Physical Activity Guidelines for Skeletal Health and Aging: Too Fit - - PowerPoint PPT Presentation

CSM 2/17/2017

Physical Activity Guidelines for Skeletal Health and Aging: “Too Fit to Fracture”

Wendy Katzman, PT, DPTSc (DSc), OCS Professor, UCSF 16th Annual Osteoporosis Update

Disclosures

UCSF license Stand TallTM exercise program

 Thanks to Dr. Lora Giangregorio and Osteoporosis Canada

Objectives

• Present best evidence for exercise and physical

activity in promotion of skeletal health in aging

• Review US Department of Health and Human

Services Physical Activity Guidelines for Older Adults

• Learn how guidelines change for skeletal health

prevention and treatment of osteoporosis and

• steoporotic fractures
• National Osteoporosis Foundation
• Osteoporosis Canada “Too Fit to Fracture”

US Department of Health and Human Services

Guidelines for physical activity essential to healthy aging:

• Avoid inactivity
• For substantial health benefits,
• At least 150 minutes a week moderate-intensity, or
• 75 minutes a week vigorous-intensity aerobic activity
• For greater health benefits, aerobic activity 300 minutes

a week moderate intensity, or 150 minutes a week vigorous intensity aerobic activity

• Muscle-strengthening moderate or high intensity and

involve all major muscle groups on 2 or more days a week

https://health.gov/PAGuidelines/

CSM 2/17/2017 Exercise for preventing and treating

• steoporosis in postmenopausal women

Pooled results from randomized controlled trial Outcome Participants Quality Comments Total number of fractures 539 (4 studies) high 4% absolute difference, but not statistically significant Bone mineral density % change: spine 1441 (24 studies) high Significant difference between groups 0.85% less bone loss Bone mineral density % change: femoral neck 1338 (19 studies) low No significant difference between groups

Howe et al, Cochrane Database Syst Rev, 2012

Effect of Exercise on Bone Density in Postmenopausal Women

Effect of exercise varies by activity

Hip Lumbar General (all studies pooled)

• +

High force dynamic (running, jumping) +

• Low force dynamic (walking)
• +

Progressive resistance + + Resistance (low weights)

• Combination: High impact/progressive

resistance + +

Howe et al, Cochrane Database Sys Rev, 2012

High‐Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial

Watson, S, et.al. JBMR, 2018

8‐month exercise training 2x/week for 30 minutes among postmenopausal women with low bone mass (n = 101)

• Supervised high-intensity

resistance and impact

• Deadlift, squat, and overhead

press

• 80–85% of one repetition

maximum

• Jumping chin ups with drop

landing

• 5 sets of 5 repetitions
• Independent, low-intensity,

home-based exercises High‐Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial

Watson, S, et.al. JBMR, 2018

• Between-group differences in

change in lumbar spine and femoral neck BMD

• +2.9 ± 2.8% EX vs
• 1.2 ± 2.8% CON, p < 0.001
• +0.3 ± 2.6% EX vs
• 1.9 ± 2.6% CON, p = 0.004
• Between-group differences in

change in all functional performance

• utcomes, p<0.001

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High‐Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial

Watson, S, et.al. JBMR, 2018

• Between-group differences in

change in lumbar spine and femoral neck BMD

• +2.9 ± 2.8% EX vs -

1.2 ± 2.8% CON, p < 0.001

• +0.3 ± 2.6% EX vs
• 1.9 ± 2.6% CON, p = 0.004
• Between-group differences in

change in all functional performance

• utcomes, p<0.001
• Bone strength increased in subset
• Adverse events: 1 in EX group

Christiansen & Bouxsein, Current Osteoporosis Reports, 2010; Briggs, AM, et al. Osteoporos Int, 2007; McIntrye, N, et al. Osteoporos Int, 2013

Other Factors Affecting Fracture Risk

load>>>strength

• Falls
• Spinal curvature
• Body posture or activity
• Neuromuscular control

National Osteoporosis Foundation

Guidelines for physical activity essential to healthy aging, and prevent and treat osteoporosis: If you're 65 years or older, generally fit, and have no limiting health conditions,

• 150 minutes of moderate-intensity aerobic activity (i.e.,

brisk walking) OR 75 minutes

• f

vigorous-intensity aerobic activity (i.e., jogging or running) every week

• weight training muscle-strengthening activities on 2 or

more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)

• daily posture exercise and balance training to prevent

falls

Component type or dose (number of studies) Reduction in falls % % Exercise with moderate or high challenge to balance (43) 22 14 - 30 Exercise with a high challenge to balance (30) 25 15 - 43 Total exercise dose more than 50 hours (equivalent 2 hours/week for 6 months (30) 23 13 - 32 Inclusion of walking training (30) 10 0 - 22 A high risk population (39) 10 0 - 20

Effect of Exercise on Falls

Pooled estimate from 54 trials of exercise on the rate of falls indicates 16% reduction (pooled rate ratio 0.84 (95% CI: 0.77 – 0.91)

Sherrington et al., 2011, NSW Public Health Bulletin

CSM 2/17/2017 Effect of Exercise on Falls

Catherine Sherrington et al. Br J Sports Med, 2017

• Exercise reduces fall rates in community-dwelling older adults 21%.
• 3 hours per week AND high challenge to balance reduces falls 39%!

Results of multivariate meta-regression exploring impact of trial-level characteristics on the effect of exercise on falls in community-dwelling older populations. Variable Effect on falls, Incident rate ratio (95% CI), p-value

High challenge balance training* 0.79 (0.71 - 0.88), <0.001 3+ hours per week of intervention 0.70 (0.60 - 0.83), <0.001 Neither high challenge or 3+ hours 0.90 (0.82 - 0.99), 0.03 High challenge balance training AND 3+ hours per week of intervention** 0.61 (0.53 - 0.72), <0.001

* High challenge includes: movement of center of mass, narrowing of the base of support and minimizing upper limb support. **Note: 72% heterogeneity explained by both variables; statistically significant comparisons in italics

Effect of Exercise on Hyperkyphosis

• Recent randomized clinical trials report targeted

exercise prevents kyphosis progression and modest improvements in measures of kyphosis

• Emphasis on back extensor muscle

strength/endurance and postural training

• Importance of training and reinforcement

Bansal S, et al. Arch Phys Med Rehabil, 2014; Katzman, WB, et al. Osteoporos Int, 2017; Katzman, WB, et al. BMC Musculoskeletal, 2017; Katzman, WB, et al. JMIR Aging, 2019

For Stronger Back Muscles

What type of activity?

Supine isometrics prone extension to neutral  core activation in standing

How often each week?

• 5-10 minutes per day of posture exercises
• Attention to posture during daily activities

Tools: Floor mat or soft but supportive surface, mirror, wall

Individuals with a history of a spine fracture:

• Might need a pillow under head if spine is curved
• Supine lying at intervals throughout the day “unloads” spine,

promotes spinal extension and stretches front shoulders and chest.

• Consultation with a trained professional

Giangregorio LM, et al Too Fit To Fracture: Outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures.Osteoporos Int. 2014

For Better Posture

Align:

• Back of head
• Shoulder blades
• Rib cage
• Buttocks/sacrum
• Feet

Practice best posture throughout the day

CSM 2/17/2017 Posture Cues

Target Example Cues Forward head posture

• Align head over the shoulders,

pelvis and feet.

• Lengthen through the crown of

the head. Hyperkyphosis, rounded shoulders

• Abdominals up and in,

shoulders back and down.

• Breathe into the concavity of

the chest, back and pelvis. Core stability  Gently brace the abdomen, contract abdominals with exhalation to improve stability.

Recommendations for older adults with osteoporosis

• r osteoporotic vertebral fracture:
• At least 30 minutes/day moderate/vigorous aerobic

physical activity

• Strength training 2 or more times a week
• Balance training daily
• Exercises for back extensor muscles daily
• Posture daily
• Spine sparing strategies like hip hinge and step-to

turn can ↓ spine loads  how to move, rather than how not to move

Osteoporosis Canada “Too Fit to Fracture”

Giangregorio LM, et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int, 2014

What is “spine sparing”?

Recommend modify activities that apply rapid, repetitive, weighted or end-range flexion (forward bending) or twisting torque to spine. How?

• Hip hinge
• Step-to-turn
• Avoid lifting from/lowering to floor
• Slow, controlled twist, not to end of range
• f motion
• Balance loads on either side of body
• Support trunk when flexing
• Hold weight close to body, not overhead

Slide courtesy L. Giangregorio; Osteoporosis Canada

Teach “spine sparing” during ADL and physical activity

Recommend modify activities that apply rapid, repetitive, weighted or end- range flexion (forward bending) or twisting torque to the spine. Saying “Don’t bend or twist” doesn’t teach how TO move  instills fear, disincentive to physical activity.

Slide courtesy L. Giangregorio; Osteoporosis Canada

CSM 2/17/2017

Slide courtesy L. Giangregorio; Osteoporosis Canada

Teach “spine sparing” during ADL and physical activity

Harms of Exercise?

• Unsafe exercises
• Unsafe transitions
• Tailor to ability,

preference, health status

• Appropriate progression

AVOID: flexion, rounding, twisting

Photos: Do It Right, American Bone Health, Sherri Betz, PT, GCS

Should physical activity recommendations vary?

Consider: vertebral fracture, current health, physical function, activity history, desire

NO YES

Osteoporosis, no vertebral fracture:

If history or strong desire, can you modify? Spine sparing!

Avoid high-impact sports, high fall risk or contact sports  do low impact, slower pace

Should physical activity recommendations vary?

Consider: vertebral fracture, current health, physical function, activity history, desire Osteoporosis with vertebral fracture, gait & balance difficulties, hyperkyphosis or pain:

• Alignment, spine sparing more important than intensity
• Moderate intensity aerobic physical activity
• May need trained instructor for classes, physical

therapist re: ADLs

• Get help beyond light ADLs
• Avoid sitting long periods
• Supine lying “unloads” the spine, promotes extension,

pain relief

CSM 2/17/2017

KEY Messages

• Exercise may reduce fractures:
• Can prevent falls, even in those at high risk
• May maintain bone density or bone strength
• Can improve posture and reduce applied loads
• Strong and consistent evidence for positive effect on

mortality, disability, other health outcomes…..

• Recommend multicomponent exercise programs –

resistance, aerobic training, balance, posture

Resources

Osteoporosis Canada Too Fit to Fracture http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/video- series-on-exercise-and-osteoporosis/ National Osteoporosis Foundation Health Professional’s Guide to Rehabilitation

• f the Patient with Osteoporosis

www.nof.org American Bone Health https://americanbonehealth.org/what-you-should-know/exercise WHO Fracture Assessment Tool http://www.shef.ac.uk/FRAX/tool.jsp Stand TallTM exercise videos www.geriatricspt.org/store/ wellness@ptrehab.ucsf.edu (em UCSF PT Health and Wellness exercise classes and exercise video wellness@ptrehab.ucsf.edu (em

REFERENCES

• 1. https://health.gov/PAGuidelines/. 2018 Physical Activity Guidelines Advisory Committee

Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018.

• 2. Moayyeri A. The association between physical activity and osteoporotic fractures: a

review of the evidence and implications for future research. Annals of epidemiology. 2008;18(11):827-835.

• 3. Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip

fracture in postmenopausal women. Jama. 2002;288(18):2300-2306.

• 4. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in

postmenopausal women. The Cochrane database of systematic reviews. 2011(7):Cd000333.

• 5. Watson SL, Weeks BK, Weis LJ, et al. High-Intensity Resistance and Impact Training

Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of bone and mineral research. 2018;33(2):211-220.

• 6. Christiansen BA, Bouxsein ML. Biomechanics of vertebral fractures and the vertebral

fracture cascade. Current osteoporosis reports. 2010;8(4):198-204.

• 7. Briggs AM, Greig AM, Wark JD, Fazzalari NL, Bennell KL. A review of anatomical and

mechanical factors affecting vertebral body integrity. International Journal of Medical

• Sciences. 2004;1(3):170.

REFERENCES (CONTINUED)

• 8. Briggs AM, van Dieen JH, Wrigley TV, et al. Thoracic kyphosis affects spinal loads and

trunk muscle force. Phys Ther. 2007;87(5):595-607.

• 9. Bansal S, Katzman WB, Giangregorio LM. Exercise for improving age-related

hyperkyphotic posture: a systematic review. Archives of physical medicine and

• rehabilitation. 2014;95(1):129-140.
• 10. Katzman WB, Vittinghoff E, Lin F, et al. Targeted spine strengthening exercise and

posture training program to reduce hyperkyphosis in older adults: results from the SHEAF randomized controlled trial. Osteoporos Int. 2017

• 11. Katzman, WB, Parimi, N, Gladin, A, et al. Sex differences in response to targeted

kyphosis specific exercise and posture training in community-dwelling older adults: a randomized controlled trial. BMC Musculoskelet Disord. 2017.

• 12. Katzman WB, Gladin A, Lane NE, et al. Feasibility and Acceptability of Technology-Based

Exercise and Posture Training in Older Adults With Age-Related Hyperkyphosis: Pre-Post

• Study. JMIR Aging. 2019;2(1):e12199.
• 13. Ball JM, Cagle P, Johnson BE, et al. Spinal extension exercises prevent natural

progression of kyphosis. Osteoporosis international 2008.

CSM 2/17/2017

REFERENCES (CONTINUED)

• 14. Gillespie L, Robertson M, Gillespie W, et al. Interventions for preventing falls in older people living in

the community. Cochrane Database of Systematic Reviews. 2009(2).

• 15. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in

nursing care facilities and hospitals. The Cochrane database of systematic reviews. 2010(1):Cd005465.

• 16. McClure R, Turner C, Peel N, et al. Population-based interventions for the prevention of fall-related

injuries in older people. Cochrane Injuries Group. The Cochrane database of systematic reviews. 2009;1.

• 17. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in

the community. The Cochrane database of systematic reviews. 2019;1:Cd012424.

• 18. Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated

meta-analysis and best practice recommendations. New South Wales public health bulletin. 2011;22(4):78-83.

• 19. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: an updated

systematic review and meta-analysis. British Journal of Sports Medicine. 2017;51(24):1750-1758.

• 20. Giangregorio LM, MacIntyre NJ, Heinonen A, et al. Too Fit To Fracture: a consensus on future

research priorities in osteoporosis and exercise. Osteoporosis international. 2014;25(5):1465-1472.

http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/