Lay the Foundation of a Program for Clients with Low Bone Density

By Sherri R. Betz, PT
Jan 8, 2016

After age 50, adults typically lose about 1% of their leg strength and 0.5% of their bone mineral density (Gourlay et al. 2012) every year. If this doesn’t sound serious, consider that decreased leg strength—not dementia or incontinence—is the biggest predictor of loss of independence in older adults (Studenski et al. 2003).

There are ways to combat this seemingly inevitable decline, but which exercises help? And which are contraindicated for clients whose bone density levels are already low?

Building Bone and Combating Falls

Science tells us that in order to build strength, we must overload targeted muscles beyond daily activity levels. To increase strength as opposed to endurance, fatigue must be reached in 8–12 repetitions. If 15–20 or more repetitions can be performed, endurance is improved, which does not build bone (Chahal, Lee
&
Luo 2014).

Muscle power (the ability to produce force rapidly) has emerged as a more crucial variable in functional decline than either muscle strength or muscle mass. In a community-based randomized controlled trial, Gianoudis and colleagues found that a targeted multimodal exercise program incorporating high-speed power training reduced falls and fracture risk factors in older adults (Gianoudis et al. 2014).

Apart from leg strength, which is crucial, key elements for maintaining independence and protecting against falls are balance; strength and mobility of the spine (especially the thoracic spine); and hip extension. Contraindicated moves for clients with (or at risk for) osteoporosis are spinal flexion and extremes of spinal rotation and side-bending.

Let’s review safety considerations that apply to clients with low bone density levels and then investigate whether Pilates or yoga can offer enough stimulation to improve key physical abilities without increasing a client’s risk of fracture.

Program Principles: Getting Started

A program for a client with either osteoporosis or osteopenia must focus above all on these five components:

  1. fracture prevention—

    most important!

  2. leg strength
  3. balance
  4. thoracic extension
  5. hip extension

All interventions for clients with low bone density should begin with an assessment (see the Web Extra for the top 10 tests). Enforcing a pre-exercise bone density test is not necessary. Occasionally, clients may lack health insurance or be unable to afford a test. Having no access to bone densitometry should not prohibit a client from beginning an exercise program that could reduce the risk of falls, fractures and loss of independence.

Even without a bone density study there are a few indicators that a client may have low bone mineral density:

  • height loss greater than 1 inch
  • presence of kyphosis
  • family history
  • previous fracture


Do not test spine mobility!

Before initiating an exercise program, teach the client to protect the spine, hip and ribs from fracture (see precautions below). Explain that focusing on fall prevention protects the wrists. Body awareness and education in principles of alignment will help the client to apply fracture prevention precautions in any exercise, sport or daily movement.

With or without the presence of a vertebral fracture, a client may safely begin an exercise program if you ensure that he or she observes the following precautions:

  1. Avoid rounding the spine when engaged in the activities of daily living.
  2. Exclude the following exercises:
  • crunches
  • sit-ups
  • toe touches with round back
  • forward bends with round back
  • abdominal oblique work with rotation
  • deep spinal side-bending (Avoid end range.)
  • deep twists/spinal rotation (Avoid end range.)
  • forced rotation of the femur, as in Pigeon pose

To identify beneficial exercises to include in a program, observe the client rising from a chair:

  1. Does the client use her hands to rise? This can indicate lower-extremity weakness.
  2. Do the client’s knees press together as he stands? This can indicate lower-extremity weakness and possibly lead to knee pain.
  3. Does the client round her back to stand? This can put the spine at risk for fracture.
  4. Can the client come to standing with good balance?

Desinging and Supplementing

To read more about how to take these principles and use them to incorporate Pilates and yoga into fitness program for clients with low bone density, please see “Are Pilates and Yoga Right for Clients With Low Bone Density?” in the online IDEA Library or in the September 2015 print issue of IDEA Fitness Journal. If you cannot access the full article and would like to, please contact the IDEA Inspired Service Team at (800) 999-4332, ext. 7.


References

Chahal, J., Lee, R., & Luo, J. 2014. Loading dose of physical activity is related to muscle strength and bone density in middle-aged women. Bone, 67C, 41-45.
Gianoudis, J., et al. 2014. Effects of a targeted multimodal exercise program incorporating high-speed power training on falls and fracture risk factors in older adults: A community-based randomized controlled trial. Journal of Bone and Mineral Research, 29 (1), 182-91.
Gourlay, M.L., et al. 2012. Bone-density testing interval and transition to osteoporosis in older women. New England Journal of Medicine, 366 (3), 225-33.
Studenski, S., et al. 2003. Physical performance measures in the clinical setting. Journal of the American Geriatrics Society, 51 (3), 314-22.

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Sherri R. Betz, PT

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