OSTEOPOROSIS THERE IS SOMETHING YOU CAN DO ABOUT IT!

Transcription

1 While waiting for webinar to begin, get a chair, preferably one with no arms for Sit-To-Stand-To-Sit Exercise OSTEOPOROSIS THERE IS SOMETHING YOU CAN DO ABOUT IT! Practical Applications for Practice THE MEEKS METHOD Sara Meeks, PT, MS, GCS that, someday in this country and, indeed, around the world, any person, no matter their age, gender, lifestyle, ethnicity, musculoskeletal condition or any other factor, can go into any environment where exercise and movement are being taught and be given a program that is Ideally, it will also be therapeutic. Although there is more awareness now than when I began teaching in 1998, there is still a lot to be done. By taking this webinar, you will help me fulfill my dream. As you learn more about movement that is you can help me take the message of safety and therapeutic intent in movement and exercise into your own life and into the lives of others.

2 Trabecular Fracture BONES At Inside Beyond The Bones F R O N T O F T H E B A C K B O N E

3 Spinomed Online CEU Course July 6 INSIDE THE BONES 2011 NORMAL BONE OSTEOPOROTIC BONE Milner, Colin. Making Bone Health A Priority. The Journal on Active Aging. May June

4 8 BEYOND THE BONES ANATOMICAL CONSIDERATIONS Boney Structure Intervertebral Discs Joints Ligaments Circulation Neurological Muscular Internal Organs 9 POSITIONING OF INTERNAL ORGANS Loss of Body Height Can Affect Speech Swallowing Breathing Heart Rhythm Digestion Elimination Any Internal Organ Function FUNCTION FOLLOWS FORM IS THE KEY

5 PATTERNS OF POSTURAL CHANGE 2000 SARA MEEKS SEMINARS Prevent, Arrest or Reverse Function Follows Form ISOLATE Determine areas of restriction and weakness ACTIVATE Relieve restriction/strengthen weakness INTEGRATE Put it all together into functional movement ALIGNMENT PERCH POSTURE HIP HINGE S T A N D I N G P O S T U R E F O O T P R E S S

6 FUNCTIONAL MOVEMENT SIT-TO-STAND-TO-SIT SIT-TO-STAND CHAIR Indicated for patients who need assist with Sit-To-Stand-To-Sit movement Use Lift of a Lift-Recliner Chair in Home Care Inability to stand up out of a chair unaided is linked to a 2 fold increase in hip fracture risk Cummings et al 1995 Weakness of lower extremities linked to impending physical frailty Judge et al 1996 Guralnik et al 1995 Low femoral neck bone mineral density is significantly associated with a low sit-to-stand performance assessed by measurement of maximum rising strength in healthy adult women. Blain et al DEFINITION A musculoskeletal disorder with compromised bone strength that predisposes an individual to increased fracture risk (broken bone) NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. JAMA 2001: 285:

7 BONE STRENGTH Bone Density Bone Quality Architecture Mineralization Micro damage accumulation Reduction of bone mass, both quantity AND quality so that the bones become fragile and easily fracture PEAK BONE MASS The amount of bone accumulated as a young adult (generally age 30-35) About 90-98% is accumulated by age Bone Health and Osteoporosis A Report of the Surgeon General October 2004

8 DETERMINANTS OF PEAK BONE MASS Heredity up to 75%* Physical Activity Ethnicity Lifestyle Factors Nutrition Hormonal Status Accessed October 21, 2011 WORLD HEALTH ORGANIZATION DIAGNOSTIC CRITERIA for ADULT WOMEN T Score O to -1 Normal Bone -1 to -2.4.Osteopenia -2.5 & Below..Osteoporosis Below -2.5 in presence of fracture Severe Osteoporosis Z Score Used for Pre-Menopausal Women Men <50 years old Children

9 Vertebral Column Bone Density Report A/P View Patient E.W. Hip Bone Density Patient R.O.

10 OSTEOPOROSIS IS A PEDIATRIC CONDITION that manifests in ADULTHOOD Also in childhood--babies are being born with osteoporosis Osteoporosis affects all populations women, men, young adults, the elderly, patients in your clinics and classes, and anyone here in this room today It knows NO boundaries regarding age, gender, lifestyle, ethnicity or any other factor Some people are more at risk than others but no-one is totally immune Osteoporosis affects 60% of persons age 60+ (men and women) Total of 57 million age 60 + should be very concerned about their bone health Total # of people estimated to have low bone mass in the United States 48 million Osteoporosis is more prevalent than coronary heart disease (12.5 million), heart attack (1.1 million) & diabetes (17 million) It is more common than breast, uterine and ovarian cancer combined PEAK BONE GROWTH In Utero Adolescence WHEN DOES PREVENTION BEGIN

11 BEFORE BIRTH Evidence that fracture risk might be programmed during intrauterine life Cooper C et al. Review: developmental origins of osteoporotic fracture Osteoporosis International 2006 Maternal smoking, diet (esp. Vit D deficiency) and physical activity appear to modulate bone mineral acquisition during intrauterine life Low birth weight & poor childhood growth are directly linked to later risk of hip fracture Optimization of maternal nutrition and intrauterine growth should also be included within preventive strategies against osteoporotic fracture QUESTIONS STAGES OF BONE DEVELOPMENT IN UTERO o One of the peak times of bone growth o Targeting healthy women to have healthy babies o Human beings are designed to move right from conception o Fetal movement during pregnancy o Skeleton formed by 7 weeks

12 STAGES OF BONE DEVELOPMENT INFANCY o Continuing with bone growth o We are born to move o Normal development roll over, prone positioning, lifting head and upper body, crawling hands/knees, walking etc. o Prone to play/back to sleep

13 BABY BOOT CAMP & STROLLER FIT A, Photograph showing an infant asleep with the insert in position. Tonkin S L et al. Pediatrics 2003;112: by American Academy of Pediatrics STAGES OF BONE DEVELOPMENT INFANCY 2 How infant development is being affected by use of car seats/baby carriers/strollers etc Oxygen deprivation Delayed development Skull deformities Torticollis Gerd Sensory deprivation Lack of movement more and more car seats are designed to keep the infant so safe that they cannot move does this affect bone development too Cutting off of the airway in cervical flexed positioning Anecdotal reports of deaths of babies in portable car seats

14 CAR BED RISK FACTORS for OSTEOPOROSIS NON-MODIFIABLE RISK FACTORS Female Family History Post-Menopausal Natural or Surgical Advanced Age Caucasian or Asian Delayed Puberty/Irregular Menstrual Cycles Early Menopause Men over age 75 Nulliparous-having had no children Small Boned

15 MODIFIABLE RISK FACTORS Smoking High Alcohol Intake Caffeine (more than 2-5 cups/day) Sedentary Lifestyle/Over-Exerciser Men-Low Testosterone High Protein Diet (Meat) Low Calcium Diet Eating Disorders DISEASES AND CONDITIONS AIDS/HIV Ankylosing spondylitis Blood and bone marrow disorders Breast cancer Chronic obstructive pulmonary disease (COPD), including emphysema Cushing s syndrome Depression Diabetes Eating disorders, especially anorexia nervosa Female athlete triad (includes loss of menstrual periods, an eating disorder and excessive exercise) Gastrectomy Gastrointestinal bypass procedures Hyperparathyroidism Hyperthyroidism Inflammatory bowel disease, including Crohn s disease and ulcerative colitis Kidney disease that is chronic and long lasting Liver disease that is severe, including biliary cirrhosis Lupus Lymphoma and leukemia Malabsorption syndromes, including celiac disease Multiple myeloma Multiple sclerosis Organ transplants Parkinson s disease Polio and post-polio syndrome Poor diet, including malnutrition Premature menopause Prostate cancer Rheumatoid arthritis Scoliosis Spinal cord injuries Stroke Thalassemia Thyrotoxicosis Weight loss NOTE This list may not include all diseases and conditions that may cause bone loss.

16 MEDICATIONS Aluminum-containing antacids Antiseizure medicines (only some) such as Dilantin or Phenobarbital Aromatase inhibitors such as Arimidex, Aromasin and Femara Cancer chemotherapeutic drugs Cyclosporine A and FK506 (Tacrolimus) Gonadotropin releasing hormone (GnRH) such as Lupron and Zoladex Heparin Lithium Medroxyprogesterone acetate for contraception (Depo- Provera ) Methotrexate Proton pump inhibitors (PPIs) such as Nexium, Prevacid and Prilosec Selective serotonin reuptake inhibitors (SSRIs) such as Lexapro, Prozac and Zoloft Steroids (glucocorticoids) such as cortisone and prednisone Tamoxifen (premenopausal use) Anti-rejection drugs in organ-transplant patients Thiazolidinediones such as Actos and Avandia Thyroid hormones in excess NOTE This list may not include all medicines that may cause bone loss. FIRST SIGNS Fracture- minimal trauma (e.g., Colles Fracture, Compression Fracture, Rib Fracture. Any fall from standing body height is a fracture of minimal trauma) Hyper-Kyphosis Loss of body height Transparent skin Periodontal disease Back Pain Protruding Abdomen

17 RISK FOR FRACTURE History of Previous Fracture Fracture Predicts Fracture Vision Problems Deconditioning/Hypokinesis Balance Problems Tall Slim Build Hip Fracture Immediate Family-especially of the mother Inability to get out of a chair unaided Being on one s feet less than 4 hours per day OSTEOPOROSIS-RELATED FRACTURE Occurs in 1 of 2 women; 1 of 4 men Happens every 20 seconds Can be immediately life-altering and lifethreatening Annual Fracture Incidence Vertebral 700,000 Hip 300,000 Wrist 250,000 Other Sites 300,000 Cost >$46 million per day By 2020 >$178 million per day More fragility fractures occur in women with normal bone or osteopenia than in those with osteoporosis Therefore, when prescribing exercise, it is important to consider bone health in all populations Pasco JA, Seeman E, Henry MJ, et al. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int (2006)17:1404 Sornay-Rendu E, Munoz F, Garnero P, Duboeuf F, Delmas PD.. Identification of osteopenic women at high risk of fracture: the OFELY study. J Bone Miner Res Oct;20(10): Epub 2005 Jun 20. E. Siris & P. D. Delmas. Assessment of 10-year absolute fracture risk: a new paradigm with worldwide application. Osteoporosis International (2008);19:

18 VERTEBRAL BODY Bones of spine usually first to show signs of osteoporosis Primarily trabecular bone Fractures occur during movement that includes TRUNK FLEXION After one vertebral fracture, the risk for having a 2 nd vertebral fracture increases 5 fold! 1 woman in 5 will sustain a 2 nd vertebral fracture within 1 year The risk of death is 2.7 times higher than those with no fracture 1 Only 20-30% of all compression fractures are symptomatic 2 1 Too Fit To Fracture: Exercise recommendations for individuals with osteoporosis of osteoporotic vertebral fracture 2014 International Osteoporosis Foundation 2005 Report of the Surgeon General on Bone Health Oct accessed November 30, 2011 CONTRAINDICATED/CAUTIONARY MOVEMENT Movements that Flex Sidebend and/or Rotate the Spine ACUTE COMPRESSION FRACTURE MANAGEMENT Adapted from work by Betsey Newcomb, OT and Denise Pontbriand, PTA Start early on day of fracture if possible UN-load the spine position in supine or as close to supine as possible, hips and knees bent and supported to relieve pull of leg muscles on the spine Position from least to most compression supine, side-lying, prone, standing (standing more likely to precede prone) Pain relief with positioning, ice, moist heat, electrical stimulation along erector spinae muscles Back Extensor, Gluteus Maximus, Abdominal Isometrics NO OUT-OF-BED-TO-CHAIR ORDERS If patient must be seated, use reclined chair. Avoid hammock effect with folded blanket on seat and back to provide flatter surfaces Any head, neck or lumbar support should be minimal and used only as necessary. Initiate weight-bearing with standing, weight shifting, gait training using rolling walker or other optimal-height-adjusted support as soon as possible Consider bracing with Spinomed-Spinal Orthosis for Osteoporosis

19 Initial non-weight-bearing therapy is important for preventing vertebral body collapse in elderly patients with clinical vertebral fractures. Kishikawa Y. Int J Gen Med 2012: CONVENTIONAL RELATIVE REST Bedrest Soft brace wearing Minimization of weight bearing to spine At 12 wks body union 97% No back pain 12% Mild back pain 75% Moderate back pain 13% Length of stay 37.9 days INITIAL NON-WEIGHT-BEARING Complete bed rest (2 weeks) No weight bearing to spine followed by soft brace wear Meals and voiding in bed At 12 wks body union 100% No back pain 37% Mild back pain 62% Moderate back pain 1% Length of stay 49.2 days 55 KUMMELL S DISEASE delayed post-traumatic osteonecrosis of the spine A rarely-reported clinical entity that likely occurs with higher frequency than recognized Treatment decisions are similar to osteoporotic compression fractures Relevant factors include patient comorbidities, level of disability and pain, degrees of kyphotic deformity and presence of neurological compromise Although early reports were centered on conservative management, more recent reports favor surgical intervention Ma, Richard et al. Kummell s Disease: delayed post-traumatic osteonecrosis of the vertebral body. Eur Spine J (2010) 19:

20 THE MEEKS METHOD 12-POINT INTERVENTION FOR OSTEOPOROSIS PRE-ASSESSMENT ASSESSMENT

21 EDUCATION Patient Advocacy **** Resources QUESTIONS SITE-SPECIFIC EXERCISE Target At-Risk Areas Fountain-Of-Youth Muscles Start with Re-Alignment Routine Focus on Strengthening of the Back Extensors

22 PRINCIPLES OF THE MEEKS METHOD Site-Specific Exercise UN LOAD the Vertebral Bodies FRONT of the Backbone DECOMPRESSION Single Best Exercise for Most Back Pain TENSILE FORCE Strengthen Support Muscles Fountain of Youth Muscles Diaphragm & Intercostals Heart Back Extensors Abdominals Pelvic Floor Gluteus Maximus Gluteus Medius RE-ALIGNMENT ROUTINE Decompression Exercise Shoulder Press Wings of Collarbone Head Press Leg Lengthener Leg Press Uni- and Bi-Lateral ******************************* Side-Lying Leg Lift Press Bottom Leg Down To Initiate Movement

23 INDICATED EXERCISE - CORE ABS Isometrics DIAPHRAGM Balloon Breath PELVIC FLOOR Isometrics BACK EXTENSORS Foot Press INTERCOSTALS Segmental Breath BODY MECHANICS SAFE MOVEMENT during ADL S **** Hip Hinge Golfer s Reach Weightlifter s Squat Lunge Assistive Devices POSTURAL CORRECTION Visual Imagery Internal Plumb Line

24 BALANCE Feet-Together Semi-Tandem Tandem & Single-Leg Stance EXPERIENCE **** Fall-Proofing the Environment Gait With Exerstriders WEIGHT-BEARING EXERCISE Not just for lower extremities Weight-Shifting Assistive Devices Random Forces-Odd Impact Exercise for the Heart LIV (low intensity vibration) Constant, Calibrated.4 G MODALITIES PAIN CONTROL Moist Heat Ice Ice Massage Massage Positioning Ultrasound Myofascial Release Active-Isolated Stretching Electrical Stimulation along Erector Spinae

25 Bracing is part of a comprehensive approach to the management of patients with osteoporosis and/or compression fracture BRACING Purposes of Bracing Support and Protection Control of motion Prevent Fracture Allow weight-bearing activities Bracing usually associated with weakening of body part it is designed to protect SPINOMED Spinal Orthosis for Osteoporosis Spinomed IV Spinomed III

26 The Spinomed Spinal Orthosis for Osteoporosis Is the only spinal orthosis designed specifically for the management of osteoporosis and compression fracture and backed up by a peer-reviewed study that shows it strengthens the body part it is designed to protect namely, the back BRACING (with the Spinomed brace) 73% Increase Back Extensor Strength 58% Increase Abdominal Strength 11% Decrease Thoracic Kyphosis 25% Decrease Body Sway 7% Increase Vital Capacity 38% Decrease in Pain 15% Increase in Well-Being 27% Decrease in Limitations ADL s Increase in Body Height Pfeifer, Begerow, and Minne 2004 After Treatment No Brace After Treatment Clam Shell After Treatment Spinomed

27 Best Posture Day 1 Brace 2 ½ Weeks No Brace Thanks to Betsey Newcomb OTR/L Physical Therapist s Perspective olightweight ocan be worn under clothing - inconspicuous oeasy to Don and Doff ostrengthens rather than weakens even with more wear time; begin slowly and increase as patients can experience discomfort from muscle activation ocan fit to very severe thoracic hyperkyphosis odo not cut the straps too early ofit is critical should conform exactly to curves of back pelvic strap below iliac crests abdominal support in lower abdomen serpentine strap DOES NOT pull shoulders back Physical Therapist s Perspective Backed up by a peer-reviewed research study Ordered by Physician Michael Pfeifer, Bettina Begerow, Helmut Minne 2004 Fit by Orthotist orthotist should make sure patient understands how to don/doff Spinomed before leaving the office Physician, Orthotist, Physical Therapist, & Patient work together for ultimate best fit and satisfaction of the patient Combine with The Meeks Method Exercises for optimum results Instruct patient that orthosis should be worn when he/she is up and active, can be worn when sitting but patient will not get the most benefit of it

28 BRACING WITH THE SPINOMED Spinal Orthosis for Osteoporosis The Spinomed orthosis is the single, most significant advancement in the conservative management of osteoporosis and compression fracture EVER. Sara M. Meeks, PT, MS, GCS Use of the Spinomed is part of the comprehensive approach of The Meeks Method Goal of Management is to Minimize the Risk of the Next Fracture QUESTIONS BREATHING Awareness Diaphragmatic Segmental Targeted Areas Umbrella

29 RELAXATION Conscious Time-Out Contract-Relax Doing Fun Things Breathing ADVANCED EXERCISE Seated Classes Fitness Center Yoga -- Pilates & More Yoga Bone Camp with Sara Meeks, PT, MS, GCS, KYT SAFE Pilates for Skeletal Health with Sherri Betz, PT, GCS

30 Non-Compliant Patients STAGES OF GRIEF DENIAL "No way - can't be!" They ve got my report mixed up with someone else s ANGER "Darn! I am so angry: I did everything right and I get OSTEOPOROSIS anyway!!!! NEGOTIATING/BARGAINING "So... it's not so bad (osteopenia, borderline).. and, if I elongate A LOT, I can still do those forward bends, side bends and twists right Maybe just breathe and move more gently DEPRESSION "I am so down about this... I have this condition for the rest of my life. I just won't move at all cause I could break a bone ACCEPTANCE "Ok, I have osteoporosis. Sucks. But I'm going to find a way to do yoga and exercise because I love it... Just have to find a way to do it safely" o Health care workers may benefit from an individual approach o Face-to-Face delivery more effective o Take time to explain benefits of physical activity o Give clear & personalized advice o Message from providers should be more consistent o Educate older patients that it takes time to adapt to new physical activity (I usually say give it 6-8 wks ) o Involve relatives, friends and important peers o Check regularly to see that older patients understand what you are asking them to do Baeert V et al. Motivators and barriers for physical activity in older adults with osteoporosis. J Ger Phys Ther. Vol 38. Number 3. July Sept PP

31 o o o o o o o Personalize your approach consider clinical condition of the patient LISTEN to your patient Engage your patient as a partner in their therapy Give your patient something they CAN do and which will make a difference right away and they will be more likely TO do it Keep instructions simple & modified for each patient Err on the side of caution When in doubt, don t In the end minimizing risk of injury is the bottom line Thoracic Kyphosis JAMES Habitual Posture Best Posture Best Posture 1 Hour Later Chan et al. Bulletin of the World Health Organization 2003, 81 (11) The World s Osteoporosis is Ticking

32 Best way to diffuse the world s OSTEOPOROSIS TIME BOMB is to!! TAKE ACTION NOW!! THINK BONE WHEN YOUR PATIENT FIRST COMES THROUGH THE DOOR BOTTOM LINE MINIMIZE THE RISK OF THE NEXT FRACTURE

33 WHAT IS YOUR NEXT STEP Mikki Rosie Raven For information on the Spinomed Sit To Stand Chair endorphin.net Exerstrider Walking Poles walkingpoles.com LivMD Low Intensity Vibration Unit marodyne.com

34 For PDF s of The Re-Alignment Routine Pre-Assessment Form PowerPoint (color) Presentation Slide on Compression Fracture Management Kishikawa study send to sara@sarameekspt.com Check website for more education by Sara Meeks, PT, MS, GCS For seminars, webinars, books, DVDs and other products designed to enhance practice please visit DISCLAIMER Sara Meeks receives no commission on sales of any products presented or mentioned in this webinar She recommends only products that enhance practice.

35 WAITING FOR ME TO FEED THEM A R C H I E M O S E S BOBBSEY JUGHEAD QUESTIONS