Written by Tim McGonigle, PT
Introduction
We continue to gain insight into osteoporosis mitigation as our exposure to clients with it expands. Passing these insights along will hopefully motivate you to get on board and stay the course while finessing the application to fit your presentation better. Starting proactively is best as the fracture fear is eliminated. However, we are gaining confidence in the ability of people with T-Scores into the 4’s participating at moderate levels without issue.
Lesson #1: Understanding Fragility at Different T-Scores
It is helpful to know how fragile bones are at different T-Scores. We have many of our clients with T-Scores in the low (-)3’s who are successfully participating pretty aggressively in the program without problems. Many even report falling without fracture. However, we do have one mid-60-year-old female client with T-Score of lumbar of (-)3.0, left femoral neck of (-)2.1, right femoral neck of (-)1.8 who has been a longtime participant in our group training sessions and is quite fit. She did suffer a fracture of her lumbar spine while moving a 75 lb. object when it struck the table top she was trying to place it on, jarring her lumbar spine. To ignore fracture potential is nearsighted, but we all agree that her bones were only moderately fragile with her (-)3.0 T-Score as she was tolerating jumping during the group exercise sessions. It took an asymmetrical jarring impulse under a 75 lb. load to cause the fracture. She resumed participation in the group training sessions and got instructions in our osteoporosis program 6 months after the fracture, including loading her lumbar vertebrae.
Lesson – It may take a reasonable amount of force to cause a fracture even in someone with T-Scores of (-)3.0 and many have been successful at participating pretty vigorously in the program without incident. Fracture risk once in the osteoporotic range should not be ignored, though.
Lesson #2: When More Vigor May Be Necessary
73-year-old with T-Scores in the (-)2’s. She was faithful in performing the cell signaling program for several months and has been working out in the group exercise sessions for several years. Her recent DEXA scan showed no change from the one taken two years ago. She was quite disappointed. Our hypothesis was that she was perhaps not performing the impact exercises vigorously enough to deform the bone and causing the cells to produce the regenerative signal. She has stepped it up and is tolerating a marked increase in vigor of the cell signaling exercises, including jumping. She expressed her disappointment to her endocrinologist. The endocrinologist told her this was really a huge win as the medication she is on for her thyroid issue facilitates rapid bone loss, so the fact her T-Scores held steady was a pleasant surprise to her doctor. We are all anxious to see what will happen with the increased vigor of her cell signaling exercises.
Lesson #1 from this example – To produce more bone cells the impact must be sufficient to deform the bone. As nobody knows when this threshold is reached, the exercises should be performed as vigorously as feels safe. As nobody knows where the failure/fracture point will be, this leads back to Belinda Beck’s “Uncomfortable truth” comment regarding the risk involved in a productive program for people who already have osteoporosis. It’s prudent to ramp up the vigor gradually as it is much better to be safe than sorry in this case, but eventually the vigor has to be enough to deform the bone for it to be productive.
Lesson #2 from this example – Medications often facilitate bone loss or inhibit bone production. Check the side effects of the medication you are on. This might provide an indication regarding how diligent you will need to be to produce the change you are looking for or even in your definition of success.
Lesson #3: Illness, Coughing, and Fracture Risk
A mid-60-year old with T-Scores of only (-)2.3. She developed “the worst respiratory illness she has ever had” last year leading to prolonged bouts of severe coughing. During a coughing fit she fractured three of her lower thoracic vertebrae.
Lesson – Viruses weaken connective tissues. It may be prudent to stop the cell signaling aspect of the program when ill if T-Scores are above (-)1.8. To be conservative, perhaps not resuming the program for three weeks after recovery from the illness. As no one knows where the fracture point will be, erring on the side of caution for a few weeks is much better than suffering one.
Lesson #4: Soft Tissue Adaptation Matters Too
One of our 70-year-old clients severely bruised her heel from the stomping exercise. She did have an x-ray that did not reveal a fracture, but the bruise has inhibited her ability to fully participate in the program for the past 4 months. A few of our other clients also developed plantar pain, thought to be plantar fasciitis, from the quick heel raise and/or the stomping
exercises.
Lesson – It may be prudent for all participants to give their tissues time to toughen with a slow ramp up of vigor over a 3-4 month period. It is better to be consistent with a slowly progressive program even if it is initially ineffective in causing the bone to signal for the first few months than getting started and having to stop due to soft tissue or bone bruise injury.
