lifting exercises
If my physical therapy patients and personal training clients take longer than half a second to lower the weights I tell them to go faster. Four seconds down is REAL SLOW and you can’t lift as heavy a weight that slow, so overall training intensity is lessened. Known to just about every weightlifter, powerlifter, bodybuilder, or strength and conditioning coach (but apparently not every researcher) is that nobody strong trains like that. Strong people generally lower their weights (eccentric contraction) in a smooth but swift manner, and if they really know what they are doing, they lift those weights (concentric contraction) as fast as they can.
Check out my blog to read more about Weight Lifting in Postmenopausal Women
2. Engage in back, core, hip, and lower extremity strength exercises
This study found that by adding back extensor muscle training they were able to significantly reduce the refracture rate. They used exercises begun in sitting and progressing to back extensions and bird dog type exercises in prone or quadruped. Unfortunately they did not give much in the way of details as to when the exercises were started after the procedure, frequency, sets or repetitions performed. However, so far it’s the only study that addresses exercise after vertebroplasty so sometimes you just have to take what you get and develop your physical therapy programs with less than perfect data.
The good news was that the back extensor exercises had significant beneficial effects at reducing additional fractures. The incidence of additional compression fractures within 12 months was reduced from 75% in the control group to 35% in the exercise group. This makes sense. If patients’ spine extensors are strong enough to hold their spines neutral during daily activities, that would take pressure of the anterior vertebral bodies, which is increased primarily due to spine flexion. Based on this, and a lot of other spine research, I would think it prudent as well to add abdominal exercises (performed with the spine neutral and perhaps with a bias into extension) as well as hip and lower extremity strength exercises. These make it easier for those with osteoporosis to lift with their legs as opposed to their backs. Not to mention that those with osteoporosis need the weight bearing through their hips to increase bone mineral density there and lessen the risk of hip fractures. If it were me I would stay away from yoga.
Check out my blog to read more about Lowering Refracture Rates with Strength Exercise
What We Don’t Do for Osteoporosis, and Why:
There was a study conducted in 2013 specifically intended to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. It was concluded that the development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss.
The author noted he had seen but not reported other compression fractures in women with yoga flexion stretches before and said they were considered incidental until other yoga related vertebral fractures were reported at which point he decided to do this paper. With a lot of vertebral compression fractures going unreported I expect the incidence is greater than this paper suggests. The author did a good job of defining which yoga stretches are the problematic ones, which are those in which the person flexes their back or neck as they bend forward to touch the floor/their feet, or flexes their neck as they bring their chin forward towards their chest. These flexion stretches mimic the direction that causes lumbar discs to herniate. Also worth noting is that extension strengthening, contrary to flexion stretching, has been shown to be protective against vertebral compression fractures and squats with accelerating progressive resistance has been shown to increase both hip and lumbar bone mineral density.
The right exercises are good, the wrong exercises are bad and physical therapists need to differentiate what exercises are going into their programs to maximize rewards and minimize risks.
Check out my blog to read more about Flexion Stretches and Osteoporosis
Stretching, Breathing, and Relaxation Exercises
To investigate whether weight bearing exercises would have beneficial effects on bone turnover markers, a type of weight-bearing exercise that includes physical postures, stretching, breathing, and relaxation called “Hatha Yoga” was used. Seven participants completed a 12-week series of one hour per week Yoga classes, in addition to home Yoga practice.
Of the remaining 8 subjects they got post test on bone markers showing positive trends but not statistical significance. They did report a trend towards an increase in bone formation, but only 3/7 showed a decrease in bone resorption. Such that they concluded yoga would have a positive benefit those with with osteopenia because it would “slow the expected trajectory” of bone resorption, thus delaying the onset of osteoporosis. I think that is all well and good when compared to nothing, which is what this study did. However, when compared to just doing squats with weights 3 times per week, which has been shown to build back bone in those with osteoporosis, just slowing the inevitable with yoga, seems like an inefficient use of one’s time at best.
The problem was that those weight bearing exercises, as described, were at most balancing on one leg. While I think single leg balance is a good exercise and I have my patients work on it from time to time, I don’t think of it as optimally effective for increasing bone mineral density.
Check out my blog to read more about Weight Bearing Exercise and Delayed Bone Loss
Chad Reilly’s physical therapy practice is constantly evolving based on current empirical evidence combined with self-experimentation and clinical results. To follow the changes, simply look at “Chad’s Blog” and receive links to novel studies, as well as Chad’s impressions on quality and real world application.