Chapter 4 ResistanceTraining Strategies for Individuals with Osteoporosis

Osteoporosis Overview • Also known as brittle bone disease • Means “porous bone” •

Osteoporosis Overview • Osteopenia – Low bone density – Precursor to osteoporosis • Resistance

Prevalence of Osteoporosis • Affects approximately 10 million Americans over age 50 • Approximately

Prevalence of Osteoporosis • By 2020, half of all Americans age 50 or more

Prevalence of Osteoporosis • Non-Hispanic black women and Mexican. American women at lower risk

Economic Impact of Osteoporosis • Up to $20, 000 per incident for treatment and

Bone Modeling • Defined as bone shape growth and alterations • Occurs during puberty

Bone Remodeling • Maintains bone mineral density, structural integrity, or strength of bone area

Remodeling Occurs via Two Processes 1. Resorption – Osteoclasts dissolve bone mineral 2. Deposition

Menopause and Osteoporosis • Women entering perimenopause lose one percent bone annually • Lack

“Swiss Cheese” Appearance of Osteoporosis Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Cortical (Compact) Bone • Comprises 80 percent of skeleton • 90 percent more dense

Trabecular Bone • Also known as cancellous and spongiosa bone • Comprises 20 percent

Trabecular Bone • Bone loss causes loss of stature, hunch back, forward position of

Comparison of Cortical and Trabecular Bone Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS

Bone Loss Ratios • Ratio of cortical to trabecular bone varies within specific bones:

World Health Organization (WHO) Bone Mineral Density Classification System • Normal – Bone mineral

World Health Organization (WHO) Bone Mineral Density Classification System • Osteoporosis – BMD 2.

Primary Osteoporosis • Marked acceleration of bone mass loss • Three types include: 1.

Secondary Osteoporosis • Consequential condition • Results from another disease process and/or its treatment

Benefits of Resistance Training • Focuses only on skeletal benefits • Assists in maintaining

Benefits of Resistance Training • Improves muscular fitness – Helping prevent and/or improve spine

Osteoporosis Prevention • Start in puberty by getting: – – Adequate intake of calcium

Benefits of Strain on Bone Tissue • • Bone mass maintenance Bone formation Morphology

Strain Needs to be in Right Amount • Multiple strain repetitions unnecessary for bone

$Strain Needs to be in Right Amount • Too much strain causes fractures –$

Building New Bone • Strain needs to be between 1500 and 3000 • High-impact

Building New Bone • High-impact exercise must be maintained for long-term – Or bone

Research Supports Resistance Training • Regular, progressive resistive exercise increases bone density at hip

Research Challenges • Men often not adequately studied • Difficult to separate impact of

Research Challenges • Subjects often have osteopenia, osteoporosis, and no/low risk of low bone

Regular Resistance Training Program • Improves and maintains overall muscular strength and bone health

Regular Resistance Training Program • Main goals: – Improve strength/functioning – Reduce risk of

Cautions • Consider overall health status • Understand that resistance training may exacerbate existing

Cautions • Understand condition – Some exercises indicated for osteopenia contraindicated for osteoporosis •

Program Design Considerations • Trainer must understand bone loading, unloading, and overloading principles –

Program Design Considerations • Programs designed to prevent osteoporosis will be more aggressive/have more

To Prevent or Improve Spine Deformity • Focus on strengthening abdominal, neck, erector spinae,

Strength Testing Considerations • • Obtain physician clearance Ensure safe environment Perform all testing

Strength Testing Considerations • Perform maximal isometric muscle strength assessment if not contraindicated –

Strength Testing Considerations • Be aware of contraindicated tests – E. g. , spinal

Program Components and Exercise Selection • Perform all exercises with slow, controlled movements •

Program Components and Exercise Selection • Conclude activity with 10 - to 20 -minute

Program Components and Exercise Selection • Perform assessments of physical performance measures at baseline

Program Overview • Individual should train twice per week with high-force loading • May

Program Overview • Maintain rating of perceived exertion (RPE) of “somewhat hard” to “hard”

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Osteoporosis Overview • Also known as brittle bone disease • Means “porous bone” • Erodes bone tissue until it becomes fragile and breaks Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Prevalence of Osteoporosis • Affects approximately 10 million Americans over age 50 • Approximately 34 million Americans have osteopenia • Annual fracture rates from weak bones affect 1. 5 million Americans Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Prevalence of Osteoporosis • By 2020, half of all Americans age 50 or more will have osteopenia and/or osteoporosis unless prevention measures implemented • Predominantly affects small-framed Caucasian and Asian women Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Prevalence of Osteoporosis • Non-Hispanic black women and Mexican. American women at lower risk • Fracture risk for women: – Age 50 = 9. 8 percent – Age 80 = 21. 7 percent • Wrist, hip, and spine – Common fracture sites Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Economic Impact of Osteoporosis • Up to $20, 000 per incident for treatment and rehabilitation for fractures • Approximately $80, 000 per incident for lifetime care from one hip fracture • More than $17 billion annually to care for bone fractures Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Bone Modeling • Defined as bone shape growth and alterations • Occurs during puberty and young adulthood • Peak bone mineral density occurs around age 20 Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Bone Remodeling • Maintains bone mineral density, structural integrity, or strength of bone area • Well-balanced across genders during 20 s and 30 s Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Menopause and Osteoporosis • Women entering perimenopause lose one percent bone annually • Lack of estrogen production causes rapid bone loss for five or more years • Resorption rate exceeds deposition rate – Resulting in less dense bone Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Cortical (Compact) Bone • Comprises 80 percent of skeleton • 90 percent more dense than trabecular bone • Apparent density = 1. 8 g/cm 3 – Grams per cubic centimeter • Comprises more than 90 percent of diaphyseal shaft of long bone Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Trabecular Bone • Also known as cancellous and spongiosa bone • Comprises 20 percent of skeleton • Apparent density = 0. 2 g/cm 3 • Comprises approximately 70 percent of spine Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Bone Loss Ratios • Ratio of cortical to trabecular bone varies within specific bones: – Trochanteric region of hip = 50: 50 – Proximal femur of hip = 57: 43 • Gender affects bone loss – Women lose 50 percent of trabecular bone – Men lose 20 percent of trabecular bone Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

World Health Organization (WHO) Bone Mineral Density Classification System • Normal – Bone mineral density (BMD) within 1 standard deviation (SD) of young adult mean – 1 SD • Osteopenia – BMD 1 to 2. 5 SD below young adult mean – -1 to -2. 5 SD Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

World Health Organization (WHO) Bone Mineral Density Classification System • Osteoporosis – BMD 2. 5 SD or more below young adult mean – > -2. 5 SD • Severe osteoporosis – BMD > 2. 5 SD below young adult mean and plus fractures Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Primary Osteoporosis • Marked acceleration of bone mass loss • Three types include: 1. Postmenopausal • Type I 2. Senile • Type II 3. Idiopathic osteoporosis • Unknown cause of origin Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Secondary Osteoporosis • Consequential condition • Results from another disease process and/or its treatment – E. g. , corticosteroid treatment for asthma, rheumatoid arthritis Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Benefits of Resistance Training • Focuses only on skeletal benefits • Assists in maintaining bone mass and affects bone morphology • Enables skeleton to resist fracture-causing loads Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Benefits of Resistance Training • Improves muscular fitness – Helping prevent and/or improve spine deformity • Reduces risk of falls and related injuries • Helps individuals functioning optimally in daily life Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Osteoporosis Prevention • Start in puberty by getting: – – Adequate intake of calcium Vitamin D-rich foods Judicious sun exposure Daily weight-bearing physical activity Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Benefits of Strain on Bone Tissue • • Bone mass maintenance Bone formation Morphology changes that improve strength Increases in cross-sectional size of bone and thickness of cortical bone • Biochemical signals that influence bone cell function and keep osteocytes vital Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Strain Needs to be in Right Amount • Multiple strain repetitions unnecessary for bone modeling or maintenance • Strain magnitude and rates must be higher than normal to signal bone production • Inadequate strain or inactivity causes bone loss Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

$Strain Needs to be in Right Amount • Too much strain causes fractures –$

Strain Needs to be in Right Amount • Too much strain causes fractures – Approximately 3000 • Strain between 700 to 1500 maintains bone mass Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Building New Bone • Strain needs to be between 1500 and 3000 • High-impact exercise provides enough strain rate and magnitude – E. g. , weight bearing activity, resistance training, impact activities (one- or two-footed jumping) Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Research Supports Resistance Training • Regular, progressive resistive exercise increases bone density at hip and spine by 0. 5 percent to 3 percent – Benefits both young and postmenopausal women – Needs to occur two to four times per week Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Research Challenges • Men often not adequately studied • Difficult to separate impact of multiple therapies • Terms such as strength training, weightbearing, weighted exercise, resistive training used interchangeably Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Research Challenges • Subjects often have osteopenia, osteoporosis, and no/low risk of low bone density • Currently, no studies conclude that resistance training prevents fractures Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Regular Resistance Training Program • Improves and maintains overall muscular strength and bone health of older adults • Benefits physical functioning and mobility • Positively impacts negative sequelae – Accompanies aging Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Cautions • Consider overall health status • Understand that resistance training may exacerbate existing medical problems, increase muscle/joint injuries, induce heart attack (rare) Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Cautions • Understand condition – Some exercises indicated for osteopenia contraindicated for osteoporosis • Involve physician • Understand severity of disease Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Program Design Considerations • Trainer must understand bone loading, unloading, and overloading principles – As well as accompanying risks • Modify general resistance training guidelines to manage specific medical issues related to varying severities of disease – Refer to Chapter 3 Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

To Prevent or Improve Spine Deformity • Focus on strengthening abdominal, neck, erector spinae, scapular, and gluteal muscles • Include exercises that stretch anterior body structures • Include spinal extension exercises • Remain alert to signs training too aggressive for individual Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Strength Testing Considerations • • Obtain physician clearance Ensure safe environment Perform all testing in upright posture Use 10 RM testing for strength assessment Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Strength Testing Considerations • Perform maximal isometric muscle strength assessment if not contraindicated – Hypertension • Perform falls risk assessment • Perform cardiopulmonary exercise test if suspect patient at risk for heart disease Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Strength Testing Considerations • Be aware of contraindicated tests – E. g. , spinal flexion, sit-and-reach, 1 RM strength assessment • Have standard emergency medical procedures in place Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Program Components and Exercise Selection • Perform all exercises with slow, controlled movements • Perform flexibility exercises almost daily • Precede all activity with five- to 10 -minute warm-up on upright cycle – Without load Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Program Components and Exercise Selection • Conclude activity with 10 - to 20 -minute cooldown stretching • Follow ACSM guidelines for progression with special considerations for osteoporotic older adult Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Program Overview • Individual should train twice per week with high-force loading • May need to begin with two- to four-week acclimatization period • Progress from 1 to 2 sets of 8 repetitions at progressive load Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Program Overview • Maintain rating of perceived exertion (RPE) of “somewhat hard” to “hard” • Target all major muscle groups • Give extra emphasis on lower body and back extensor strengthening • Review sample 24 -Week Program Copyright © 2010 Delmar, Cengage Learning. ALL RIGHTS RESERVED.