Exercise programs designed specifically to decrease risk of fractures for your elderly patients
Osteoporosis and its complications are affecting greater numbers of our aging and sedentary patients. Physical activity and exercise have been shown to provide significant protection from osteoporosis1 and fractures.2 As doctors of chiropractic, we have a duty to identify patients at risk for fractures, and to recommend exercises that will decrease this risk. Most importantly, we can tailor exercises to prevent the spinal complications of osteoporosis, such as kyphosis, vertebral wedging, and compression fractures.
Exercise is a form of repetitive loading that facilitates osteoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption.3 Even a moderate amount of exercise recommended for general wellness (a minimum of 30 minutes a day) is helpful in preventing osteoporosis.4
Feel the Burn
Aerobic/endurance: Two of the most commonly recommended exercises for the elderly are walking and swimming. While improved aerobic capacity is good for the cardiopulmonary system and is generally beneficial for most older patients, skeletal improvement must not be expected. Bone mineral density can be increased by walking, but only when it is done above the anaerobic threshold.5 Most older women are unlikely to be willing to walk at this intensity, especially those who have been sedentary. Women who participate in a regular swim program have no significant difference in bone mass from women who do not swim.6 This is also true of a standard weightbearing, water-based exercise program (aquacise).7
Impact/weightbearing: To create sufficient stimulus to increase bone density, exercise needs to be weightbearing and have some impact, such as step-training (10 minutes stepping up and down from an 8-inch high step).1 Caution should be used when recommending impact exercises to elderly patients.
Figure 1. Hip extension exercise.
Exercises are effective when done in an upright, weightbearing position, since the entire body is in a closed-chain position during training. Stabilizing muscles, cocontractors, and antagonist muscles all coordinate with the major movers during movements performed during closed-chain exercising (Figure 1). This makes these types of exercises valuable for the elderly, not just to increase bone density, but also to prevent stumbles and falls.
Figure 2. Exercise tubing - ideal tool for elderly osteoporotic patients.
Resistance/strength: Resistance training is safe and quite effective for increasing strength and function in the elderly.8 Older patients make relatively similar, but smaller absolute strength gains when compared with younger adults. Weight training in a submaximal controlled, supervised situation can also preserve9 and even increase10 bone deposition. Exercise tubing is an excellent tool for strength training of the elderly since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Figure 2).
Watch Your Back
We often encounter osteopenia and osteoporosis on patients’ spinal X-rays, but by the time changes are visible, substantial bone loss has already occurred. The vertebral fractures are the most common due to osteoporosis, but less than one-third of all these fractures are clinically diagnosed.11 These skeletal changes can significantly impact posture and the ability to handle subluxation complexes. Specific corrective exercises should be recommended in order to relieve the postural strain on the spine and prevent further wedging and compression fractures. Back-strengthening exercises constitute a powerful intervention for reducing pain and increasing functional capacity. Avoiding exercise is the worst approach.
An important caveat to remember: some commonly used back exercises may cause more fractures. For patients with spinal osteoporosis, the most harmful activity is one that places an anterior load on the vertebral bodies. Patient education must emphasize the dangers of lifting in flexion and performing flexion exercises. An exercise study12 found an increase in new vertebral deformities when postmenopausal women performed flexion exercises—such as forward stretches and abdominal curls— while those who performed only spinal extension exercises had a significant reduction in the number of vertebral compressions.
Spinal osteoporosis is often associated with poor postural support, specifically an increase in the thoracic kyphosis. This posture is secondary to many decades of flexed activities and may be compounded by poor posture habits and tendencies to slump. One important factor in chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, all patients (especially the elderly) should be shown corrective exercises that are specific for postural imbalances.
The thoracic kyphosis of estrogen-deficient women is directly correlated with weakness of the back extensor muscles,13 and strengthening these muscles decreases the kyphosis.14 When the torso is carried flexed forward, the patient will need to retrain the extensor muscles of the spine with isotonic resistance exercises in an upright, weightbearing position.
For some elderly patients, orthotic support will be necessary to reduce shock and ensure correct alignment of the lower extremities during weightbearing exercises.
The end result is an effective rehab component for osteoporosis and aging patients who will make a rapid response to chiropractic care. A well-designed exercise program can improve posture, help reduce bone loss, and prevent fractures, while also reducing symptoms.
About the Author
Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Ave, Ridgefield, WA 98642, or via email: kimdchristensen@hotmail.com.
References
1. Chien MY, Wu YT, Hsu AT, et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000;67:443–448.
2. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J. 1997;315:1065–1069.
3. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med. 1987;8:331–335.
4. US Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: 1996.
5. Hatori M, Hasegawa A, Adachi H, et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Int. 1993;52:411–414.
6. Orwoll ES, Ferar J, Oviatt SK, et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med. 1989;149:2197–2200.
7. Bravo G, Gauthier P, Roy PM, et al. A weightbearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being. Arch Phys Med Rehabil. 1997;78:1375–1380.
8. Fiatarone MA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990;263:3029–3034.
9. Nelson ME, Fiatarone MA, Morganti CM, et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA. 1994;272:1909–1914.
10. Kerr D, Ackland T, Maslen B, et al. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. 2001;16:175–181.
11. Ross PD. Clinical consequences of vertebral fractures. Am J Med. 1997;103:30S–43S.
12. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984;65:593–596.
13. Sinaki M, Itoi E, Rogers JW, et al. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil. 1996;75:370–374.
14. Itoi E, Sinake M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc. 1994;69:1054–1059.
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