Building Better Bones

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Building •

Better Bones COURSE MANUAL • 1 Osteoporosis Prevention, Treatment & Management

MARGARET MARTIN, PT, CSCS

Building Better Bones: Osteoporosis Prevention Treatment & Management Level 1 Training Manual for Health Care Professionals

www.melioguide.com 3

Building Better Bones: Osteoporosis Prevention Treatment & Management. Level 1 Training Manual for Health Care Professionals. Š 2010 by Margaret Martin. Version 2.0.0 Part number: bbb-g-001 Find us on the Web at www.melioguide.com To report errors, please send a note to info@melioguide.com All illustrations and photos are property of and developed by MelioGuide. All of the content in this book is owned by MelioGuide and is protected by worldwide copyright laws. The trademarks, service marks, trade names, and trade dress featured in this book are protected by the laws of Canada and those of other countries and jurisdictions around the world.

Notice of Rights. All Rights Reserved. This book may not be reproduced, in whole or in part, including illustrations, in any form (beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and except by reviews for the public press), without the written permission from the publishers. For information on getting permission for reprints and excerpts, contact Richard Martin at info@ melioguide.com

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Building Better Bones - Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 How to Complete This Course . . . . . . . . . . . . . . . . . . . . . . . 10 Course Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Course Outline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2. Fundamentals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Definitions and Consequences . . . . . . . . . . . . . . . . . . . . . . 20 Bone Physiology Overview . . . . . . . . . . . . . . . . . . . . . . . . . 25 Testing Bone Density and Bone Quality . . . . . . . . . . . . . . . 29 Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Effect of Exercise on Bone — Part A . . . . . . . . . . . . . . . . . 37 Effect of Exercise on Bone — Part B . . . . . . . . . . . . . . . . . 42 Nutrition and Bone Health — Part A . . . . . . . . . . . . . . . . . . 47 Nutrition and Bone Health — Part B . . . . . . . . . . . . . . . . . . 51 Pharmaceutical Intervention . . . . . . . . . . . . . . . . . . . . . . . . 56

3. Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Assessment and Senior Fitness Test — Part A . . . . . . . . . 60 Senior Fitness Test Application — 65 Year Old . . . . . . . . . 64 Senior Fitness Test Application — 85 Year Old . . . . . . . . . 65

4. Exercise Safety Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Instructions for Client Athletic Stance . . . . . . . . . . . . . . . . 68 Instructions for Client Breathing . . . . . . . . . . . . . . . . . . . . . 68 Instructions for Client Abdominal Activation . . . . . . . . . . . 69 Getting Up and Down From Floor – Option 1 . . . . . . . . . . 70 Getting Up and Down From Floor – Option 2 . . . . . . . . . . 71 Head Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Safely Using a Physio Ball . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Getting On The Physio Ball Safely . . . . . . . . . . . . . . . . . . . 74 Positioning Your Legs for Floor Exercises . . . . . . . . . . . . 75 Wrapping the Theraband . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Instructions for Client Tongue Placement . . . . . . . . . . . . . 77 Body Mechanics Training for Clients . . . . . . . . . . . . . . . . . 77 Hip Hinging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Facet Joint Arthritis or Spinal Stenosis . . . . . . . . . . . . . . . 78

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5. Fall Prevention/Balance Testing . . . . . . . . . . . . . . . . . . . . . 81 Fall Prevention/Balance Testing . . . . . . . . . . . . . . . . . . . . . 82 Fullerton Advanced Balance Scale . . . . . . . . . . . . . . . . . . . 87 Balance Exercise Application . . . . . . . . . . . . . . . . . . . . . . . 87

6. Beginner Level Balance Exercises . . . . . . . . . . . . . . . . . . . 89 Body Sway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Stepping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Stepping On The Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Single Leg Stance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Single Leg Stance With Movement . . . . . . . . . . . . . . . . . . . 93 Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Physio Ball Balance Exercise . . . . . . . . . . . . . . . . . . . . . . . 95

7. Active Level Balance Exercises . . . . . . . . . . . . . . . . . . . . . . 97 Weight Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Stepping Forward and Backward . . . . . . . . . . . . . . . . . . . . 98 Walking the Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Walking as You Look Away . . . . . . . . . . . . . . . . . . . . . . . . . 99 Taking a Turn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Physio Ball Balance Exercises . . . . . . . . . . . . . . . . . . . . . 100

8. Posture Analysis and Retraining . . . . . . . . . . . . . . . . . . . . 103 Posture Assessment and Cuing . . . . . . . . . . . . . . . . . . . . 104 Flexicurve Demonstration . . . . . . . . . . . . . . . . . . . . . . . . . 106 Improving Postural Alignment — Tips . . . . . . . . . . . . . . . 109 Posture Exercises — Application . . . . . . . . . . . . . . . . . . . 109

9. Posture Building Exercises . . . . . . . . . . . . . . . . . . . . . . . . 111 Chin Tuck Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Shoulder Tuck Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Chest Stretch - Floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Arm Reach Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Ear to Chest Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Chin to Chest Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Spinal Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Neck Press . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Shoulder Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

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Overhead Press . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Neck Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Arm Pull Back . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Straight Leg Press . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

10. Core Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Application of Core Exercises Part A — Theory . . . . . . . 128 Beginner and Active Core Exercises — Part B . . . . . . . . 129

11. Flexibility Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Safe and Effective Flexibility Exercises . . . . . . . . . . . . . . 132

12. Flexibility Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Quadricep Stretch – Standing . . . . . . . . . . . . . . . . . . . . . . 137 Quadricep Stretch – On Your Stomach . . . . . . . . . . . . . . . 138 Quadricep Stretch – Lying on Your Side . . . . . . . . . . . . . 139 Calf Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Hamstring Stretch Part 1 – Lower Hamstrings . . . . . . . . 141 Hamstring Stretch Part 2 – Upper Hamstrings . . . . . . . . 142 Iliopsoas Stretch – Kneeling . . . . . . . . . . . . . . . . . . . . . . . 143 Iliopsoas Stretch – Standing . . . . . . . . . . . . . . . . . . . . . . . 144 Chest Stretch - Doorway . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Ankle Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Lat Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Inner Thigh Stretch – Bent Knees . . . . . . . . . . . . . . . . . . . 148 Inner Thigh stretch – Straight Knees . . . . . . . . . . . . . . . . 149 Hip Rotator Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Spinal Stretch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

13. Weight Bearing and Cardiovascular . . . . . . . . . . . . . . . . 153 Determine Your Client’s Training Range . . . . . . . . . . . . . . 154 Low Fracture Risk Cardiovascular Exercises . . . . . . . . . 155 Moderate Fracture Risk Cardiovascular Exercises . . . . . 156 High Risk Fracture Cardiovascular Exercises . . . . . . . . . 157 Recovering from a Fragility Fracture . . . . . . . . . . . . . . . . 159 Therapeutic / Senior Exercise Classes . . . . . . . . . . . . . . . 159 Cardiovascular Exercise Considerations . . . . . . . . . . . . . 159 Swimming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

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14. Alternative Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Alternative Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

15. Contraindicated Exercises . . . . . . . . . . . . . . . . . . . . . . . . 167 Crunches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Chest Fly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168 Knee Extensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Lat Pull Down (Behind the Head) . . . . . . . . . . . . . . . . . . . 169 Seated Rows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Toe Touch With A Twist . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Hamstring Stretches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Back Stretches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Cardiovascular Exercise Considerations . . . . . . . . . . . . . 173

16. Vertebral Fracture Management . . . . . . . . . . . . . . . . . . . 179 Vertebral Fracture Management . . . . . . . . . . . . . . . . . . . . 180 Daily Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Orthotic Braces for Vertebral Fractures . . . . . . . . . . . . . . 186

17. Beginner and Active Strength Theory . . . . . . . . . . . . . . . 191 18. Beginner Level Strength Exercises . . . . . . . . . . . . . . . . . 193 Warm Up 1 – Energy Tree . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Warm Up 2 – Curtsey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 Warm Up 3 – Marching . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Wall & Ball Squats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198 Reverse Fly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199 Reverse Lunge Between Chairs . . . . . . . . . . . . . . . . . . . . 200 Horse Stance Vertical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Bridging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Bow and Arrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Alternating Leg Lifts - Prone . . . . . . . . . . . . . . . . . . . . . . . 204 Side Lying Leg Lifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Angels in the Snow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Wall Push Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Standing Biceps Curl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Triceps Extension from Floor . . . . . . . . . . . . . . . . . . . . . . 209 Heel Drops . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

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Abdominal Activation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

19. Active Level Strength Exercises . . . . . . . . . . . . . . . . . . . 213 Warm Up 1 – Energy Tree . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Warm Up 2 – Curtsey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Warm Up 3 – Marching . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Chair Squats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218 Floor M’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Forward Lunge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220 Horse Stance Horizontal . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Bridging With Weight on Pelvis . . . . . . . . . . . . . . . . . . . . . 222 Row With Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Hip Raise With Feet on Chair . . . . . . . . . . . . . . . . . . . . . . . 224 Side Lying Leg Lift With Weight . . . . . . . . . . . . . . . . . . . . 225 Pullovers From Floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Step Push Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Alternating Bicep Curl Standing . . . . . . . . . . . . . . . . . . . . 228 Triceps Extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 Step Ups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Abdominal Activation With Leg Drop . . . . . . . . . . . . . . . . 231

20. Osteoporosis in Special Populations . . . . . . . . . . . . . . . 233 Osteoporosis in Special Populations . . . . . . . . . . . . . . . . 234

21. Tai Chi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Tai Chi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Tai Chi for Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

22. MelioGuide Methodology . . . . . . . . . . . . . . . . . . . . . . . . . 245 MelioGuide Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Introduction to Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

23. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 About the Author - Margaret Martin . . . . . . . . . . . . . . . . . . . 269

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1. Introduction

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illions of people around the world have been diagnosed with low bone density, osteopenia or osteoporosis and many more will be subject to this condition as the population ages. Some individuals will have the misfortune of a fracture, which in turn will lead them to search for a health care practitioner to assist them with pain control, daily function, ambulation, and ultimately, future fracture prevention. These people are looking for professionals like you to guide them through a safe and effective exercise program that strengthens bone, reduces fracture risk and builds confidence. This course will provide you with the knowledge and skills to assist individuals with these needs at all levels of fracture risk and activity. The online course follows the same format as the 2 day live course except that you have 60 days to complete the material and the quiz, and you can review the material at anytime convenient to you. You can review presentations online as many times as you want during your 60 day access to the course material. Once you have successfully completed the quiz, you will have the option of having your name listed as a Level 1 trained MelioGuide Professional on MelioGuide.com. The screencasts cover the slides presented in the live course. However, the advantage of the online screencasts is that they allow you to pause the presentation at any time and review the material. Most screencasts are no more than 15 minutes in length. This allows for better focus and attention. You may choose to do one at a time or consecutive screencasts. Sections that have consecutive screencasts will be identified as such. The video demonstrations of all the exercises are embedded within exercise section of the web site. This will be explained to you in more detail through the web site overview screencast 11

available once you sign on to your account. The most frequent comment I had from therapists who have taken my live course is that I could easily have spread it over 3 days and that they find the 2 day format rushed. The advantage of the online approach is that you can cover the course material without that feeling of urgency. There is a lot of material here. I have given you estimated times that it should take you to review each chapter. The online version gives you the time you need to explore, learn and absorb the material at your pace. Happy learning!

How to Complete This Course In this training manual and in your online MelioGuide account, you will find all the information that you need to complete the course. You should follow these to successfully complete this online course: »» Review the Course Objectives on the next page. »» Review the Course Outline (after the Course Objectives). »» Follow the Course Outline: • View the corresponding online tutorials (screencasts). Notes for each screencast are your training manual. • View any accompanying videos. • Download any documents or resources in each of the online chapters. • Complete the Course Evaluation and Course Quiz. »» Write down any questions that may come to mind during the screencasts and videos. As with the live presentations, most participants found that their questions were addressed in the presentation. During your online course we will have a webinar (we will announce the details of the webinar via email) in which you will be able to ask your questions and discuss any issues. Should additional questions arise after the webinar, send them to me via the Contact Us on our site.

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Course Objectives By the end of this course the student will be able to: »» Identify the consequences of osteoporosis. »» Understand the fundamentals of bone physiology. »» Understand the basics about bone density and bone quality testing. »» Identify risk factors for osteoporosis. »» Understand the effect of exercise on bone. »» Understand the nutritional guidelines and use of pharmaceutical in building stronger bones. »» Identify the items involved in a comprehensive assessment. »» Understand how to take an accurate height assessment. »» Administer the Senior Fitness Test. »» Identify the safety tips that need to be part of your clients’ exercise program. »» Instruct patients in safe body mechanic. »» Identify contraindicated exercises. »» Provide exercise modifications. »» Identify the yoga and Pilates exercises that should either be modified or left out of your clients program. »» Identify and understand the most common fall prevention strategies. »» Administer the Fullerton Advanced Balance Scale. »» Instruct Beginner and Active level patients in appropriate balance training exercises. »» Identify the key elements in a postural assessment. »» Administer the Flexicurve for postural assessment. »» Instruct clients in postural cues. »» Instruct patients in postural retraining exercises. »» Instruct Beginner and Active level patients in safe and effective flexibility exercises. »» Instruct Beginner and Active level patients in safe and effective core exercises. »» Consider alternatives approaches to bone building and clinical implications related to osteoporosis. »» Identify the most beneficial cardiovascular exercises for low, moderate and high fracture risk patients. 13

»» Understand the cause, diagnostic and treatment approach of vertebral fractures. »» Instruct Beginner and Active level patients in strength training exercises. »» Identify medical conditions/diseases and medication that impact bone health »» Understand the benefits of Tai Chi as it relates to bone health. »» Access the MelioGuide™ web site as an educational resource.

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Course Outline Estimated time to complete the course is a minimum of 15 hours. If you are taking this course online and need to take more time to review certain concepts you should feel free replay individual videos and screencasts — in which case the course may take more than the 15 hours. The time to complete the screencast or video is provided below (and is also listed on the opening screen when you go to the screencast or video). And do not forget to complete your quiz and course evaluation! Chapter 1 — Introduction (approximately 30 minutes) Chapter 2 — Fundamentals (2 hours, 31 minutes and 49 seconds) »» Screencast: Definition and Consequences (20 minutes and 15 seconds) »» Screencast: Bone Physiology Overview (14 minutes and 8 seconds) »» Screencast: Testing Bone Density and Bone Quality (14 minutes and 31 seconds) »» Screencast: Risk Factors (12 minutes and 16 seconds) »» Screencast: Effect of Exercise on Bone — Part A (22 minutes and 13 seconds) »» Screencast: Effect of Exercise on Bone — Part B (24 minutes and 29 seconds) »» Screencast: Nutrition and Bone Health — Part A (15 minutes and 11 seconds) »» Screencast: Nutrition and Bone Health — Part B (16 minutes and 39 seconds) »» Screencast: Pharmaceutical Overview (12 minutes and 0 seconds) Chapter 3 — Assessment (30 minutes and 8 seconds) »» Screencast: Assessment and Senior Fitness Test — Part A (10 minutes and 43 seconds) »» Video: Senior Fitness Test Application — 65 Year Old (11 minutes and 15 seconds) »» Video: Senior Fitness Test Application — 85 Year Old (8 minutes and 10 seconds) Chapter 4 — Exercise Safety Tips (approximately 60 minutes) »» Review Exercise Safety Tips videos online and in chapter Chapter 5 — Balance Theory (31 minutes and 0 seconds) »» Screencast: Fall Prevention/Balance Testing (19 minutes and 15 seconds) »» Video: Fullerton Advanced Balance Scale (8 minutes and 43 seconds) »» Video: Balance Exercise Application (3 minutes and 2 seconds)

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Chapter 6 — Beginner Balance Exercises (approximately 30 minutes) »» Review seven beginner balance exercises online and in chapter Chapter 7 — Active Balance Exercises (approximately 30 minutes) »» Review six active balance exercises online and in chapter Chapter 8 — Postural Analysis and Retraining (47 minutes and 46 seconds) »» Screencast: Posture Assessment and Cuing (13 minutes and 25 seconds) »» Video: Flexicurve Demonstration (5 minutes and 26 seconds) »» Video: Improving Postural Alignment — Tips (10 minutes and 48 seconds) »» Video: Posture Exercises Application (18 minutes and 7 seconds) Chapter 9 — Posture Building Exercises (approximately 30 minutes) »» Review thirteen posture building exercises in the chapter and online at Posture Building Exercises Chapter 10 — Core Theory (23 minutes and 27 seconds) »» Screencast: Application of Core Exercises — Part A Theory (6 minutes and 11 seconds) »» Video: Beginner and Active Core Exercises — Part B Demonstration (17 minutes and 16 seconds) Chapter 11 — Flexibility Theory (10 minutes and 22 seconds) »» Screencast: Safe and Effective Flexibility Exercises (6 minutes and 36 seconds) »» Video: Active or Static Stretching (3 minutes and 46 seconds) Chapter 12 — Flexibility Exercises (approximately 30 minutes) »» Review fifteen flexibility exercises in the chapter and online at Flexibility Exercises Chapter 13 — Weight Bearing and Cardiovascular (7 minutes and 56 seconds) »» Screencast: Weight Bearing Considerations/Cardiovascular Training (7 minutes and 19 seconds) »» Video: Weight Bearing/Cardiovascular Application (37 seconds) Chapter 14 — Alternative Approaches (16 minutes and 0 seconds) »» Screencast: Alternative Approaches to Bone Building/Therapeutic Considerations (16 minutes and 0 seconds) Chapter 15 — Contraindicated Exercises (approximately 30 minutes) »» Screencast: Contraindicated Exercises (4 minutes and 50 seconds)

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»» Review 9 Contraindicated Exercises online and in chapter Chapter 16 — Vertebral Fracture Management (approximately 65 minutes) »» Screencast: Vertebral Fracture Management (29 minutes and 3 seconds) »» Review Daily Activities (approximately 30 minutes) »» Review Orthotic Braces for Vertebral Fractures (approximately 5 minutes) Chapter 17 — Beginner and Active Strength Theory (14 minutes and 34 seconds) »» Screencast: Strength Training Beginner and Active Level (12 minutes and 20 seconds) »» Video: Beginner Strength Application (2 minutes and 14 seconds) Chapter 18 — Beginner Strength (approximately 90 minutes) »» Review bone building warm up and strength training for osteoporosis online (text, photo and video) and in chapter (seventeen exercises) Chapter 19 — Active Strength (approximately 90 minutes) »» Review bone building warm up and strength training for osteoporosis online (text, photo and video) and in chapter (seventeen exercises) Chapter 20 — Osteoporosis in Special Populations (18 minutes and 14 seconds) »» Screencast: Osteoporosis in Special Populations (18 minutes and 14 seconds) Chapter 21 — Tai Chi (17 minutes and 41 seconds) »» Screencast: Tai Chi (7 minutes and 21 seconds) »» Video: Tai Chi for Osteoporosis (10 minutes and 20 seconds) Chapter 22 — MelioGuide Methodology (30 minutes and 31 seconds) »» Screencast: MelioGuide™ Methodology (10 minutes and 53 seconds) »» Screencast: Introduction to Site (19 minutes and 38 seconds) Course evaluation and quiz (approximately 20 minutes). Delivered to you via email.

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18. Beginner Level Strength Exercises

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here are two major Exercise sections in this chapter. The Beginner Level Exercises are categorized into Warm Up and Strength. As you progress through the chapter, the type of exercise (Warm Up, Strength) will be indicated at the bottom of each page. The Cardiovascular, Flexibility and Postural Exercises have been covered in earlier chapters. Please refer to these chapters for more detail. The client printed guide for the Exercise for Better Bones Program provides the following detail: The frequency and progression of the Warm Up and Strength exercises should be followed as described in the Beginner Exercise Schedule. For the Strength exercises you will require dumbbells, an exercise mat or comfortable carpet to lie on and a burst resistant exercise ball. The equipment you will need can be found at most major outlet stores. Before you start, let me clarify what I mean in the Exercise Schedule when I say “sets” and “reps”? Reps is an abbreviation for repetitions. This is the number of repetitions you do before your muscles are too tired to do any more. Thus, if I ask you to do a set of ten repetitions, I want you to pick a weight that makes the exercise hard enough that by the tenth repetition the muscle you are targeting is very fatigued and you would have a hard time completing another repetition with good form. If the recommended second set indicates that you perform less repetitions than the first set, then you should choose a heavier weight. Sets represent the number of times you redo the exercise. If I ask you to do two sets you should not do them back-to-back. The muscle being targeted needs time to recover - a full minute at the very least! This doesn’t mean you have to sit around and wait. Your recovery time can be used working 195

another muscle group or working on your Balance exercises. I designed the exercise series so that you could do them one after another. This approach allows for an active recovery period. This saves you time and builds a cardiovascular component into your program. Under the Strength Exercises I have listed the prime or main muscles involved in executing the exercise as well as which part of your skeleton gets the most stimulation from the exercise. The three most frequent bone fracture areas (spine, hip, and wrist) are identified. The muscle groups and affected bones are listed under “Targets”. For example, while doing a squat, your muscles at the front of your thighs and your buttocks are the most active and your hip bones are loaded. Your spine gets loaded as you hold weight or wear a weighted vest while doing your squat.

Use of Affirmatives During the Warm Up Exercises You should use personal affirmatives as you go through your Warm Ups to start your session off on the right foot and get yourself into the right frame of mind. An affirmative is a positive personal thought. As you inhale, say to yourself “I am”. As you exhale, choose an affirmation to take with you into your workout: “energized”… “balanced” ... “strong” .... “focussed”. Now onto your first Warm Up Exercise. By the end of this chapter you will be able to: »» Instruct Beginner level clients in strength training exercises.

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WArM uP 1 – energY Tree sTArTing POsiTiOn: » Stand tall.

MOVeMenT: » Inhale as you as you raise arms overhead, lifting your rib cage up - gathering energy as you reach to the sky. » Exhale as you bring your arms by your side, keeping your rib cage lifted. » Repeat.

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WArM uP 2 – CurTseY sTArTing POsiTiOn: » Stand tall between two chairs. Your hands should be resting above, but not on, the chairs. » Inhale.

MOVeMenT: » Exhale as you cross your left leg behind your right leg, gently bending both knees. » Return to start position by pushing your front foot into the floor. Inhale. » Exhale as you cross your left leg behind your right, gently bending both knees. TiPs: » Keep your chest up and pelvis facing forward. » Most of the weight will be on the front leg. » The heel of the back leg will be raised.

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WArM uP 3 – MArCHing sTArTing POsiTiOn: » Stand tall. MOVeMenT: » Alternate raise your knees in front of you as you breathe in and out. » Simultaneously swing your opposite arm towards the ceiling as you march. » Raise your knees as high as you comfortably can. If you feel unstable you should do this between two chairs.

TiPs: » If you are unsteady on your feet, stand between two chairs with your hands resting above them but not on them. » Swinging your arms with a bent elbow will allow you to march at a quicker pace. This has good carryover for brisk walking.

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WALL & BALL sQuATs TArgeTs: » Muscles: Quadriceps, Buttocks. » Bones: Hips. sTArTing POsiTiOn: » Place the ball against the wall in the small of your back. » Stand tall with your feet hip width apart, hands resting by your side. » Step forward 3 to 5 inches (approximately a half of your foot length) from your upright position. » Inhale. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Bend your knees as though you are sitting on a stool placed under the ball. » Return to standing position & repeat movement until set is completed. TiPs: » Keep the middle of your knee cap tracking over your second toe. » Only go as far as you can comfortably go. With time, you will be able to get into a seated position with your thighs parallel to the floor. » Squeeze your buttocks and push the floor away from you as you return to your standing position. » As you squat, the ball will move to your mid and upper back region, your weight should be evenly distributed between your heel and forefoot. Keep your eyes facing forward.

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reVerse FLY TArgeTs: » Muscles: Middle & Upper Back. » Bones: Spine. sTArTing POsiTiOn: » Stand with your buttocks, upper back and the back of your head against the wall. Keep your chin tucked in and eyes facing forward. » Your feet should be four to six inches from the wall, your knees slightly bent. » Hold the Theraband allowing roughly 12 to 18 inches of band between hands. » Inhale as you raise your arms to shoulder height with your thumbs pointing to the ceiling. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Squeeze your shoulder blades together and your arms back. » Return in a controlled manner to starting position and repeat until set is completed. TiPs: » To ease into this exercise, you can bring one arm back at a time. » You should have no more than a hand size space in the small of your back throughout this exercise. » Adjust the length of the band between your hands to get the resistance you need. » Refer to “Wrapping the Theraband” in Chapter 4. This is especially important if you have arthritis. » If your head does not rest easily against the wall hold a rolled face cloth between your head and the wall.

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reVerse Lunge BeTWeen CHAirs TArgeTs: » Muscles: Hamstrings, Buttocks and Quadriceps. » Bones: Hips. sTArTing POsiTiOn: » Stand with an athletic stance. » Place hand (s) on chairs. » Inhale.

MOVeMenT: Exhale and gently tighten your lower tummy as you: » Take a long step back onto your right forefoot (your right heel will be off the floor). » Lunge as deep as you are comfortable. Your right knee should be in vertical line with your hips and shoulders. » Return to your start position by pressing your left leg into the floor while pushing off with your right foot. » Repeat movement until your set is complete. You can either alternate legs or do all right and then all left. TiPs: » If your toes do not like the pressure, you may try this exercise wearing running shoes. » As you feel steadier, release the chair.

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HOrse sTAnCe VerTiCAL TArgeTs: » Muscles: Deep Back Muscles. » Bones: Spine and Wrist. sTArTing POsiTiOn: » Assume a four point kneeling position. » Keep your knees directly under your hips and your hands directly under your shoulders. » Keep your elbows unlocked and pointing towards your thighs. » You should have a hand-width space in your low back. A yardstick along your spine would keep you in perfect alignment. Contact points will be your pelvis, mid-back and back of your head. » With your spine kept in a neutral alignment position, take a deep relaxed breath and allow your belly to drop towards the floor. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Begin by transferring your weight off the limb to be lifted. » Raise one hand slightly (enough to slide a sheet of paper between your hand and the floor). » Hold this position for up to five seconds. » Repeat this pattern with your opposite hand, your left leg and your right leg (one at a time!) » Each individual lift corresponds to a single repetition on your Exercise Schedule. TiPs: » Throughout the exercise, keep your spine motionless. » If you are unable to tolerate resting on your wrist, you can do the exercise with your forearms on a small bench, or with a small towel rolled under your palms (but not your fingers).

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Bridging TArgeTs: » Muscles: Buttocks, Hamstrings, and Back. » Bones: Hips and Spine. sTArTing POsiTiOn: » Lie on your back, knees bent, knees and feet hip width apart, arms out from your side with palms up. » Squeeze a rolled towel or pillow between knees. » Inhale. MOVeMenT: Exhale as you: » Squeeze your buttocks and push down through your heels. » Transfer your weight onto your shoulder blades as you lift your hips towards the ceiling. » Raise your toes as you raise your hips, lowering your toes as you lower your hips. » As you come down lengthen your spine as though your tail-bone is reaching towards your heels. » Return in a controlled manner to starting position & repeat movement until set is completed. TiP: » You should feel this in your buttocks, back of your thighs and muscles along your spine. » Transfer your body weight to your heels and shoulder blades and not the back of your neck. » Go high enough that you are bringing your hips into the line drawn between your hips and shoulders.

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BOW And ArrOW TArgeTs: » Muscles: Upper and Middle Back. » Bones: Spine. sTArTing POsiTiOn: » Stand with your buttocks, upper back and the back of your head against the wall. Keep your chin tucked in and eyes facing forward. » Your feet should be 4 to 6 inches from the wall, knees slightly bent. » Hold the Theraband such that only 6 to 8 inches of band remains between your hands. » Inhale as you raise your arms to shoulder height with your knuckles pointing to the ceiling. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Pull your right elbow into the wall as you keep your left arm out as though holding a bow. » Focus on your shoulder blade drawing towards your spine as you pull your elbow back. » Return in a controlled manner to the starting position and repeat until set is completed. TiPs: » You should have no more than a hand size space in the small of your back throughout this exercise. » You may need to double up your Theraband for more resistance. » You may return your arms down to your thighs in between each repetition. » If your head does not rest easily against the wall hold a rolled face cloth between your head and the wall.

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ALTernATing Leg LiFTs - PrOne TArgeTs: » Muscles: Hamstrings, Buttocks, and Lower Back. » Bones: Hips and Spine. sTArTing POsiTiOn: » Lie on your stomach with a pillow under your pelvis. » Rest your forehead in your palms. » Inhale. MOVeMenT: Exhale and gently press the front of your pelvis into the floor as you: » Bend your right leg slightly and lift your leg off the floor. » Focus on squeezing your butt as you lift. » Repeat until your set is completed. » Repeat on the other side. » Raise your leg only as far as you can without lifting hips off the floor. TiPs: » If you are uncomfortable lying on your stomach, you can place a second pillow under your pelvis.

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side LYing Leg LiFTs TArgeTs: » Muscles: Abductors (the muscles in your upper hip/buttocks). » Bones: Hips. sTArTing POsiTiOn: » Lie on your side with head, neck, back, hips and top leg forming a straight line with your body and your foot pulled towards your shin. » Bottom leg should be comfortably bent. » Your top hand should be on the floor in front of your belly button to help maintain your position. » Your bottom arm should be bent and resting under your head to allow your neck and head to be in a neutral position (or you can use a pillow or rolled towel under your head). » Inhale. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Keep you foot pointing straight ahead and slowly lift your top leg as you lead with your heel. » Repeat the movement until your set is completed. » Switch leg and repeat movement. TiPs: » If your hips are wider than your waist, you should place a small pillow or rolled towel in the space between your pelvis and rib cage as illustrated in the photo to the immediate right. » Line yourself up against a wall to encourage proper leg lift. Your top heel should remain in contact with the wall throughout the exercise.

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AngeLs in THe snOW TArgeTs: » Muscles: Back and Shoulders. » Bones: Spine. sTArTing POsiTiOn: » Lie on your back, knees bent, feet on floor hip width apart, arms at your side with palms facing upward. » Inhale.

MOVeMenT: Exhale and gently tighten your lower tummy as you: » Press your upper arms into the floor and move both arms at the same time as though making angel wings in the snow. » Inhale at the top of your movement. » Exhale as you return to your starting position. » Repeat movement until set is completed. TiP: » Only go as far as you can keep contact with the floor at all times. » Be sure to press your upper arms (above your elbow) into the floor to ensure you are using your back muscles to do the movement.

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WALL PusH uP TArgeTs: » Muscles: Chest, Triceps and Abdominals. » Bones: Wrists and Spine. sTArTing POsiTiOn: » Place your hands one and one-half shoulder width apart on the wall with your hands turned slightly towards each other » Stand far enough back to create a lean into the wall as if you were the Leaning Tower of Pisa. » Inhale.

MOVeMenT: Exhale and gently tighten your lower tummy as you: » Lower your body towards the wall, bending your elbows away from you. » Push away, straightening but not locking the elbows. » Repeat movement. TiPs: » Keep your head, shoulders, hips and ankles in line throughout the exercise. » Let yourself rock forward onto the balls of your feet, lifting your heels. » If a wall pushup feels too easy, you can progress to a pushup from a counter top or the stairs. The lower the surface, the more challenging the exercise will become.

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sTAnding BiCePs CurL TArgeTs: » Muscles: Biceps. » Bones: Spine and Wrists. sTArTing POsiTiOn: » Stand with an athletic stance with a weight in each hand, hips and chest facing forward. » Arms at your side, elbows unlocked, palms facing your thighs. » Inhale.

MOVeMenT: Exhale and gently tighten your lower tummy as you: » Move your palms from their start position, facing thighs, to palms facing forward. » Bring the weights to your shoulders and return to start position in a controlled manner. » Repeat movement until set is completed.

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TriCePs exTensiOn FrOM FLOOr TArgeTs: » Muscles: Triceps. » Bones: Wrists. sTArTing POsiTiOn: » Lie on back, knees bent and feet on floor, knees and feet shoulder-width apart. » Hold one weight in both hands with your arms straight and raised slightly higher than shoulder height (hands are in line with eyes/ forehead). » Inhale. MOVeMenT: Exhale and gently tighten your lower tummy as you: » Bend your elbows, lowering the weight until it almost reaches the floor behind you. » Return to start position in controlled manner. » Repeat the movement until set is completed. TiPs: » Keep your shoulders and upper arms steady through the bending and straightening of your elbow. » Do not lock your elbows.

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HeeL drOPs TArgeTs: » Muscles: Calves. » Bones: Hips. sTArTing POsiTiOn: » Stand with an athletic stance, arm length distance from the table. » Touch the counter top lightly with your fingertips to balance yourself. » Rise up on your toes as high as possible. » Keep your back straight, chest high and eyes looking forward. » Inhale.

MOVeMenT: Exhale and gently tighten your lower tummy as you: » Quickly drop your heels while keeping body tall. » Repeat movement until set is completed. TiPs: » Do not bend at the knees. Keep your legs straight but do not lock your knees. » Do not let your hips move forwards or backwards. nOTe: » If you have any joint pain in your lower body or have had a previous compression fracture, then you should drop down gently on your heels.

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ABdOMinAL ACTiVATiOn TArgeTs: » Muscles: Transverse Abdominus. » Bones: Spine. sTArTing POsiTiOn: » Lie on floor with knees bent, feet and knees hip-width apart and arms resting out from your sides, palms up. » Place a small rolled towel in the small of your back (roll should be the width and depth of your hand). » Inhale with your diaphragm. MOVeMenT: » As you exhale, slowly, gently tighten your pelvic floor muscles and your lower tummy. » If you cannot feel your deep abdominal muscles tighten, I find that many of my clients are successful when I ask them to pull their pelvic bones together. The bones do not actually move, but the deep muscles will tighten. » Hold for 5 seconds and relax. » Repeat up to 10 times. TiP: » Please refer to “Pull in Your Tummy” for proper abdominal activation tips in Chapter 4 Exercise Tips.

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23. References

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National Health and Nutrition Examination Survey American Journal of Hypertension July 2007, Volume 20, Issue 7, Pages 713-719 Pharmaceutical Intervention Bisphosphonates, About Osteoporosis, February 1, 2008 <http://www.osteoporosis.ca/english/ About%20Osteoporosis/Drug%20Treatments/Bisphosphonates/default.asp?s=1> Medications, NOF web site, March 1, 2008 <http://www.nof.org/patientinfo/medications.htm> FDA Alert January 7, 2008 Cummings SR et al. NEJM Vol 365:1895-1896, May 3, 2007 SERMs, About Osteoporosis, February 1, 2008 February 1, 2008 <http://www.osteoporosis.ca/ english/About%20Osteoporosis/Drug%20Treatments/SERMs/default.asp> Medications, NOF web site, March 1, 2008 <http://www.nof.org/patientinfo/medications.htm> Calcitonin, About Osteoporosis, February 1, 2008 <http://www.osteoporosis.ca/english/ About%20Osteoporosis/Drug%20Treatments/Calcitonin%20and%20Testosterone%20 Replacement%20Therapy%20and%20Parathyroid%20Hormone/default.asp?s=1> Hormone Replacement Therapy, About Osteoporosis, February 1, 2008 <http://www. osteoporosis.ca/english/About%20Osteoporosis/Drug%20Treatments/Hormone%20 Replacement%20Therapy%20or%20HRT/default.asp?s=1> Parathyroid Hormone, About Osteoporosis, February 1, 2008 <http://www.osteoporosis.ca/ english/About%20Osteoporosis/Drug%20Treatments/Bisphosphonates/default.asp?s=1> Medications, NOF web site, March 1, 2008 <http://www.nof.org/patientinfo/medications.htm> Assessment: Asomaning K., et al.The association between BMI and Osteoporosis in patients referred for a BMD examination. Journal of Women’s Health. November 1, 2006, 15(9): 1028-1034 Siminoski K, “Tools and Techniques” Osteoporosis Update Spring/Summer 2005 Vol. 2 Rikli RE and Jones JC, Senior Fitness Test Manual. Champaign: Human Kinetics 2001 Fall Prevention/Balance Testing: Kalyani RR et al. Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis. J Am Geriatr Soc. 2010 Jul; 58(7):1299-310. Menant JC et al. Optimizing foot wear for older people at risk for falls. Arch Phys Med Rehabil. 2008 261

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Arnold CM, et al. A Randomized Clinical Trial of Aquatic versus Land Exercise to Improve Balance, Function, and Quality of Life in Older Women with Osteoporosis. Physiotherapy Canada, 2008;60:4 pg. 297-306 Posture Analysis and Retraining: Lewis CB. The Relationship Between Posture and Psychological Variables in Students Age 18 25. Oregon Free Press. 1983. Paul Hodges Lumbopelvic Motor Control: Clinical techniques in motor control training for lumbopelvic pain. Hamilton, ON Feb. 7, 2009 Meeks, SM, OSTEOPOROSIS: A Comprehensive Treatment Strategy Level 1 by Sara M. Meeks, PT, MS, GCS. San Francisco, CA, 2001 FlexiCurve References: 1. Milne JS, Lauder IJ. Age effects in kyphosis and lordosis in adults. Ann Hum Biol. 1974;1:327-337. 2. Chow RK, Harrison JE. Relationship of kyphosis to physical fitness and bone mass on postmenopausal women. Am J Phys Med. 1987;66:219-227. 3. Arnold CM. The reliability of five clinical postural alignment measures for women with osteoporosis. Physiotherapy Canada. 2000;52:286-294. 4. Lundon KM, Li AM, Bibershtein S. Interrater and intrarater reliability in the measurement of kyphosis in postmenopausal women with osteoporosis. Spine. 1998;23:1978-1985. 5. Instructional Video: Kypholordosis Measurement Using a Flexible Curve. Produced by the APTA Section on Geriatrics, 2007. Application of Core Exercises: Guillarme, Luc. Rééducation thoraco-abdomino-pelvienne par le concept Abdo-MG. Guillarme Luc,2004. Ed Frison-Roche. Safe and Effective Flexibility Exercises: Rob D Herbert, Michael Gabriel, Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ 2002; 325:46 Bacurau et al. Acute Effect of a Ballistic and a Static Stretching Exercise Bout on Flexibility an dMaximum Strength. J Strength Cond Res 23:304-308, 2009

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About the Author Margaret Martin

M

argaret Martin is a Physical Therapist, licensed in California and registered to practice in Ontario, with over 25 years of experience helping individuals achieve their health and fitness goals. She graduated from McGill University - School of Physical Therapy in 1984. She is certified with the National Strength and Conditioning Association as a Strength and Conditioning Specialist. Margaret has worked in a variety of clinical and industrial settings in Canada and the US. Margaret combined her clinical Physical Therapy experience, her knowledge of fitness training and her study and review of the most current medical and scientific literature to develop the MelioGuide programs. She designed each of the programs to challenge individuals at their level of fitness and bone health without putting them at risk. Her private Physiotherapy and Personal Training studio, Function to Fitness, is located in Ottawa, Ontario. Find out more about her at: www.MelioGuide.com and at www.FunctionToFitness.com.

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