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Osteoporosis; Prevention and physiotherapy

Osteoporosis; Prevention and physiotherapy. Hamzeh Baharlouei PT, MSc Instructor, Isfahan University of Medical Sciences Secretariat of Geriatric branch of Iran-PTA. International Classification of Functioning, Disability and Health. The ICF Core Set for osteoporosis brief version.

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Osteoporosis; Prevention and physiotherapy

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  1. Osteoporosis; Prevention and physiotherapy HamzehBaharlouei PT, MSc Instructor, Isfahan University of Medical Sciences Secretariat of Geriatric branch of Iran-PTA

  2. International Classification of Functioning, Disability and Health Baharlouei H; PT, MSc, IUMS

  3. Baharlouei H; PT, MSc, IUMS

  4. The ICF Core Set for osteoporosis brief version (b), Body Functions (s), Body Structures (d), Activities and Participation (e), Environmental Factors 0 = NO problem (0–4%) 1 = MILD problem (5–24%) 2 = MODERATE problem (25–49%) 3 = SEVERE problem (50–95%) 4 = COMPLETE problem (96–100%). Koehler, 2011 Baharlouei H; PT, MSc, IUMS

  5. The Goals of Prevention and Treatment • Treatment of any disease causing bone loss • Ensure dietary calcium and protein intake • Correct and prevent vitamin D insufficiency • Promote weight-bearing physical exercise • Reduce the risk of falling • Reduce the consequences of falls Rizzoli 2006 Baharlouei H; PT, MSc, IUMS

  6. Patient Education and Counseling • compliance with an exercise program or pharmacological regimen declines as early as 1 year after initiation • anxiety and depression Papaioannou 2003 Baharlouei H; PT, MSc, IUMS

  7. Physiotherapy • Postural exercises • Modalities for pain reduction • Pulsed electromagnetic fields • Body mechanics • Gait training • Balance training • Breathing exercises Duque 2009, Brunton 2014 Baharlouei H; PT, MSc, IUMS

  8. Posture Baharlouei H; PT, MSc, IUMS

  9. Modalities for Pain Reduction Baharlouei H; PT, MSc, IUMS

  10. Body Mechanics Baharlouei H; PT, MSc, IUMS

  11. Pulsed Electromagnetic Fields • influences the metabolism of bone (Spadaro2002) • concentration of calcium in blood and bone mass (Elsisi 2015) • increased blood supply (Darendeliler 19996) • inhibitory effect on the resorption phase on bone repair (Darendeliler19996) • increasing the rate of bone formation by osteoblasts (Darendeliler19996) • as effective as alendronate in treating postmenopausal osteoporosis within 24 weeks (Liu 2013) • is more effective than circuit weight training programs in elderly women (Elsisi 2015) • gait characteristics in older adults adults with low bone mineral density (Giusti 2013) Baharlouei H; PT, MSc, IUMS

  12. Falling • one-fourth of community-dwelling persons 65 years • doubles for residents in nursing homes • 90% of hip fractures are due to a fall • About 2% to 6% of falls result in death Ganz, 2007, Rubenstein 2006, Graham 2010 Baharlouei H; PT, MSc, IUMS

  13. Sarcopenia • European Working Group on Sarcopenia in Older People: the combination of low skeletal muscle mass with either low muscle strength or low muscle performance (Cruz-Jentoft 2010) • loss of muscle mass can be as much as 3% to 5% per decade after age 30 • association between sarcopenia and osteoporosis, irrespectively of age (Sjöblom 2013, Di Monaco 2011) • odds ratio (OR) for a woman with sarcopenia to have osteoporosis ranges from 1.80 to 12.9 (Anagnostis 2015) • 2.7 times greater risk of fracture and 2.1 higher risk of falls (Sjöblom 2013) Baharlouei H; PT, MSc, IUMS

  14. Falling and Bone Density • 11% of hip fracture fractures were spontaneous, with 25% of them associated with standing or sitting transfers and 60% during simple ambulation • fractures of the proximal femur can be the result of muscle forces acting on the hip exceeding the mechanical ability of the femur to withstand stress Baharlouei H; PT, MSc, IUMS

  15. Falling and Bone Density • Several important determinants govern the forces applied to the femur as a result of falling: • Weight • thickness of subcutaneous tissue • height of the fall • configuration of the body during the fall • velocity at which the hip strikes the impact surface • nature of the impact surface Baharlouei H; PT, MSc, IUMS

  16. Mechanisms of Falls • The severity of the fall is an independent risk factor for hip fracture • direction of the fall • the specific anatomic location of major impact • the elderly tend to fall sideways • impact forces that greatly exceed the mechanical strength of the proximal femur and therefore result in fracture Baharlouei H; PT, MSc, IUMS

  17. Risk factors of Falls • Balance and gait abnormalities • Impaired vision • Decreased ADL function • Polypharmacy • Cognitive impairment Ganz 2007 Baharlouei H; PT, MSc, IUMS

  18. Balance Assessment • Berg Balance Scale • Timed Up and Go • Functional Reach • Standing Test Baharlouei H; PT, MSc, IUMS

  19. Fear of Falling • Permanent decline in ADLs • Hospitalized more frequently • Higher mortality rate • Fall Efficacy Scale-International • Baharlouei 2013 Baharlouei H; PT, MSc, IUMS

  20. Four Phases Of Falling • Instability phase, where balance is lost • Descent phase • Impact phase • Post-impact phase • A fall prevention program should address these four phases of a fall and present interventions at each level Baharlouei H; PT, MSc, IUMS

  21. Hip Protectors • Recognition that increases in soft-tissue thickness around the hip substantially reduce peak force to the trochanter at fall impact. • use of hip protectors could reduce fracture by 53% • Cochrane review however showed no clear benefit from hip protectors in preventing fractures, citing poor compliance due to discomfort and practicality as important factors (Parker2006) • Pads are designed in two primary configurations: • a simple pad that covers the trochanter • U pads Baharlouei H; PT, MSc, IUMS

  22. Environmental Baharlouei H; PT, MSc, IUMS

  23. Neuromuscular Baharlouei H; PT, MSc, IUMS

  24. Medical Baharlouei H; PT, MSc, IUMS

  25. Exercise • trenuousor moderate exercise: higherBMD • calcium supplementation plus exercise, less bone loss at the hip than calcium alone. • Muscle mass • Strengthening exercise • Balance • Wight bearing • trunk stabilization • Aerobic exercise • Stretching exercise Duque 2009 Baharlouei H; PT, MSc, IUMS

  26. Exercise Program For Optimal Bone Health • weight-bearing activities: 45 minutes 3 or 4 times per week • weight lifting: 20- to 30 minutes 2 or 3 times per week • Regular exercise has been shown to improve bone mass (0.5% to 3.0%), with 20% to 45% reduction in hip fractures Kaplan 2005 Baharlouei H; PT, MSc, IUMS

  27. Critical Period • Critical period of bone growth: 25% to 30% of adult bone mass • 12 to 14 years old in girls • 13 to 15 years old in boys • During prepuberty and early adolescence: periosteal surfaces • Late adolescence: endocortical apposition is occurring and cortical thickness is increasing • Boys: periosteal expansion • Girls:endosteal contraction Weaver 2008, Seeman2001 Baharlouei H; PT, MSc, IUMS

  28. Tai Chi • Gentle, slow movements • BMD • Balance • Strength • Cardiovascular fitness • Respiratory function • Flexibility • Decreased injury Li 2005, Wayne 2007 Baharlouei H; PT, MSc, IUMS

  29. Exercise Principles • Specificity • Reversibility • Progression • Initial Values • Diminishing Returns Baharlouei H; PT, MSc, IUMS

  30. WHO Exercise Recommendations • 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic physical activity weekly or an equivalent or combination • Aerobic activity: least 10 min duration. • Increase their moderate-intensity aerobic exercise to 300 min or 150 min vigorous-intensity aerobic exercise or combination. • Poor mobility: balance and prevent falls, 3 days every week. • Muscle-strengthening: 2 days per week. • Be as physically active as their abilities and conditions allow Baharlouei H; PT, MSc, IUMS

  31. Talk Test • Moderate-intensity activity: you can talk, but not sing • vigorous-intensity: you will not be able to say more than a few words without pausing for a breath Baharlouei H; PT, MSc, IUMS

  32. Perceived Exertion • Intensity is measured by perceived exertion

  33. Patient Evaluation • the patient's current activity level? • Do they have any conditions which would affect their ability to exercise? • Categorizing patients by • Age • BMI • current activity level • condition affecting their ability to exercise Woodward 2015 Baharlouei H; PT, MSc, IUMS

  34. Exercise Prescription • Frequency: how often per week • Intensity: moderate or vigorous activity • Time: how long they should exercise • Type: specific exercises • Progression • Individualized Baharlouei H; PT, MSc, IUMS

  35. درد در تنظیم برنامه ورزش موثر است. بیمارانی که از درد شدید رنج می برند باید قبل از شروع ورزش با پزشک مشورت کنند. • از انجام ورزش‌های با شدت و حجم بالا بپرهیزید. تمرینات باید براساس شدت پوکی استخوان تعیین و با مقاومت و فشار کم آغاز شوند. شدت تمرینات را برای6 تا 8 هفته ثابت نگه دارید. • شدت و حجم تمرینات را به‌تدریج افزایش دهید تا در نهایت به 3 تا 4 ست با شدت متوسط برسد. • از انجام ورزش‌هایی با فشار زیاد مانند پریدن روی دو پا یا یک پا پرهیز کنید. • حرکات سریع در ستون مهره‌ها و اندام‌ها، فشار زیادی بر استخوان‌ها وارد می‌کند و نباید این حرکات را انجام داد. • خم کردن تنه همراه با چرخش در دامنه انتهایی، فشار زیادی را بر قسمت جلویی مهره‌ها وارد می‌کند و ممکن است باعث شکستگی گوه‌ای شکل آنها و کاهش قد شود. تمرین سفت کردن شکم مفیدتر از تمریناتی است که با خم شدن به جلو همراه است. • در حالت ایستاده، حرکاتی را که با چرخش پا همراه است، انجام ندهید. این کار به‌ویژه برای آنهایی که در قسمت بالایی استخوان ران دچار پوکی شده اند، خطرناک است. • برای پیشگیری از بر هم خوردن تعادل و زمین خوردن، از یک سطح با ثبات برای انجام تمرینات استفاده کنید. چنانچه تعادل مناسبی ندارید یا چندین بار زمین خورده‌اید، بهتر است تمرینات را در وضعیت نشسته انجام دهید Baharlouei H; PT, MSc, IUMS

  36. Woodward, M. J., C. W. Lu, et al. (2015). "The exercise prescription for enhancing overall health of midlife and older women." Maturitas. • Julián-Almárcegui, C., A. Gómez-Cabello, et al. (2015). "Combined effects of interaction between physical activity and nutrition on bone health in children and adolescents: a systematic review." Nutrition Reviews 73(3): 127-139. • Hida, T., H. Shimokata, et al. (2015). "Sarcopenia and sarcopenic leg as potential risk factors for acute osteoporotic vertebral fracture among older women." European Spine Journal: 1-8. • Elsisi, H. F. E. M., G. S. M. Mousa, et al. (2015). "Electromagnetic field versus circuit weight training on bone mineral density in elderly women." Clinical interventions in aging 10: 539. • Brunton, S., B. Carmichael, et al. (2014). Chapter 18 - Osteoporosis and spine fractures. A Comprehensive Guide to Geriatric Rehabilitation (Third Edition). T. L. K. S. O. B. L. Moran. Oxford, Churchill Livingstone: 124-133. • Graham, P., R. A. Adler, et al. (2010). The Prevention and Treatment of Osteoporosis. DeLisa's Physical Medicine & Rehabilitation: Principles and Practice. W. R. Frontera, Wolters Kluwer Health/Lippincott Williams & Wilkins Philadephia. Baharlouei H; PT, MSc, IUMS

  37. Baharlouei H; PT, MSc, IUMS

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