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Hello, I’m Margaret Martin. If you’re not familiar with me or my website, I encourage
you to go to blog.melioguide.com where you’ll get lots of information on osteoporosis and
exercise. Today’s talk is a summarized version of
a talk that I gave recently in Montreal on osteoporosis and bone health. And since it
was so well received, I decided to share it with a broader audience. So, welcome.
A little more about me. My career journey started in St. John’s, Newfoundland. Although
I am a McGill graduate, I went over to St. John’s did rotations in ICU, NICU, and neuro
rehab. Then across the country into young adult long term care.
Life brought me to middle of Canada in Toronto in peds, ortho, pulmonary rehab, and then
onwards to five years in the area of health, fitness and safety in a large corporation.
Then went down and worked in California for nine years where I went back into a hospital
setting in spinal cord rehab, burns, inpatient, outpatient ortho, neuro, and then finally
brought the family back to Canada in Ottawa, which is where we are currently located and
where my clinic, Function to Fitness, is located and the head office for MelioGuide.com.
So one thing in reflecting on my career is that I came to realize is that the one common
denominator of all my clients is that they had a skeletal system. So often when I was
addressing their stroke or was addressing the range of motion in the burn client I wasn’t
always considering their skeletal system. And so that’s the purpose of today’s talk
is for you, regardless of the setting that you are working in, is to give a deeper consideration
to your client's health and that deeper consideration is their bones.
I'm not going to spend a lot of time looking at bone physiology but the one thing I do
want you to think about is our bones undergo a constant modeling and remodeling and if
my big toe was a good representation of my skeleton at 50, my big toe would take ten
years to totally regenerate. Fortunately, it's only going to take about
a year. It's about six months old since my injury in this photo but the osteoblasts and
osteoclasts are always working to make adaptations to our skeleton based on the stresses of the
skeleton. In our youth there's a whole vibrant time
of going modeling which then starts to enter a more remodeling phase.
In today's talk I'm really wanting the message to get across of the different stages of life.
In thinking of those different stages and keep getting the idea that would stick in
your mind. With my menopause I went back and thought what movie sticks in my mind. Eat,
Pray, Love sticks in my mind. Let's look at bone health with that same concept.
Eat, Move and Greed. The nutrition that we take into our body. What we do in terms of
skeletal movement and challenges to our bones. Then what is happening to our hormones and
as physical therapists we are more in control of asking somebody what their menstrual cycle
is like. If their *** urges are more natural. We are going to be looking more at the estrogen/testosterone.
There are many other hormones that impact bone health but primarily as physical therapists
those are the ones that we should at the very least be paying attention to.
In today's talk we look at bone health from utero to university, from kids to careers
and visit big chunks of time in our life that the next one is post menopause to post-op.
We're going to look at these as stages of bone health through my eyes because these
are clients that I got to see. Let me share with you some of their case histories. Their
photos are obviously not truly them except for some of the clients but to protect their
health. Let's start with the first picture of bone
health, from utero to university. Two clients that I want to bring up, Molly,
who was presented to me with upper back pain and Kim, who came to see me because of knee
and hip pain, mostly in her sport which was basketball. Both these young ladies were in
their late teens when I first saw them. Their findings on first observation was that Molly
was on a vegan diet. I'm not going to go into the positives and
negatives of each because this will take an hour long talk but know that each one of the
things that I'm bringing up is because these things have either a positive or negative
impact on bone health. Kim was on a low protein diet, no omega 3.
Both of these diets have challenges when it comes to bone health. Molly was working with
a personal trainer which technically should have been a positive thing except the type
of exercises that she was being given that were inappropriate.
Kim was doing daily basketball practice and she had games on weekend which is great for
your bones except that there was a disproportionate amount of energy output for her energy input.
She was just having way too much breaking down, not enough anti-inflammatories in her
diet to support the level of intensity that she was training at.
Molly had irregular menstrual periods. Kim was on Depro Provera birth control which causes
cessation of menstrual periods. If you have a female who is entering a female athlete
triad type scenario you don't actually know if their body weight is problematic for their
cycle and whether or not their entering in amenorrhoea as well, as the drugs have other
issues. Molly presented in a teen with a cephalic
posture that was not able to be corrected so it's quite concerning and Kim had good
spinal alignment but with high level sports movements. She had poor hip and knee alignment.
I had some serious concerns with Molly. I did send her back to her doctors and ask for
a spinal x-ray before seeing her again. Sure enough the x-ray came back with fractures
at T6, 7, and 8. She went on to have a bone mineral density which showed severe osteoporosis
and yes, she was still in her teens. Then went on within two weeks time to have vertebroplasties
done at T6, 7, and 8.
Let's look at the bone health from utero to university for Molly and for Kim. Molly's
mother wears religious coverings significant in meanings in regards to vitamin D. Kim's
mom is a physical therapist, outdoorsy, a little more ability to absorb the Vitamin
D. Molly was premature, whereas Kim was a full term baby. Very different in terms of
the health of the bone even years later. Molly had benign hypotonia whereas Kim had
normal growth and development. Because of the hypotonia Molly had very limited outdoor
playing. No sports. She didn't actually start walking until the age of two and had sustained
an ankle fracture when she had started walking. Kim was very active in very many sports.
Molly didn't start her period until she was 14 whereas Kim started at a younger age, at
11. Given the number of years within a woman's lifespan that they've had their periods is
going to positively impact bone health. The last thing Molly had a fracture at her
elbow and at the patella from falling on ice. So simple which is still considered a puglian
fracture when she was 15. Kim because of the concern, as I mentioned earlier, in regards
to the female athlete triad and although she had a lot of good bone health leading up to
her late teens, she was starting to have some negative changes and had a hairline fracture
at 17. What was the intervention for both of these
young ladies? Molly, as I mentioned, did have vertebroplasty. Following her vertebroplasty
she did work with a nutritionist. The exercise intervention was very much around not modifying
her daily activities, isometrics and gradually we introduced more weight bearing and strength
training. An important component for Molly was the education
to gain weight, to maintain her weight, to maintain her normal periods so that she'd
have not only the nutrition, the eat. Not only the move, the exercise but also the greed.
The hormones working in her favor for optimizing her bone health.
Kim was really quick in terms of modifying. I was comfortable in looking at her protein
requirements, her omega 3 requirements. She upped those. She modified some of the exercises
we were giving to her. We worked on hip and knee alignment and she's done great. She's
made the provincial team and one other recommendation for her bone health was to make a consideration
about the birth control of choice that she made so that it would not negatively affect
her bone health. Here's a great example of two young women
where as a standard physical therapist we would see them, take care of their issues
but not always regard the bone health. In order to allow these two young ladies to enter
the next phase of life with as much bone in their bank as possible, I think we need to
make clear definitions. We are musculo-skeletal specialists and we
need to look at those skeletons. Let's move on into the next phase of life where eat,
move and greed is very important from kids to careers.
A really busy time in a woman's life where whatever they choose to eat. They are really
often making meals on the run and they're not only making them for themselves but for
their family. The movement is very limited to activities with kids or activities when
you're running to or from work. Then greed the effect of pregnancy and lactation on hormones
and then obviously the effect on bones. I'm going to introduce to you Simone who is
a client that I thought wow, she's a client who has really got it together. She's got
a well balanced diet. She was exercising 60-90 minutes a day. She had regular menstrual periods.
Birth control was taken care of by her husband who had had a vasectomy. But she came to see
me with vertebral compression fractures, when I first saw her.
The vertebral compression fractures were as a result of tobogganing with her kids. Wow,
then you start looking back. What is it that is missed in this ladies bone health? Let's
go back in her bone remodeling. She had three fractures as a child. Obviously,
no one noticed that as a red flag so there was no intervention done other than taking
care of the fractures, healing and things went on.
She was undiagnosed until her late 40's that she had had celiac. So many years really her
life of not absorbing all of her nutrients. She had had three children which wasn't an
issue except that she had them later on in life and she had had them fairly close together.
She had not only the years she was pregnant but she also nursed each of them for two years.
She had a long period of time and then she didn't have a lot of time before going into
menopause. These are things that affect bone modeling.
Her activity it was great that she was active so much but most of her activity was around
swimming which we know it isn't as weight bearing as it could be and walking her dog
or her dog walking her and that was a really brisk pace.
We know we need a brisk pace in order to affect bone health, at least at the level of the
hip. Last thing, an important thing, as a primary school teacher Simone was always bending
forward. A lot more weight bearing on the interior vertebral body of the vertebrae and
we know in the interior vertebral body there are less trabeculae than in the posterior
vertebral body so there's already possibly some micro-fracturing occurring but was just
stressed to a much higher level with the tobogganing an caused a vertebral fracture.
My intervention initially with Simone was pain management, teaching her body mechanics
both for safety and for pain management. Then we went on to gait retraining and exercise
hoping that she will have enough time to rebuild her bone back. She's going to have to have
some intervention. Possibly some HRT. Things she'll have to discuss with her doctor
but bringing her into the next phase of life, the post menopause to post operative period
because now we know that just with strictly loss of estrogen this is a significant time
where people actually start thinking about low bone health, low bone density, osteoporosis
because of the decrease in estrogen. It's also a time in people's lives in their
50s, things start to break down and we haven't been optimizing our healthy choices and so
medications get introduced and core morbidities happen.
There are many medications that have a lot of influence on bones. The Depro provera I
mentioned. Glucocorticosteroids, medication for anti-seizures, medication chemo therapy
meds. There's a long list of medication that can have a negative impact on our bones.
Just to put any other assault to our body that affects movements, so strokes, Parkinson's,
COPD, so many things that will affect the ability to stress our bones that then obviously
will then lead to lower bone density. Food intake, most people get older, they're
not preparing foods for their family anymore. They're just making small meals. They might
not be ingesting as much protein, calcium, the nutrients, they're not out in the sun
as much so their vitamin D absorption as well as their aging skin doesn't absorb as much
vitamin D. The weight bearing and strength training if
it has not been part of their life before a lot of people don't start taking it on.
But, it's such an important thing to do especially as we enter this last phase of life.
Lastly, in this stage, we most of us as physical therapists are thinking fall prevention, great
but we need to be considering at a deeper level all the other things that we brought
up. If you haven't met Babs before, Babs is somebody
who I feature a lot on my website and in my blogs and she's a dynamic 97 year old. We've
worked a lot through strength training, flexibility, balance.
With Babs she was a unique case study where I got to work with her twice a week. We worked
on agility training. Similar to what you do with football players and the progression
was just phenomenal. When we started to introduce this to local hospitals, and giving them services
around Ottowa and Montreal. The therapists that have been using this on a daily basis
have just found it really exciting and finding really good results with their clients and
fun to do for them as well. I encourage you to think about your bone health,
whether your clients are in the stages in utero to university, kids to careers, or post
menopause to post-op, learn a little bit more. Come and take my free course; blog.mealio.guide.com.
Come to this page with hundreds of articles that you can search for in the search box.
Click on the free course and encourage you as a musculo-skeletal specialist to take into
consideration the skeleton of your patients. Thank you very much for tuning into Melioguide
today. It was a pleasure sharing this with you.