Bone Matters with Dr. Marla Shapiro
This is the third in a series of columns, exclusive to HealthandBone.ca that will focus on issues that are important to you, as a person concerned about their own bone health, or of that of a family member or friend. Dr. Marla Shapiro will draw upon her expertise and that of other expert colleagues to keep you up-to-date on the latest thinking in osteoporosis.
When it comes to osteoporosis, do you know your score?
As I discussed in my first column on health and bone, although it may seem as though it snuck up on you, osteoporosis is not something that develops overnight. Osteoporosis is a long-term disease — the result of low bone mass and the breakdown of bone over time. The first sign that there is any problem at all may very well be a bone break or fracture. Osteoporosis steals valuable bone mass and corrodes bone tissue, without you even knowing it, leaving your bones weak and vulnerable to a break.
Detecting osteoporosis early is important and can help prevent fractures from occurring in the first place. Having your bone mineral density (BMD) tested will help your doctor determine whether you are at risk or whether or not you have low bone mass or osteoporosis.
A BMD test is safe and painless. It involves lying on a table for about 10 to 20 minutes while low x-ray radiation is used to measure the thickness of your bones. Small amounts of x-ray radiation are transmitted through your bones. The amount passing through is measured. A particular kind of doctor called a radiologist can determine how thick or thin (dense) your bones are by measuring the amount of light passing through them. The more light passing through, the less dense your bones are.
BMD test results are given to you in the form of a number called a T-score. How is this number calculated? When you have your bone mineral density tested, it is compared to an established standard. The T-score represents this comparison. T-scores tell you how far your bone mineral density differs or deviates from what is considered to be normal for a young adult.
According to the World Health Organization, a T-score between +2.5 and -1 is considered normal; a T-score between -1 and -2.5 is considered low bone mineral density (osteopenia) and a T-score below -2.5 indicates osteoporosis.
BMD testing is an important diagnostic tool but it is only part of the equation in determining fracture risk.
Do you know your fracture risk?
While BMD is important, doctors are likely to look at other factors as well to determine what is referred to as absolute 10-year fracture risk. This is your likelihood of having a hip or major osteoporosis-related fracture within the next 10 years.
There are four key factors that can increase your risk for fracture.
| Risk factors for fracturing |
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Using your BMD and age and taking into consideration any of the risk factors you may have from the table above can help your doctor determine your absolute 10-year fracture risk.
Adapted from Siminoski 2005, p. 182.
This table represents your fracture risk taking into account age and BMD T-score. For example, if you are a 65 years old woman and your BMD T-score is -2.0, you are at moderate risk of fracture. However, your fracture risk goes up one level (from low to moderate or, in this case, from moderate to high) if you have had a fracture or are taking steroids such as prednisone. If you have both of these risk factors, then you are at high risk no matter what your T-score is
Knowing your 10-year absolute fracture risk is helpful for your doctor in determining what is the best way to manage your osteoporosis. Based on your fracture risk he or she may recommend any or all of the following, depending on what your risk is:
- increasing the amount of calcium and vitamin D you take in each day
- strengthening your bones through certain kinds of physical activity
- taking medication
Don’t wait for a break
One way that you can help yourself is by strengthening your bones through physical activity. Remember to always talk to your doctor before starting any exercise program to determine what is right for you.
I asked Certified Older Fitness Expert and owner of Toronto's Vintage Fitness, Erin Billowits, about the link between exercising and osteoporosis.
She stresses that leading a more active lifestyle, which includes exercise, is directly related to lowering your risk of developing osteoporosis and to maintaining bone mineral density later in life. The goals of an exercise program for someone with low bone density should be:
- increasing your muscle strength especially in the upper body to prevent sloping shoulders;
- developing a strong core to properly support your back; and
- improving your balance to prevent falls which are the leading cause of fractures.
How does exercise help increase bone density?
Bone is a living tissue that has both cells that build bone (osteoblasts) and cells that break down bone (osteoclasts). And like muscle, bone responds to exercise by becoming stronger. As Erin explains, “bones get stronger and denser when you make them work. And “work” for bones means handling impact, the weight of your body, or more resistance. Exercise causes the cells that build bone to replace weak or damaged bone. If someone is inactive and malnourished, the cells that break down bone take away more than the cells that build bone can deposit and bone density declines.”
Exercises that are good for your bones
Currently, we know the most about two types of exercises that are important for building and maintaining bone density. These are weight-bearing and strength training exercises.
Weight-bearing exercises are simply those done staying upright so that the force of gravity is working through the skeleton. Our skeletons aren’t choosy; any exercise that involves working against gravity, such as running, walking, weight lifting, or stair-climbing, can potentially build bone.
Some exercises, such as those done on a fixed machine in a gym, are not using your own body weight to get stronger but an actual weight to strengthen your muscles and build your bones. Strength training against gravity using your own body weight, or working with weights, bands or medicine balls is also weight bearing.
Erin adds "I recommend mostly standing exercises for osteoporosis clients because they not only build muscle but can train balance and core-stability as well."
There are hundreds of other weight-bearing exercises. Some traditional examples include chair squats, where someone sits in and out of a chair, wall push-ups and standing bicep curls. For other examples of exersice that is safe for people with osteoporosis, click here.
My patients often ask me if "cardio" exercises help bone. Erin advises "traditional cardiovascular exercise such as walking, swimming and the elliptical machine will help to build bone density, reduce cholesterol and stress. And increasing your activity level from household chores to climbing stairs will have a positive impact on your health. However, for most people, the missing part of their exercise program is proper strength training, which for osteoporosis clients is critical. Runners and walkers can develop sloped shoulders and issues with bone density in their upper body if their posture is poor and muscles in their arms, chest, shoulders and back are not being used.
The most effective and safest exercises for people with osteoporosis involve movements that are done in short bursts. This means a moving exercise such as squatting into a chair holding weights is better than a static exercise such as squatting against a wall and holding the position. Exercising several times per week (20 to 60 minutes) is better than less frequent longer sessions and the exercises should change to provide a varied challenge to the bones.
How much exercise do I need?
To get started try some safe weight-bearing exercises 2-4 times a week and walk for 20-30 minutes every day. For example, 3 sessions for 10 minutes each will provide the same bone benefit as one 30-minute session. If you can’t fit 10 minutes in, spread your impact exercises throughout your day by taking the stairs or by parking farther from the store or work.
If you don’t have much time for strengthening/resistance training, do small amounts at a time. You can do just one body part each day. For example do arms one day, legs the next and trunk the next. You can also spread these exercises out during your normal day.
Caution - Exercises to Avoid
Trainers that specialize in older adult fitness know that clients with osteoporosis should minimize bending forward from the hip (forward flexion) and twisting. More severe cases should avoid high impact activities such as running.
Here are some other precautions you should consider:
- avoid jarring or twisting movements
- avoid abrupt and sudden or high impact movements
- avoid abdominal curl-ups
- avoid heavy lifting
- don’t overdo it
Be back smart. Don’t store heavy objects on very high or low shelves. When exercising or performing everyday activities, think before you lift and always practise good lifting technique:
- Bend your hips and knees, not your back
- Keep your tummy muscles pulled in tight
- Keep the load close to your body
- Move your feet, don’t twist your back
What about yoga or Pilates?
Many of my patients ask me about these two popular forms of exercise. I asked Erin about the safety of yoga and Pilates for women with osteoporosis. Erin concedes that “Pilates has exploded in popularity in the last 10 years leading to a diverse range of different programming. I attended a workshop with one of the leading Pilates companies STOTT PILATES a few months ago focussing on osteoporosis. Many of the standard Pilates exercises are safe for someone with osteoporosis including matwork to stabilize the spine (arm circles, one leg circles, side leg lifts) and spinal extension exercises (breast stroke, swan dive). A few Pilates moves that are not recommended are:
- flexion exercises such as cat stretch, rolling like a ball and the open legged rocker
- twisting or rotation exercises such as the saw and side twist sitting
There are dozens of different types of yoga from hot yoga such as Moksha to slower paces of movement in Hatha yoga. Avoid spinal twists and excessive forward bending which is typical of “flow” types of yoga. Don’t be afraid to try Pilates or yoga as many of the exercises are excellent for strengthening the core and spine. Ensure that your instructor has done the full 200 hour yoga course or is accredited by a well known Pilates studio and has experience modifying exercises for osteoporosis.”
It is always a good idea that you speak to your doctor or physiotherapist prior to beginning an exercise program.
In closing – Knowledge is key to effectively determining fracture risk
Having your bone mineral density tested and knowing what the test results mean is important knowledge for you and your doctor to have. With it your doctor can determine whether or not you have osteoporosis.
However, BMD testing only tells part of the story when it comes to determining your fracture risk. Talk to your doctor and discuss any risk factors you might have. If you have not already been provided with it, ask your doctor for your 10-year absolute fracture risk. Having more information is always helpful and can aid you and your doctor in making the best decision about your course of treatment.
Finally, don’t wait for a break. If you are not already doing so, get your bones moving. Just walking regularly is a step in the right direction!
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