REP 15: TOO FIT TO FRACTURE
The 2010 Clinical Practice Guidelines for the Management of Osteoporosis recommend pharmacological treatment for those at high risk, and potentially for those at moderate risk as well. Strength and balance training are also recommended. However, for health professionals, there is little guidance on frequency, intensity, time and type, or on safe performance ofphysical activity, including activities of leisure and daily living. Moreover, patients often report receiving very conflicting or discouraging advice from physicians, physiotherapists, and exercise instructors when asking about physical activity.
What is a patient to do when the advice we give is a barrier to getting more active?
The Big Idea
Health professionals need to speak the same language when addressing patient questions about physical activity.
In 2012, an international team of researchers and clinicians launched Too Fit To Fracture, an initiative aimed at synthesizing best evidence and developing recommendations for bothexercise and physical activity for individuals with osteoporosis. Part of the process was establishing consensus on questions commonly asked by patients, so that we could begin to give similar answers.
My take on things…
When I started as a tenure-track professor at the University of Waterloo, I would get requests from local osteoporosis support groups and church groups to speak about exercise and osteoporosis. I would confidently gather the research, summarize it in lay language, and deliver it to the eager listeners looking for advice on physical activity. I would speak about how research has shown that exercise might slow bone loss in postmenopausal women, and howexercise can prevent falls. They would nod and smile approvingly.
Then, the questions would come in rapid succession:
“Can I go to Curves? Is it a good way for me to exercise?”
“Is it safe for me to do yoga?”
“What about golf? My doctor told me that I shouldn’t do it,
but I really enjoy it.”
“How do I get rid of this hump on my back?”
“My doctor told me not to bend or twist, does that mean
I have to walk around like a robot?”
“I like to go to the community exercise class, but I have to take the bus and
carry my things in a gym bag. In the winter I need to wear boots and then my bag
weighs more than 5lbs. My doctor told me I have severe osteoporosis and can’t lift
more than 5lbs, so how can I get to my class safely?”
“My doctor told me that walking is the best exercise, but you are telling me
to do resistance training – why aren’t the doctors giving me that advice?
I was a helpless, book-smart rookie who did not know how to address their concerns – either for their immediate need for information and resources, or their larger concerns regarding the lack of consistency in physical activity and exercise advice. Moreover, many patients were being advised on physical activity using disincentivising language, in the form of restrictions, rather than language that would encourage them to stay active. They were being presented with lists of cannot’s rather than lists of can’s. So, I rallied the troops and together we launchedToo Fit To Fracture.
Building consensus and consistency
Our first step was to use the GRADE methodology to review the literature regarding the effects of exercise on bone mineral density, fractures, falls, and other health outcomes. Our two key recommendations following this review:
- Individuals with osteoporosis (with or without vertebral fractures) should engage in a multicomponent exercise program that includes resistance training in combination with balance training; and
- Individuals with osteoporosis should not engage in aerobic training to the exclusion of resistance and balance training.
Recommendation 2 was included to discourage the “Just get moving! Start a walking program!” advice that patients often receive from health professionals – advice that disregards best evidence. Arguably, many older, inactive adults find it difficult to get moving, or might be at increased risk of falls with an unsupervised aerobic walking program if impairments in strength and balance are not addressed first.
Our next step was to provide consistent answers to questions frequently asked by patients. We sent a list of patient FAQs with three clinical cases to researchers and clinicians in several countries to see how they would answer them, and how the answers would vary based on clinical presentation.
- 68 year-old female with osteoporosis based on BMD,
- 68 year-old female with osteoporosis and one vertebral fracture, and
- 68 year-old female with multiple vertebral fractures, hyperkyphosis and pain.
The result is a comprehensive guide to exercise and physical activity for people with osteoporosis. Unfortunately, the guide is not open access, but it is available via the Osteoporosis International journal site.
Key messages from the Too Fit to Fracture recommendations include:
- Encourage daily balance training
- Include resistance training to improve strength (not endurance) at least twice weekly for major muscle groups
- Teach spine sparing strategies, such as a hip hinge and step-to-turn
- Encourage exercises to increase back extensor muscle endurance daily, and
- Encourage moderate to vigorous aerobic physical activity for individuals at moderate risk of fracture, but only moderate intensity for those at high risk
“Can I still do…?”
Not all bending and twisting is bad for individuals with osteoporosis.
Our research and practice needs to be patient-centred. The recommendations were designed to provide information that can be used to answer questions that patients ask. We found that patients often ask about activities of daily living and leisure. Importantly, the recommendations encourage health care providers to advise patients on how to do things, rather than how not to do them. It needs to be noted that not all bending and twisting is bad for individuals with osteoporosis – the types of movements that are most risky are those that involve rapid, repetitive, weighted, and end-range flexion and twisting of the spine. Patients without a history of vertebral fracture that ask “Can I do ____?” might still be able to do it if they practice spine sparing strategies, and perhaps get guidance on how to do it safely.
Things that influence physiotherapists’ decision-making should include the patient’s history of doing the activity, amount of time receiving therapy, strong desire to do the activity, and overall health and physical function. Naturally, more caution is advised when a vertebral fracture is present, and consultation with a physical therapist with specialized training is strongly encouraged to promote safe physical activity. Physical therapists might consider pursuing training to put the Too Fit To Fracture research into action.
What do you tell a patient with osteoporosis when it comes to physical activity and exercise? What strategies or resources have you used to encourage safe and effective exercise and physical activity? What tools would you like to see developed?
We are working with Osteoporosis Canada to develop tools and resources on exercise and physical activity for health care providers and patients. To learn more about osteoporosis, check out their website.
If you want access to tools or continuing education, check out:
- BoneFit.ca – Advanced training for physiotherapists and kinesiologists (2-day workshop), and basic training for exercise instructors (1-day workshop)
- Osteoporosis Canada –Videos, and webcasts for patients and health care providers
- Contact Osteoporosis Canada’s hotline to get access to a free comprehensive booklet on exercise for patients Toll-free (English): 1-800-463-6842 *Hours: M-F, 9-5, Toll-free (French): 1-800-977-1778 (in Canada only)
- 2014 Report on future research priorities
About Dr. Lora Giangregorio
Lora Giangregorio is an Associate Professor in the Department of Kinesiology at the University of Waterloo, and an Adjunct Scientist at the Toronto Rehabilitation Institute – University Health Network. Her research aims to reduce the burden of osteoporotic fractures, one lunge at a time. More about Lora’s research