As with so much in life, success in any endeavor begins with communication. Have you had the bone health talk with your clients? If you work with adults 50 and older, it may be time to educate them about the impact exercise can have on bone density and healthy aging.
If clients are not asking about osteoporosis, consider nudging the conversation forward: 54 million adult Americans are at risk of breaking a bone (NOF 2019a). You probably already know that people who have osteoporosis should do weight-bearing exercises to slow the degradation and ease the effects. However, most people are given no more explanation about bone density than that.
Since this degenerative bone disease can make seemingly mundane activities—like carrying groceries, walking the dog or hugging grandchildren—risky, even your most proactive, engaged clients may become timid and reserved in the gym as they question their abilities and lose trust in their bodies. As their coach, you are left to figure out what kinds of exercise to suggest, as well as how to offer emotional support for the fear and uncertainty that this diagnosis can bring.
The good news is that by giving proper guidance on exercise, and other factors such as sleep and Vitamin D, you can help your clients to maintain build, their bone density, improve their bone health, and you’ll also be a valuable partner to allied health professionals.
Building Bone Density Via Stress
Osteoporosis is the most metabolic bone disease, marked by decreased bone mass and structural deterioration of tissue, leading to bone fragility and a greater likelihood of fractures, especially of the spine, hip and wrist (Hsu et al. 2014). Osteoporosis occurs for a number of reasons, including family history, nutritional and gastrointestinal problems, and sedentary lifestyle (IOF 2017). For most people, Wolff’s Law applies: Putting stress on the axial points of a bone activates bone cells called osteocytes, and engaging these cells alters the balance between bone formation and resorption in favor of formation, called osteogenesis. In short, bones will adapt based on the demands placed on them. The result? Increased bone density and stronger bones (Frost 1994; Office of the Surgeon General 2004).
And while most things erode with use, the musculoskeletal system does not. The more we use our muscles and bones, the stronger they get. According to American Bone Health—a community-based nonprofit organization focused on public education and advocacy—regular gym-goers need to focus on a wide range of high- and low-impact exercises to strengthen their bones (ABH 2016a). Weight-bearing activities are the best for achieving this. (Think about giving clients exercises that require them to have one foot on the ground at any given time.) ABH (2016a) and the Cleveland Clinic (2015) recommend a variety of exercises for safely strengthening bones (see “Building Bone Density With Exercise,” below).
Because our skeletons are not visible on the surface, it can be tough to know how to challenge your clients without inadvertently putting them at risk of fracture. When clients first express concern about their bone density, they may bring you their results from a DXA scan, a medical test that measures bone mineral density (BMD). Skeletal strength is presented in the form of a T-score, a measurement that compares a person’s bones with a peak bone mass, represented by a healthy 30-year-old of the same sex. The T-score indicates the number of standard deviations of a person’s BMD above or below a reference value of 0.0. A score of –1 and above is considered normal; –1 to –2.5 means osteopenia, or low bone mass; –2.5 and below indicates osteoporosis (ABH 2016b).
T-scores sometimes leave people puzzled, so it’s important that trusted professionals know what a client’s score means so they can correctly identify where it falls on the chart and then respond appropriately (e.g., by modifying the client’s workouts). Studies have also shown that, in addition to BMD, bone microarchitecture may contribute significantly to bone strength and to the risk of fracture (Dalle Carbonare & Gianni 2004).
At least when they’re in the gym, clients should do exercises that require a lengthened spine. Avoid oblique dips and crunches on the floor, for example, and replace these exercises with straight-spine substitutes, such as plank variations. With all exercises, keep safety top of mind (ABH 2018).
See also: Bone Health: A Primer
Loading Up for Bone Density
Osteogenic loading complements traditional exercise to increase bone density.
Building strength through isometric exercise is helpful, but to actually trigger osteogenesis, clients need to “load” multiples of their own body weight onto their bones (Deere et al. 2012). This can be difficult to do safely at the gym, but more facilities are opening where clients can engage in a practice called osteogenic loading (OL), a form of exercise done on special equipment to safely simulate multiples of body weight in the arms, shoulders, legs, hips and spine.
Most exercise loads bone to a certain degree, but for strong osteogenic stimulation, the load needs to reach a level that’s about four times the client’s body weight (Brown 2018).
Osteogenic loading is not a substitute for traditional exercise, but rather a complement to increase bone health. The Journal of Osteoporosis and Physical Activity states: “OL therapy as an adjunct to standard care, or as a preventative approach, is both feasible and effective in improving BMD for ambulatory individuals with below –1 T-scores” (Hunte, Jaquish & Huck 2015). As clients increase their skeletal strength, reversal of osteoporosis becomes possible. Try these ideas for osteogenic loading.
Building Bone Density With Exercise
Before working with clients who have osteoporosis, ensure that they have clearance from their doctor or physical therapist. Here are some suggestions from the Cleveland Clinic (2015):
- Exercise should be weight-bearing.
- Clients should start slowly. If they have spinal fractures, do not suggest activities in which they reach down, bend forward, make rapid twisting motions, attempt any heavy lifting or do anything else that increases the chances of a fall.
- High-impact weight-bearing exercises can help to rebuild lost bone; these include dancing, hiking, stair climbing, tennis, squash and jumping rope.
- Low-impact weight-bearing options include brisk walking; use of elliptical machines; use of strength training machines; body-weight exercises; functional movements, such as standing and rising up on your toes; yoga; and Pilates.
- Tai chi and other forms of martial arts improve endurance, balance, flexibility and coordination.
Bone Up on Bone Health
Trainers play an important role in helping clients build bone strength.
The National Osteoporosis Foundation has found that about 10 million older Americans have osteoporosis and another 44 million have low bone density; in other words, half of adults age 50 and older are at risk of breaking a bone. The NOF (2019a) predicts that, by 2025, osteoporosis will be responsible for an annual total of three million fractures and $25.3 billion in costs. The good news is that educated fitness professionals can help, as weight-bearing exercises are recommended.
Be assured, diagnoses of osteoporosis among your clients does not mean an inevitable end to your sessions. As always, clients should work with their physicians to determine the best course of action. From there, the trainer fills an important role in partnering with clients to build strength, discuss available resources for increasing bone density and foster hope.
See also: The Anatomy of Functional Training Risks
ABH (American Bone Health). 2016a. Which exercises are best for building healthy bones? Accessed June 2019: americanbonehealth.org/exercise/which-exercises-are-best-for-building-healthy-bones/.
ABH. 2016b. Understanding bone density results. Accessed June 2019: americanbone-health.org/bone-density/understanding-the-bone-density-t-score-and-z-score/.
ABH. 2018. Is my exercise program safe? Accessed June 2019: americanbone-health.org/exercise/is-my-exercise-program-safe.
Brown, S.E. 2018. Osteogenic loading—A key to reversing osteoporosis. Accessed June 2019: betterbones.com/exercise/osteogenic-loading/.
Cleveland Clinic. 2015. Exercising safely with osteoporosis. Accessed June 2019: my.clevelandclinic.org/health/articles/15074-exercising-safely-with-osteoporosis.
Dalle Carbonare, L., & Gianni, S. 2004. Bone microarchitecture as an important determinant of bone strength. Journal of Endocrinological Investigation, 27 (1), 99–105.
Deere, K., et al. 2012. Habitual levels of high, but not moderate or low, impact activity are positively related to hip BMD and geometry: Results from a population-based study of adolescents. Journal of Bone and Mineral Research, 27 (9), 1887–95.
Frost, H.M. 1994. Wolff’s Law and bone’s structural adaptations to mechanical usage: An overview for clinicians. The Angle Orthodontist, 64 (3), 175–88.
Hunte, B., Jaquish, J., & Huck, C. 2015. Axial bone osteogenic loading-type resistance therapy showing BMD and functional bone performance musculoskeletal adaptation over 24 weeks with postmenopausal female subjects. Journal of Osteoporosis and Physical Activity, 3 (3).
Hsu, W-L., et al. 2014. Balance control in elderly people with osteoporosis. Journal of the Formosan Medical Association, 113 (6), 334–39.
IOF (International Osteoporosis Foundation). 2017. Fixed risk factors. Accessed June 2019: iof-bonehealth.org/fixed-risk-factors.
Laird, E., et al. 2010. Vitamin D and bone health; potential mechanisms. Nutrients, 2 (7), 693–724.
Maria, S., & Witt-Enderby, P.A. 2017. Circadian regulation of bone. In S.M. Jazwinski, V.P. Belancio, & S.M. Hill (Eds.), Circadian Rhythms and Their Impact on Aging (pp. 65–82). New York: Springer Publishing.
NOF (National Osteoporosis Foundation). 2019a. Osteoporosis fast facts. Accessed June 2019: nof.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf.
NOF. 2019b. Keeping your balance. Accessed June 2019: nof.org/patients/fracturesfall-prevention/exercisesafe-movement/keeping-your-balance/.
Office of the Surgeon General. 2004. The basics of bone in health and disease. Bone Health and Osteoporosis: A Report of the Surgeon General. Accessed June 2019: ncbi.nlm.nih.gov/books/NBK45504/#ch2.s7.
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