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    Physical and Rehabilitation Medicine
  • 2. Bone Health
    Increased physical activity,
    - especially weight bearing and
    - resistive exercises
    stimulates bone building
    via the piezoelectric effect
    of contracted muscle on bone
  • 3. Life span Bone Phases
    Growth phase,during childhood and adolescence
    Maintenance phase,young and middle adulthood
    Mid-life phase, ages 50-70, bone lose phase
    Frailty phase, after age 70
  • 4. Exercise in the Elderly
    need not to be strenuous to confer benefit
    T’ai chi, gentle slow movements confer benefits
    in balance, strength, cardiovascular fitness,
    respiratory function, flexibility
    and decrease injury
    Reduction in Multiple Falls 55%, 3 times/weekly
    Delayed Bone Density Loss, in postmenopausal female
  • 5.
  • 6. Whole body vibration
    Benefit in residents of long term facilities in
    Muscle strength
    Bone mass
  • 7.
  • 8. 1. Preventive exercise2. Therapeutic exercise
  • 9. Preventive exercise
    Alife long dedication to:
    physical activity
  • 10. Preventive exercise
    Children aged 8 and older… 60 min. daily
    Adults … 30 min. daily
  • 11. Therapeutic exercise
    Essential element
    of the rehabilitation program
    for the patients with osteoporosis
    Tailored to the patient’s level of fitness
    and anticipated propensity to fracture
  • 12. Therapeutic exercise
    the term Therapeutic: relates to the treatment of disease, or physical disorder
    the term Exercise: refers to bodily exertion for the sake of training, or improvement of health, (including those to develop Endurance, Strength, Flexibility, and Proprioception)
  • 13. Therapeutic exercise
    Hippocrates (460 to 370 B.C.)
    reportedly advocated exercise as an important factor in the healing of injured ligaments
    Hindus and Chinese (1000 B.C.)
    used Therapeutic Exercise in the treatment of athletic injuries
  • 14. Therapeutic exercise Principles
    Principle of Specificity
    Principe of Reversibility
    Principle of Progression
    Principle of Initial Value
    Principle of Diminishing Returns
  • 15. Therapeutic exercise1.Principle of Specificity
    Exercise should stress the specific physiologic system being training
    to patients with Normal Bone Mass: should stress sites most at risk of fracture (i.e., hip, spine, wrist
    Osteopenia and Osteoporosis: exercise for Osteogenesis
    High-impact exercises (jumping and strength training), better than low-to-moderate (brisk walking), and has positive bone mass effect at spine and hip, in as little as 5 to 10min./day
  • 16. Therapeutic exercise 1. Principle of Specificity
    High-Impact exercise: Notfor very low bone mass and multiple fractures. They need skeletal protection while building strength, and increase balance and flexibility
    Isometric, core-strengthening ex. With the spine in neutral position: for all patients.
    Spinal flexion: not for low bone mass
  • 17. Therapeutic exercise2. Principle of Reversibility
    The Positive effect of ex., will slowly be lost if the program stops
    A Lifelong dedication to exercise and Physical Activity to prevent bone changes with aging, and abandonment of exercise goals
    Sarcopenia(muscle mass loss 5% per decade, after age 30, and more after 65), may be reversed by exercise.
    Emphasize bone strengthening, while it still has adaptive ability, especially in the elderly and persons with disability
  • 18. Therapeutic exercise2.Principle of Reversibility
    Passive Standing: is not recommended for active adults exercise
    Passive Standing: is a rehabilitative strategy to prevent bone loss to severe disability such a spinal cord injury through the use of a standing frame or standing wheelchair.
  • 19. Therapeutic exercise3. Principle of Progression
    To Increase Bone Mass, the stimulus must exceed previous bone-loading activity.
    Progressive Resistive Increase in the Intensity exercises, are site specific (i.e. hip) for the bone health and improved functional capacity.
    Slowly increasing time or intensity 10% weekly to avoid mechanical bone stress
  • 20. Therapeutic exercise4.Priciple of Initial values
    Patients who initially have low capacity will have the greatest functional improvement from a given program
    Attention for Inactive Participants, to begin with short sessions, of low intensity and progress
  • 21. Therapeutic exercise5. Principal of Diminishing Returns
    There is a biologic ceiling to exercise-induced improvements in function. As this ceiling is approached, greater effort is needed to achieve minimal gain.
    Optimal Calcium Intake for all; (if no contraindications), with Physical Activity, improve bone mass. Calcium supplements in postmenopausal women reduce bone loss by 2%, and 23% spine fractures.
  • 22. Therapeutic exercise5. Principle of Diminishing Return
    Vitamin D supplements may reduce spine fracture by as much as 7%.
    Adequate Caloric Intake andGlycemic Index must support exercise
    Weight loss, with Adipose tissue loss, and depletes estrogen production stores, may cause amenorrhea in females increasing the risk of osteoporosis and stress fractures
  • 23. Therapeutic exercise5.Principle of Diminishing Return
    The prevention of falls and fractures, through an ongoing exercise program, with proper nutrition, strength, and aerobic capacity, should be coupled with adjunctive measures such as the provision of adequate support for the spine, pain management, and psychological support when developing objectives for long term goals.
  • 24. Regular Program of Exercise The Activity Pyramid
  • 25. Regular Program of ExerciseHealth Benefits
    Reduction in All-Cause Mortality
    Primary and Secondary Prevention of Cardiovascular Disease
    Blood pressure Regulation
    Lipid Management
    Weight Control
    Type 2 Diabetes Mellitus Prevention
  • 26. Regular Program of ExerciseHealth Benefits
    Improved Psychological Well-being and Quality of Life
    Maintenance of Bone Density
    Increased Fibrinolytic Activity
    Decrease Inflammatory Marker (CRP)
    Improved Endothelial Function
  • 27. Regular Program of ExerciseHealth Benefits
    Improved Sleep
    Possible Enhanced Immune Function
    Reduced Cancer Risk ( colon , breast, prostate, lung)
  • 28. SPEED Program
    in Osteoporotic-KyphoticWomen, through a Spinal Proprioceptive Extension Exercise Dynamic (SPEED) Program, intervention with a spinal weighted kypho-orthosis (WKO)
    Significant Reduction in Risk of Falls and Back Pain
    Balance, gait, and risk of falls improved significantly with the 4-week SPEED program (using CDP = computerized dynamic posturography)
    FIGURE 1. An 86-year-old woman with osteoporosis and kyphosis. Left, Radiograph of spine shows osteoporotic
    and postural changes. From Sinaki M. Musculoskeletal challenges of osteoporosis. Aging (Milano). 1998;
    10:249-262, with permission. Middle, Severe kyphotic posturing, which made ambulation difficult. Right, Same
    patient wearing weighted kypho-orthosis. Middle and Right from Sinaki M. Rehabilitation of osteoporotic
    fractures of the spine. Phys Med Rehabil. 1995;9:105-123, with permission from Elsevier.
  • 30. Suggested
    Rehabilitation Guidelines Based on
    Bone Mineral Density
    T Scores
  • 31. T score Reduction to −1 SD(Normal)
  • 32. T Reduction to −1 to −2.5 SD (Osteopenia)
  • 33. T Reduction to −1 to −2.5 SD (Osteopenia)
  • 34. T score Reduction to −1 to −2.5 SD (Osteopenia)
  • 35. T Reduction to -2.5 SD or more (Osteoporosis)
    Pharmacologic intervention
    Pain management
    Range of motion, strengthening, coordination
    Midday rest, heat or cold, stroking massage, if needed
    Back extensor strengthening
    Walking 40 min/day as tolerated; Frenkel exercises
    Aquatic exercises once or twice a week
    Fall prevention programme
  • 36. T Reduction to -2.5 SD or more (Osteoporosis)
    Postural exercises : WKO program with pelvis tilt and back extension
    Prevention of vertebral compression fractures (orthoses as needed)
    Prevention of spinal strain (lifting ≤ 5- 10 lb)
    Evaluation of balance, gait aid
    Safety and facilitation of self-care through modification of bathrooms and kitchen, occupational therapy consultation
  • 37. T Reduction to -2.5 SD or more (Osteoporosis)
    Start strengthening program with 1-2 lb and increase, as tolerated, to 5 lb in each hand
    Speed program, if needed
    Hip protective measures
  • 38. New Hypothesis on the Most Effective Exercise to Reduce the Risk for Vertebral Fracture
    Back strengthening exercises, performed in a prone position rather than in vertical position, (nonloading), can decrease risk of vertebral fractures through improvement of horizontal trabecular connections. The exercise needs to be progressive, resistive, and nonloading to avoid vertebral compression fracture.
  • 39. Non Strenuous Progressive Exercises for severe Osteoporosis
  • 40. Static and Dynamic Correct Postures
  • 41. FIGURE 41-7 A, Lateral radiograph of the spine in a 77-year-old man with persistent back pain. No evidence of metastatic lesion was identified. B, Magnetic resonance image demonstrating extensiveskeletal metastases from T3 through lower lumbar spine, with involvement of nearly every vertebral body. The most extensive involvement is at T3, T8 through T11, T12, and L4. 
  • 42. Spinal Cord Injury and Exercise
    Intensive exercise preserve bone mass of upper limbs,
    butdid not stop demineralization of lower body
    Danger to damage joints or bone fractures when pushing wheel chair or do transfers
    Recommended exercises: weight bearing using a standing frame or harness, treadmill training, Parastep, and functional electrical stimulation
    The PASIPD questionnaire: (Physical Activity Scale for individuals with Physical Disabilities) can be useful in assessing levels of activity.
    Need more controlled studies using physiological loads to examine the effects of the above methods
  • 43.
  • 44. Fall reduction strategies
    Fall etiologies:
    - Decreased neuromuscular coordination
    - Sarcopenia, 71% of elderly hip fractures
    - Mental status, confusion, dizziness
    - Medication
    - Environmental factors, pure lighting,
    loose rugs
  • 45. Fall reduction strategies
    Using proper footwear
    Appropriate environmental adaptations
    Assistive devices, canes, walkers, wheelchairs
  • 46. Exercises for Preventing Falls
    Education to eliminate fall risks
    Exercises improving balance,
    such as gait training,
    coordination and functional exercises
    and muscle strengthening
  • 47.
  • 48. Gait Analysis and Training System, with EMG Biofeedback, Goniometer, Force Distribution Platform, Video
  • 49.
  • 50. Balance system, for Fall Risk Screeningand Conditioning Program
  • 51. Conclusion
    Patient’s education, can contribute to prevention, better understanding and management, of the consequences of osteoporosis.
    Posture and exercise programs, body mechanics,increasing strength and aerobic capacity, fall reduction strategies, is an essential component of both short-term and long-term interventions, for both men and women, which lead to
    a better quality of Aging.