Question

Subjective

Medical History

Mr. GD, a 78 yr old Caucasian man, is referred by his physician for the development of an exercise prescription. Seven years ago he underwent treatment for prostate cancer that included aromatase inhibitors and is now cancer-free. Mr. GD is 5 ft 11 in. (180 cm) tall with a weight of 165 lb (75 kg). He walks his dog daily for 40 minutes, and he generally keeps himself busy with activities around the home and community, but otherwise he does not follow a regular exercise regimen. He says that his walks are often at a fairly leisurely pace. He plays cards with friends on Wednesday nights.

Diagnoses

He was recently diagnosed with osteoporosis. He was surprised, because he thought it was a woman’s disease. He takes vitamin D (400 IU per day) and calcium (500 mg per day), and consumes calcium-containing foods to get sufficient calcium in his diet. His doctor prescribed Fosamax for his osteoporosis. His mother had a hip fracture when she was 85, and passed away 6 mo later. He is taking medication for his blood pressure, which is well controlled (resting blood pressure is 129/79 mmHg; resting heart rate is 82 beats · min– 1).

Objective and Laboratory Data

Exercise Test Results

He recently underwent an exercise stress test that was normal, but no physiological testing was done other than regular blood chemistries. His 6 min walk distance is 507 m. His occiput to wall distance is 2 cm, and his scapulae appear protracted. His Short Physical Performance Battery score is 14; he could not complete the tandem stand. His knee extension and grip strength are within normal limits for his age but on the low end of normal. He has reduced hip extension range of motion in both legs, but greater on the right.

Assessment and Plan

Exercise Prescription

Mr. GD already walks daily, so you encourage him to time his walks, monitor his heart rate intermittently throughout, and estimate his rate of perceived exertion. Based on the treadmill test, you both agree that he should aim to be at a 5 or 6 on a 0-10 scale for his rating of perceived exertion (RPE) to start, and you suggest that he should feel like his heart is beating faster and he is breathing harder, and that he might be able to carry on a conversation while walking, but he should not be able to sing without stopping to catch his breath. His goal is to complete his 40 min walk, but at least 15 min should be at that pace. He will progress to completing the whole 40 min at the new pace.

He agrees to start a progressive resistance training program but would like exercises that he can do at home rather than having to join a gym. He agrees to attend visits with you twice weekly for 3 wk to practice the exercises and follow up with you every few months to progress the exercises. You ask him about what days of the week would be best, the time of day, and the “trigger” that will remind him to exercise. He suggests that after breakfast on most days would work well. He will start with six exercises, performed on Monday, Wednesday, and Friday mornings. To start, you select counter push-ups, singlearm rows done in standing with elastic tubing, body weight squats, and step-ups with hip extensions, using the stairs in his basement, and having him step up to the second step. You teach him how to do abdominal bracing during each exercise. The step-ups were chosen because they challenge his balance. Before teaching the exercises, you show him how to do a hip hinge so he can apply that to his squats and also his daily activities. He will also add 2-3 sets of 10 longer strides to his walks as a balance challenge, and practice balancing on one foot while brushing his teeth while standing near a counter in case he needs support. The long strides and step-ups with hip extensions are also dynamic range of motion activities targeting his tight hip flexors. He will start with two sets of 8 repetitions of each exercise. He will also add in supine lying with arm lengthener and leg lengthener exercises for his posture and back extensors, which he will do every evening before bed—he will hold each position for 3 s, rest 3 s, and repeat 5 times.

By the end of your sessions with him, you have progressed him to 10 repetitions of each exercise or progressed him to a more difficult version. You have given him suggestions for how to progress the resistance or intensity once he can complete 12 repetitions of an exercise. You tell him to contact you or his doctor if he feels any pain during or after exercise, and suggest to him to make a follow-up appointment in 2 mo.

Case Study Discussion Questions

1. What other information should be obtained from Mr. GD? What risk factors for fracture does he have?

2. What recommendations might you make regarding his gardening? What movement strategies could you teach him?

3. How might you progress his resistance training program or balance challenges?

Answer 1

Mr. GD is 180cm tall with 75 kg Wight. He walk 40 min daily . He recently diagnosed with osteoporosis.

The most robust risk factors are advancing age and personal history of fragility fracture. Others include low body mass index (BMI), long-term glucocorticoid therapy, cigarette smoking, excess alcohol intake, high levels of bone turnover markers, and parental history of hip fracture.

Other risk factors that increase your risk of fracture:

Smoking. Smoking is a risk factor for fracture because of its impact on hormone levels. ...
Alcohol. Drinking alcohol in excess can influence bone structure and mass. ...
Steroids. ...
Rheumatoid Arthritis. ...
Other Chronic Disorders. ...
Diabetes. ...
Previous Fracture. ...
Family History.
Patients with a single fracture are considered to be potentially high risk if they have additional major risk factors (e.g. frequent falls [more than 3 per year]), are elderly, or have a very low bone mass, among other factors. Very low bone mass (T score lower than −3 or −3.5).

Factors that will increase the risk of developing osteoporosis are:

Female gender, Caucasian or Asian race, thin and small body frames, and a family history of osteoporosis. (Having a mother with an osteoporotic hip fracture doubles your risk of hip fracture.)
Cigarette smoking, excessive alcohol and caffeine consumption, lack of exercise, and a diet low in calcium.
Poor nutrition and poor general health.
Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as Celiac Sprue.
Low estrogen levels such as occur in menopause or with early surgical removal of both ovaries. Another cause of low estrogen level is chemotherapy, such as for breast cancer. Chemotherapy can cause early menopause due to its toxic effects on the ovaries.
Amenorrhea (loss of the menstrual period) in young women also causes low estrogen and osteoporosis. Amenorrhea can occur in women who undergo extremely vigorous training and in women with very low body fat (example: anorexia nervosa).
Chronic diseases such as rheumatoid arthritis and chronic hepatitis C, an infection of the liver.
Immobility, such as after a stroke, or from any condition that interferes with walking.
Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is caused by taking too much thyroid hormone medication.
Hyperparathyroidism, a disease wherein there is excessive parathyroid hormone production by the parathyroid gland (a small gland located near the thyroid gland). Normally, the parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis.
Vitamin D deficiency. Vitamin D helps the body absorb calcium. When vitamin D is lacking, the body cannot absorb adequate amounts of calcium to prevent osteoporosis. Vitamin D deficiency can result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis.
Certain medications can cause osteoporosis. These include heparin (a blood thinner), anti-seizure medications phenytoin (Dilantin) and phenobarbital, and long term use of corticosteroids (such as Prednisone).
2 )

The following are some basic recommendations to help make gardening an effective and safe form of exercise for those of us suffering from osteoporosis or weak bones.

Aim to be active at least 2.5 hours weekly. The goal is to raise your breathing and heart rate, which help strengthen your muscles. Did you know you can burn around 150 calories by gardening in about 30-45 minutes?
If you suffer from osteoporosis, don’t bend over, instead stand up straight, kneel or work on your hands and knees.
Avoid bending and twisting movements, they can put too much strain on the body.
If you need to reach down for something, try bending from the hips and keep your back straight.
Gardening exercise includes: walking, reaching, squatting, kneeling, digging holes, planting, watering, hoeing, weeding, and harvesting over and over again.
Like any workout, stretch before beginning your gardening and take breaks when you feel tired. Pushing yourself too far may result in an injury or osteoporosis-related fracture.
Consider using raised beds, retractable hanging baskets, wheelbarrows and containers on castors to make moving around in your garden much easier.
Whenever possible, choose longer-handled and lighter-weight gardening equipment.
Use care with gardening equipment; when you shovel, rake or hoe do not bend forward or twist. Try standing with your feet apart, one foot a little ahead of the other. Shift your weight from one foot to the other in a rocking motion.
If you need to carry an object, hold it close to your body. It will help with balance and it will keep from putting too much strain on your extremities. If you are carrying items in a bucket, try to divide the load between two buckets to maintain balance by carrying them in each hand.
If you feel discomfort while gardening, stop immediately.
As spring turns into summer enjoy your garden’s progress and growth. This activity is one that can bring seasons of enjoyment with beautiful and tasty results while improving your bone health.

Too Much Sitting? 5 Movement Strategies That Get Students Thinking

Gallery Walks/Chalk Talks. In some lessons, students may need to analyze multiple texts. ...
White Board Meetings. White Board Meetings are a strategy I have seen two science teachers use often. ...
North Pole-South Pole/Continuum. ...
Musical Mingle. ...
Stations.
Daily activity also helps boost balance, motor function, brain function, and cognition. According to a growing body of research, movement increases blood and oxygen flow, which positively affects cognitive development, physical health, and mental well-being.

According to a growing body of research, movement increases blood and oxygen flow, which positively affects cognitive development, physical health, and mental well-being. ... Teachers can also allow for free dance or movement periods during their classes.

Increased movement and physical activity does create healthy habits and has numerous benefits for the child. It helps improve confidence, self-esteem and also in developing healthier social, cognitive, and emotional skills.

3 )

Can exercise therapy be used to enhance bone density in females with osteoporosis-

Conclusion: Addition of weight-bearing exercise program to medical treatment increases BMD more than nonweight-bearing exercise in elderly subjects with osteoporosis. Furthermore, both weight-bearing and nonweight-bearing exercise programs significantly improved the QoL of patients with osteoporosis.

Exercise Rx: Resistance band step-outs

Weight training with them is usually safe even with osteoporosis. “Bands work your muscles without taxing your joints – because you hold the contraction rather than lifting and lowering, which may cause inflammation,” she says.

Exercise Improves Strength and Balance in Women With Osteoporosis

—Simple, low-cost exercise programs may give postmenopausal women with osteoporosis the physical strength and balance they need to prevent falls and fractures.

According to the International Osteoporosis Foundation, osteoporosis affects an estimated 200 million women worldwide and causes more than 8.9 million fractures each year.

Preventing bone fractures is crucial to reducing the physical difficulty and financial expense of living with osteoporosis.

Exercise is known to reduce the risk of falls and fractures, but there is no consensus on the duration, intensity, or type of physical activity that would be most beneficial to postmenopausal women with osteoporosis.

New research into simple exercise programs to build strength and balance is partially motivated by an increase in osteoporosis diagnoses in both developed and developing countries.

One in three women worldwide is at risk of a fracture associated with low bone mineral density (BMD)

“Exercise is important for everyone, including women at risk of osteoporotic fractures,” said Lora Giangregorio, PhD, an associate professor in the department of kinesiology at the University of Waterloo in Ontario. “Exercises targeting balance can reduce falls, and programs that combine moderate-high intensity resistance training and weight-bearing aerobic physical activity may prevent bone loss.”

Basic, low-intensity exercises that women can do in their own homes might help them develop the strength and balance required to avoid suffering severe falls and fractures. A recent study by Otero and colleagues set out to determine the possible benefits of a simple exercise program designed to help postmenopausal women build strength of upper and lower limbs and both static and dynamic balance.

3

The study focused on exercises that women could do without incurring extra costs associated with advanced exercise equipment or gym membership.

3

The 60-minute exercise program consisted of warm-up and stretching (10 minutes), static balance exercises (10 minutes), dynamic balance exercises (10 minutes), muscle strengthening exercises (20 minutes), and stretching and relaxation (10 minutes).

3

A total of 65 women participated in the study, which was conducted in collaboration with the Landako Health Center in Spain. The women, aged 50 to 72, had been diagnosed with postmenopausal osteoporosis and had expressed interest in learning more about the study. They were then contacted by phone to evaluate their eligibility. The women who were selected were capable of simple exercise but had not participated in an organized exercise program within the past two years.

3

The study randomly assigned them to either the experimental group (33 women) or the control group (32 women).

3

For the duration of the 24-week study, all of the women were asked not to change their regular habits so that the effects of the exercise program could be more reliably determined. The experimental group participated in three 60-minute, supervised exercise sessions each week. In addition to mats, seats, balls, and ropes, the weights used in the exercise program were made from household objects such as plastic bottles filled with water and sand, in accord with the study’s emphasis on low-cost materials.

3

The investigators gauged the women’s strength and balance development by taking measurements at the beginning and at the end of the 24-week exercise program. The measurements included physical activity aptitude and personal data questionnaires, anthropometric measurements of body mass and height, static balance (through the blind monopodal stance static balance test), dynamic balance (“8-foot up and go” test), upper limb muscle strength (“arm curl” test), and lower limb muscle strength (“30 s chair stand”).

3

Analysis was carried out using Statistical Package for the Social Sciences software. In the four tests of balance and strength, there were statistically significant (P<0.001) differences between the control and experimental groups, with a 47.4% increase in upper limb strength and 80.2% increase in lower limb strength in the experimental group.

3

In the case of static balance, women in the experimental group improved by 36.7% and took fewer attempts to complete the test. Dynamic balance improved by 21.2% in the experimental group, and the women could also complete the test in less time than it took those in the control group. Women with better static and dynamic balance also had greater upper and lower limb strength.

3

The study’s combination of low-intensity strength and balance training in steady sessions over a period of 24 weeks suggests that there are great benefits to this exercise program. The experience of women in the control group was also telling. Over the course of the study these participants had a decline in upper limb strength (-15.9%) and lower limb strength (-10.5%).

3

The study demonstrated that a lack of physical exercise could lead to a reduction in strength and balance over time—and perhaps a consequential increase in the risk of falls and osteoporotic fractures.

3

“Challenging balance exercises (e.g., reduced base of support, weight shifting to limits of stability, dynamic movements that challenge balance like dancing or tai chi) are most effective for preventing falls,” Dr. Giangregorio said. “Strength training in combination with weight-bearing aerobic physical activity may prevent bone loss. Intensity matters. To improve strength or require your bones, balance systems or other body systems to adapt, you have to do exercises that are difficult, or harder than your body is used to doing, and you have to progressively increase the challenge over time by increasing the frequency, intensity or duration of exercise.”