How many times have you told your patients to stand up straight and stop looking down while walking? How’d that work out? Probably not so good. At best you may have noticed a temporary correction only for the patient to return to the formerly mentioned poor posture. We know that balance is affected by alignment of our trunk and spine. ¹  Everyone needs to avoid falls but it’s particularly important with osteoporosis patients due to bone fragility. We want our patients not only to move, but to move with optimal alignment According to Fritz, et al ² in the White Paper: “Walking Speed: The Sixth Vital Sign”, walking is a complex functional activity. Our ability to influence motor control, muscle performance, sensory and perceptual function, endurance and habitual activity level can result in a more efficient and safer gait. Visual imagery cuing had been popular in the sports world for decades. By changing one or two words, physical performance has been shown to improve.³ In a study involving standing long jump, Wu et al instructed undergraduate students to either “Jump as far as you can and think about extending your legs” (internal focus) or “Jump as far as you can and think about jumping as close to the green target as possible” (external focus). The external focus group jumped 10% farther.  Lohse et al ⁴  and Zachry et al ⁵surmised that an external focus reduces the “noise” in the motor system which affects muscular tension and optimal function. It Starts with Posture Before you can expect your patients to walk well, they have to stand well- stability before mobility. Assess their posture from all angles and determine where to start. One visual image may change a host of problems. A common postural fault, “slumping” is seen as forward head, increased thoracic kyphosis accompanied with either lumbar hyper or hypo lordosis. Your goal is to get the optimal alignment image that you have in your mind……. into their body. Most people think in pictures rather than words.⁶  Yet the medical industry uses words to communicate. Often we say, “Don’t slouch. Don’t look down.” Telling your patient what not to do is not helpful. Our brain hears the words, “Slouch or look down.” We don’t discern the negative. If I say to you, “Don’t think of a pink elephant,” what does your mind see? How can you not see a pink elephant? Below are five common visual cues to improve a patient’s posture in standing and walking.  These tend to follow the Pareto Principle. 20% of your cues work 80% of the time.

1. “In standing, imagine a bungee cord running from the top of your head to the ceiling. Visualize a mother cat lifting her kitten up by the scruff of the neck.”
2. “When breathing, imagine an umbrella inside your ribcage, opening up upon inhale, and closing on exhale. Breathe in all directions including into the back of your lungs as if you were filling up the sails of a sailboat.”
3. “When walking, widen your collarbones as if they were arrows, shooting off the tips of your shoulders. Imagine your head is a floating balloon, gliding along above your shoulders.”
4. “Pretend you are the King (or Queen) of England as you walk among your subjects. “
5. “Slide your shoulder blades down toward your opposite hip pockets.”

Choose a cue and instruct your patient. Observe changes in posture, alignment, efficiency of movement, or length of step during gait. Ask your patient for feedback. “What did you notice?” Certain cues resonate more than others. Give them variety and options. The best cues are the ones they create themselves. When a patient says, “You mean like………..?” you know it’s a great cue for them. They have an intuitive understanding and relate to it which translates into their body. A patient’s response to the bungee cord cue was, “You mean like a Christmas ornament hanging from the tree?”  My response? Absolutely! While some visual cues may seem too flowery or not “medical” enough, the research is solid and the impact powerful. Plus your patients love it! Visual cues are sticky. They help remind us when we’re out in the real world. Isn’t that the ultimate goal – helping patients become independent in their pursuit of health and safety?

---

1. Shiro Imagam, et all. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013 Jun;
2. Fritz S. et al White Paper: “Walking Speed: The Sixth Vital Sign” J Geriatr Phys Ther. 2009
3. Wu, et al Effect of Attentional Focus Strategies on Peak Force and Performance in the Standing Long Jump. Joun of Strength and Conditioning Research 2012
4. Lohse and Sherwood Defining the Focus of Attention: Effects of Attention on Perceived Exertion and Fatigue
5. Zachry, T et al. Increased Movement Accuracy and Reduced EMG Activity as a Result of Adopting an External Focus of Attention. Brain Research Bulletin Oct 2005
6. Dynamic Alignment Through Imagery. Franklin, Eric. Second Edition, 2012

Do you work with osteoporosis patients? This may be a trick question because you probably do whether you know it or not- even if you are a pediatric therapist! Osteoporosis is defined by the World Health Organization¹ as a systematic skeletal disease characterized by:

• Low bone mass
• Micro-architectural deterioration of bone tissue
• Consequent increase in bone fragility and susceptibility to a fracture

Osteoporosis occurs in men, women and even children. It is sometimes called the “silent disease” because often people don’t know they have it until they break a bone. And even then, compression fractures are painful only 20-30% of the time. Old fractures are often found on x-rays when a person is imaged for illnesses such as pneumonia. According to the National Osteoporosis Foundation,² about one in two women and one in four men over the age of 50 will suffer a fracture due to bone fragility. At this point in time, it is estimated 80% of patients entering Emergency Departments with a fragility fracture (a fall from a standing height) are never followed up for care.
As therapists, we see patients for a variety of diagnoses with co-morbidities but osteoporosis may not be listed. This could be because they have never been identified. We are in a prime position to screen for signs associated with the disorder. Below are the top 3 signs to look for.

1. History of fracture from minimal trauma (fall from a standing height, sneeze, lifting groceries, etc). The typical fracture areas are wrist, hip, and spine although fragility fractures can happen anywhere in the body.
2. Hyper-kyphosis. Note, I said hyper-kyphosis, not kyphosis. We are meant to have a thoracic kyphosis but an excessive curve, particularly when it hinges around T8 area may indicate a collapse of the anterior portion of the vertebral bodies. This is the pie shaped wedging seen on x-rays and further increases the stress on the anterior aspect of the spine. Observe your patients’ sagittal posture for proper alignment.
3. Loss of height. Ask your patient their tallest height remembered; then measure them. A loss of 4 cm (1.5 inches) or more may indicate fractures in the spine.
   Remember pain may or may not accompany a compression fracture. Patients may complain of a “catch” or muscle spasm or nothing at all.

These quick and simple screens can alert the healthcare provider and may help prevent further disintegration of the bones. Research is showing that not only weight bearing exercises but a site specific back and hip strengthening program decreases the risk of fracture.³

 References

---

1. World Health Organization. www.who.int
2. National Osteoporosis Foundation. www.nof.org
3. Current Osteoporosis Reports. Sept, 2010. The Role of Exercise in the Treatment of Osteoporosis. Sinaki M, Pfeifer M, Preisinger E, Itoi E, Rissoli R, Boonen S, Geusens P, Minne HW.

Osteoporosis is a disease of increasingly porous bones that are at greater risk for fracture. The normal bone remodeling of breaking down and building up bone as we age is out of balance. Similar to a bank account with withdrawals outpacing deposits, as time goes on there is more breaking down than building back up. This leaves the bone more vulnerable for fracture.
We tend to think of Osteoporosis as an old person’s disease and in fact age is certainly a risk factor. We see a sharp decline in bone density the first few years following menopause; a withdrawal from the “bone bank account.” But let me share a startling statistic. At the age of 20 we have 98% of the bone density we will ever achieve. We reach Peak Bone Mass by age thirty when our bones have reached their maximum strength and density.
Factors affecting peak bone mass include both non-modifiable and modifiable. The non-modifiable factors are gender (peak bone mass is higher in men), race (peak bone mass is higher in African Americans), and hormonal factors (early onset of menstruation and use of oral contraceptives tend to have higher peak bone mass). Family history is another important factor with individuals whose mother had osteoporosis are more predisposed to it.
Modifiable factors include nutrition (adequate calcium in the diets of young people), physical activity during the early years (specifically weight bearing and resistance exercises), and lifestyle behaviors (smoking, high alcohol intake, and sedentary lifestyle) have been linked to low bone density in adolescents).
The graph below shows a comparison of the Peak Bone Mass of males to females and to individuals with suboptimal lifestyle factors. You can see that the suboptimal group never catches up and enters the osteoporosis stage at around age 40.

According to the Department of Human Services “Osteoporosis is a pediatric disease with geriatric consequences. Peak bone mass is built during our first three decades. Failure to build strong bones during childhood and adolescent years manifests in fractures later in life.”

What can we do?

Start early: Encourage young children to move more and sit less. The American Physical Therapy Association has a section on Container Baby Syndrome due to babies and young children remaining in a “container”- car seats, baby carriers, strollers, etc., for extended lengths of time. Due to the SIDS scare, many young parents are afraid to allow their child to spend time on their abdomen. Share the “Supine to Sleep, Prone to Play” mantra.

Spread the word: Speak to Young Mothers’ Clubs, Girl Scout Troops; anywhere to influence adolescent and teens about the importance of exercise and nutrition (for a variety of reasons).

Write a blog (such as this): Share this information in newspapers, social media, or on your website. Get the word out!

Because the bones of our future generation depend on it.

---

References:

1. NIH Osteoporosis and Related Bone Diseases National Resource Center
2. Department of Human Services
3. American Physical Therapy Association

In 1984, Mersheed Sinaki MD and Beth Mikkelsen, MD published a landmark article based on their research with osteoporotic women. (Yes, it was 1984 but this is one study no one would want to reproduce).⁽¹⁾
The study follows 59 women with a diagnosis of postmenopausal spinal osteoporosis and back pain who were divided into 4 groups that included spinal Extension (E), Flexion (F), Combined (E+F), or No Therapeutic Exercises (N). Ages ranged from 49 to 60 years (mean, 56 years). Follow-up ranged from one to six years (mean for the groups, 1.4 to 2 years). All patients had follow-up spine x-rays before treatment and at follow-up, at which time any further wedging and compression fractures were recorded.
Additional fractures occurred as follows:

• Group E: 16%
• Group F: 89%
• Group E+F: 53%
• Group N: 67%

This study suggests that a significantly higher number of vertebral compression fractures occur in patients with postmenopausal osteoporosis who followed a flexion based exercise program, than those using extension exercises. It also indicated that patients who did no exercises were less likely to sustain a vertebral compression fracture than those doing flexion exercises.

Due to the anatomical nature of the thoracic spine, the vertebral bodies are placed into a normal kyphosis. The anterior portion of the thoracic spine carries an excess load which can predispose an individual to fracture. Combine the propensity of flexion based daily activities such as brushing teeth, driving, texting or typing, with the fact that vertebral bodies are primarily made up of trabecular (spongy) bone and you have a recipe for disaster.

In the US, studies suggest that approximately one in two women and one in four men age 50 and older will break a bone due to osteoporosis.⁽²⁾ Now picture the many individuals who think that the only way to strengthen their core is by doing sit ups or crunches, further compressing the anterior portion of the spine. Often these exercises are being taught or led by fitness instructors who unknowingly put their clients at risk. Only 20-30% of compression fractures are symptomatic.⁽³⁾ This means that individuals may continue performing crunches, sit-ups, or toe touches even after they have fractured. No one realizes it until the person may notice a loss in height (they have trouble reaching a formerly accessible shelf or trouble hanging up clothes,) or the fracture is seen on an x-ray for pneumonia, etc. The Dowager’s Hump (hyper-kyphosis) may begin to appear. Or the person sustains another fragility fracture; possibly a hip.

Note that the E Group (Extension) still sustained fractures but significantly less than the other 3 groups. This suggests that there is a protective effect in strengthening the back extensors which has led to an emphasis on Site Specific back strengthening exercises as well as correct weight bearing activities.

Telling osteoporosis patients that they should exercise without giving them specific guidelines (such as in the Meeks Method) is doing them a disservice. General exercise provides minimal to no benefit in building stronger bones and the wrong exercises could put them at great risk for fractures. Educating our referral sources for the need to recommend therapists trained in correct osteoporosis management and the difference between “right” and “wrong” exercises may be the first step in reducing fragility fractures.

---

References:

1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Archives of Physical Medicine and Rehabilitation 1984 Oct; 65.
2. NOF.org. National Osteoporosis Foundation
3. McCarthy J, MD, Davis A, MD, Am Family Physician. Diagnosis and Management of Vertebral Compression Fractures