Understanding Bone Health

Bone is living tissue that is constantly changing and is influenced throughout the life span by the balance between bone formation and reabsorption. The functions of bone are: 1) storing minerals, 2) making red blood cells, 3) providing the skeletal foundation for movement & posture.

Age Related Changes in Bone

Cortical (80% of skeletal mass) and trabecular (20 % of skeletal mass) bone are the two types of bone which make up our bony skeleton.

Cortical bone is the outer dense layer found predominately in the long bones of the body such as the femur and the humerus. Trabecular bone (the primary culprit in osteoporosis) makes up the porous or sponge-like interior bone marrow. Trabecular bone predominates in vertebral bodies and the neck of the femur, hence the vulnerability of these bones when osteoporosis is present.1

Bone mass doubles from birth to age 2, it doubles again by age 10, and it doubles a third time so that at about age 18 to 25 years the peak bone mass or density will be reached.2 If a higher peak bone mass is reached the likelihood of developing osteoporosis may diminish in later years. The calcium intake in these formative years also influences peak bone mass and is one factor that influences your bone health for years to come. After our mid-30’s we lose about �% to 1% of bone mass per year. With hormonal changes, specifically the decrease in estrogen associated with menopause, women are more prone to developing osteoporosis than men. Bone loss increases in women from 1% to 5% per year with menopause and for about 5 to 6 years after a women’s last period. After this transitional period up to age 70 it returns to about the rate of decrease that was present before menopause.2

Although 1 in 2 women compared with 1 in 8 men will be affected by osteoporosis during their lifetime according to the Foundation for Osteoporosis Research and Education3, please remember that bone loss is a natural part of aging that has been occurring for eons.

Bone mineral density (BMD) is the test and measure recommended by current medical standards of care however, it is only one indicator of bone health. See our article Bone Mineral Density for more information. It is important to separate out facts from popular media myths and consider the financial impetus of drug companies, doctors, and milk producers when discussing the topic of osteoporosis.4

What is Osteopenia?

Osteopenia where the bone mass or density is mildly reduced (a loss of 10% to 20%) and may indicate the first sign of age related changes in bone. When a BMD test is done there is a comparison of the T-score obtained to that of a young adult (25-30 year old). Osteopenia is diagnosed if the T-score is -1 to -2.5 standard deviation points below the mean of the comparative young adult score.5

What is Osteoporosis?

If the standard deviation is more than -2.5 below the young adult norm, osteoporosis is diagnosed. As osteoclast activity (cells that breakdown bone) exceeds osteoblast activity (cells responsible for build up of bone) trabecular bone begins to deteriorate as bones become increasingly fragile. The inside of the bone can become more brittle with holes or spaces thus decreasing the density of the solid tissue. If the bony tissue breakdown becomes severe enough even normal daily activities such as coughing or sneezing can cause spontaneous fragility fractures.6

Among women over 50 years of age, the statistic from the National Osteoporosis Foundation (NOF) is that 50% or every 1 in 2 will have osteoporosis (NOF 2005). Hopefully this statistic will make it clear why a Somatic Educator should be informed about osteoporosis and know how to limit potential risks when teaching movement classes.

Promoting Healthy Lifestyle Changes

Looking beyond the medical model of bone mineral density, as a Somatic Educator, it may be important to inform yourself about what can be done to promote bone health in addition to teaching processes and classes. The Osteoporosis Education Project suggests a simple yet holistic approach to bone health where women are educated about avoiding foods and activities that contribute to the breakdown of bone while encouraging the behaviors that lend to building bone.4

The following contributors are known to deplete bone stores and contribute to bone loss.4 When working with clients, the first six contributors are lifestyle changes of which clients can make informed choices. The other factors are related to the client’s health and pharmaceutical use history.

  1. Smoking – Decreases BMD and Estrogens2
  2. Alcohol Consumption – In excess suppresses osteoblast activity2
  3. Caffeine – 300 to 400 mg/day doubles fracture risk
  4. Weight Loss ‐ Fat cells produce estrogen which stimulates osteoblast activity. The extra few pounds that come with menopause may actually be helpful to your bone health!
  5. Stress – High and sustained levels of adrenal cortisol suppress the immune system and cause calcium to be removed from bony stores.
  6. Acidosis – The body will deplete mineral stores in bones to counter the effects of a highly acidic diet (sugar, animal protein, refined carbohydrates) and maintain a slight alkaline blood pH.
  7. Prescription Drugs – Corticosteroids(with 4 months use bone mass decreases 8%), Thyroid replacement hormones, Antacids, Proton pump inhibitors (Nexium, Prevacic, Prilosec)
  8. Digestive Disorders – Celiac, Crohns, Colitis, Irritable Bowel Syndrome. All interrupt calcium and mineral absorption
  9. Endocrine Disorders – Especially Pituitary, Thyroid and Parathyroid gland imbalances as they assist in calcium regulation.

In addition to avoiding these risk factors, what are the most important factors that can contribute to bone formation? A diet rich in fresh green vegetables and fruits will help maintain the proper alkaline levels in your blood and avoid acidosis. Vitamin D will help in calcium absorption and can be taken through a dietary supplement (D3 or cod liver oil) or through daily sun exposure without sunscreen (15-20 minutes of full body exposure).4 Ample calcium in the diet is necessary for good bone health, but dairy consumption may be overemphasized, according to some studies that show that increased dairy intake does not decrease fracture rates.4 Weight bearing exercise which places stress on bones will strengthen them at any age. Swimming is an example of a cardio and muscle-firming workout that does not lend itself to bone strengthening. Activities that improve balance are also beneficial in improving risk of falling.

We know that exercise, movement, and increased activity are recommended to help counter the effects of aging and osteoporosis. As Somatic Educators we need to be aware of which movements and processes to modify or avoid with a client with severe osteoporosis.

Bone Fractures from Osteoporosis

Vertebral bodies are more prone to fracture secondary to osteoporosis due to the higher percentage of trabecular bone versus cortical bone. Research has shown that the most vulnerable area of the spine, at risk for fracture, is the thoracic spine due to additional factors described below. In a 1984 study, Sinaki and Mikkelson found that the vertebrae between the shoulder blades, T6-T8, are the most likely fracture sites.7

Thoracic vertebrae are smaller and have a decrease in force load distribution as compared to the lumbar vertebra (a typical BMD test site). Also the flexed or kyphotic curve normally occurring in the thoracic spine increases weight bearing in the anterior aspect of the vertebral bodies. For the purposes of exercise, the thoracic spine may be considered osteoporotic when the lumbar spine bone density test indicates osteopenia in a client.8 Precautions described below for osteoporosis could also apply to persons diagnosed with osteopenia.

Which Movements are at Risk?

There is consistent research that points to flexion as the movement which places clients with osteoporosis at increased risk for developing further wedge or compression fractures.7, 9-11 Side-bending of the thoracic spine and combining flexion with rotation or side-bending also significantly increases the load on the anterior vertebrae where trabecular bone cannot withstand these compressive forces.

Sinaki & Mikkelson tested four groups of osteoporotic subjects in 1984 with one group only doing extension exercises, one only doing flexion exercises, a third group doing both flexion and extension exercises and the fourth group doing no exercise.7 Eighty-nine percent of the group doing flexion exercise sustained additional fractures during the course of the study. This is compared to an increase of 16% for the extension group, 53% for those doing flexion & extension, and 67% for those doing no exercise. Flexion movements involving the thoracic spine are of significant concern in clients with osteoporosis.

Spinal extension is less risky than flexion due to the higher percentage of cortical bone in the posterior aspect of the vertebrae (pedicles and lamina). In fact, research shows that strengthening back extensors may increase bone mineral density12, 13, 14 and result in fewer vertebral fractures.13, 14

Given the contraindications and knowing that safe movement is vital, focused somatic programs can offer important and unique benefits to possible prevention of osteoporosis, falls and fractures through improved posture, balance, joint alignment and increased activity. The below addendum explores how the Bones for Life® program, designed specifically to work with these issues, is valuable.

Addendum

Bones for Life® Keys to Prevention

How can Bones for Life® (BFL) be useful in the prevention of osteoporosis? The strong emphasis placed in the BFL Processes on weight bearing, use of gentle resistance, dynamic alignment, proportional flexibility, and carry over into activities of daily living, especially walking, all serve to make BFL a unique preventative program.

Weight Bearing & Use of Resistance in Bones Processes

Throughout the 90 processes, there are several key ways in which weight bearing is ingeniously used including bouncing, tapping activities, the use of the wall and floor for weight bearing, and the addition of graduated and gentle resistance.

A cornerstone of BFL classes is teaching Bouncing on Heels (#2) based on the premise that pressure builds bone. The vibrations throughout the entire skeleton when the heels contact the floor in standing with rhythmic pulsations lends itself to the stimulation required for bone building. This theme is consistently reinforced, embellished, clarified and progressed throughout the sequential series with processes such as; Crossed Arms (#12), Bouncing on Heels in Rotation (#19), Jumping in the Bones Wrap (#30), Twisted Arms (#31), Goat Skipping (#44), Running with Inclined Head (#58), Bouncing on Elevation (#61), Bouncing on One Foot (#70), and Morning Towel (#81).

Certain processes, which use tapping and pressure of various body parts to increase circulation, glandular function, and build bone, are found in Segment I. These processes include; Stimulating the Roots of the Teeth (#7), Tapping Head, Chest, & Kidneys (#8), Tapping Pelvis (#10).

While there are many contributors to osteoporosis, poor posture as one ages has been shown to produce pressure in the thoracic spine resulting in fractures.10 It is in this area of improving postural alignment that the BFL processes excel. The use of the wall and floor for the spine, upper and lower extremity pressure are also found throughout BFL Processes. Weight bearing of the spine is provoked against the wall at each vertebral level with great specificity in Knot on the Wall (#28) and Bagel or Two Knots (#65). The integration with walking makes these processes uniquely beneficial for improving both posture and possibly positively impacting osteoporosis.

Another important theme woven throughout the BFL experience are processes that use the wall to provide resistance and cultivate weight bearing precision, integration of extremities with the spine and other body parts, and ultimately improved use and carry over into ambulation and into everyday activities. Examples are; Wave Response (#4), Axis Response (#5), Tapping Pelvis (#10), Hand Pushes a Wall Spiraling the Spine (#11), Bicycle (#16), Function

Denise Deig is the author of Positional Release: from a dynamics systems perspective. A Physical Therapist, Guild Certified Feldenkrais Practitionercm and Bones for Life® Teacher/Trainer, she has a private practice in Fishers, Indiana. You can find out more about her and her practice at www.denisedeig.com. Deig can be reached by email at denisedeig@comcast.net. She offers certification and continuing education programs through www.integrativelearningcenter.org.

References

  1. Betz S. The Osteoporosis Exercise Book. Osteo Physical Therapy; 1999.
  2. Nelson ME. Strong Women, Strong Bones. GP Putnam’s Sons, 2000.
  3. Foundation for Osteoporosis Research and Education (FORE) http://www.fore.org/patients/osteo_and_osteo.html online 9/8/07
  4. Keough J. Roughly halfway through the so-called Bone and Joint Decade, it’s time to ask a simple question: Who’s selling osteoporosis? Alternative Medicine. 2007 April; 63-91.
  5. Betz S. Modifying Pilates for Clients with Osteoporosis. http://www.inneridea.com/library/modifying-pilates-for-clients-with-osteoporosis online 9/17/07
  6. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002; 359(9319): 1761-67.
  7. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: Flexion versus extension exercises. Archives of Physical Medicine and Rehabilitation. 1984; 65 (10): 593-96
  8. Grote HJ, et al. Intervertebral variation in trabecular microarchitecture throughout the normal spine in relation to age. Bone. 1995; 116 (3): 301-8.
  9. Bassey EJ. Exercise for prevention of osteoporotic fracture. Age and
    Aging. 2001; 30 (4): 29-31.
  10. Keller TS, et.al. Prediction of spinal deformity. Spine. 2003; 28 (5):455-462.
  11. Meeks S. The role of the physical therapist in the recognition, assessment and exercise intervention in persons with, or at risk for, osteoporosis. Topics in Geriatic Rehabilitation. 2004; October.
  12. Sinaki M, et al. Relationship between bone mineral density of spine and strength of back extensors in healthy postmenopausal women. Mayo Clinic Proceedings.1986; 61 (2): 116-122.
  13. Sinaki M, et al. Can strong back extensors prevent vertebral fractures in women with osteoporosis? Mayo Clinic Proceedings. 1996; 71 (10): 951‐956.
  14. Sinaki M, et al. Stronger back muscles reduce the incidence of vertebral fractures: A prospective 10 year follow‐up of postmenopausal women. Bone. 2002; 30 (6):836‐841.