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[Physio Explained] Practical Osteoporosis management for Physios with Dr Lora Giangregorio

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In this episode we explore all things to do with managing patients with Osteoporosis. We cover:

  • Factors to consider in treating patients with Osteoporosis
  • Importance of fall risk in fracture risk
  • Risk assessment calculators and how to use these
  • Exercise prescription with this patient population, including those with vertebral fractures
  • Recommendations regarding more structured exercise/involvement in sports
  • Risks clinicians need to be aware of in this patient population

Want to learn more about managing patients with Osteoporosis? Lora recently did a brilliant Masterclass with us, called “Strategies for Osteoporosis Management and Fracture Prevention” where she goes into further depth on managing patients with low bone density. 

👉🏻 You can watch her class now with our 7-day free trial: https://physio.network/masterclass-giangregorio

Lora Giangregorio, PhD is a Professor in the Department of Kinesiology and Health Sciences at the University of Waterloo, and a Schlegel Research Chair in Mobility and Aging. She completed her PhD in Human Biodynamics at McMaster University. She leads the Bone Health and Exercise Science Lab, where her team conducts research on physical activity for older adults and people with osteoporosis. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

UNKNOWN:

So,

SPEAKER_00:

We did a study, actually, where we looked at the data from the Canadian Multicenter Osteoporosis Study, and we looked at, like, what are the activities that caused fractures? And I would say probably 6% of them are related to sport. So it happens. And then a lot of the other ones are fall-related, you know, and some of them were during activities of daily life, as well as, you know, activities of leisure. So I would say that there's lots of different types of activities we do in our daily life that can increase our risk of fracture. And I think you can also talk about what are the strategies you can put in place to reduce the risk.

UNKNOWN:

Thank you.

SPEAKER_02:

Welcome to the Physio Explained podcast. In today's episode, we're joined by Dr. Laura Jean-Gregorio, a PhD, a professor in the Department of Kinesiology and Health Sciences at the University of Waterloo. Laura leads the Bone Health and Exercise Science Lab and is a key figure in osteoporosis research and guideline development, including the 2023 Clinical Practice Guidelines for Osteoporosis and Fracture Prevention in Canada. In this episode, we'll be diving into some of the critical factors to consider when treating patients with osteoporosis, exploring how to apply a multifactorial approach to treatment, the types of exercises and activities to consider, and the risks clinicians need to keep in mind when supporting this population. Laura has also created an excellent masterclass for the Physio Network on osteoporosis, where you can explore these concepts in even greater depth. Be sure to check out the link in the show notes. Enjoy the day's episode. It's packed with clinical insights you won't want to miss. I'm James Armstrong, and this is Physio Network. Physio Explained. Laura, it's great to have you on the Physio Explained podcast today. Thanks for coming along. Thanks for having me. Wonderful. So really excitedly, we are going to be talking about a topic that is osteoporosis and the treatment of this patient group, which you've done a masterclass for the Physio Network on. So we're really excited to have that and to talk a little bit more about that today. We were talking about off-air really about what we're going to talk about and so that broad context, that broad subject matter but I think what we really wanted to focus in on today was some of the things that we might want to consider as physiotherapists when treating patients with osteoporosis and obviously it's a patient group that some physios sometimes a bit fearful of treating. So from your point of view what are some of the key things that you think useful to consider and why with this patient group, Laura?

SPEAKER_00:

I think the first thing is, you know, we think about osteoporosis as a diagnosis and osteoporosis is, you know, defined by reduced bone strength, right? But a person that has an osteoporosis based on their bone mineral density, so that would be like a T-score minus 2.5 or below, that might not necessarily be equivalent to their fracture risk. So I think you need to think about fracture risk rather than just osteoporosis. So for example, if someone has osteopenia and not osteoporosis, but they fall three times a day, then their potential risk may be higher just because the falling increases the risk of hurting themselves, right? So you have to think about all All of the things that influence risk of fracture and bone mineral density is one of those things, but there are other things that influence fracture risk. And in fact, you use the FRAX risk assessment calculator, other risk assessment calculators, they use BMD or bone mineral density, but they also use other factors. Interestingly, fall risk is not often part of that. So I would say, you know, understand a person's fracture risk by looking at all of their risk factors, and then also think about their fall risk, because the interventions that you might do for fall risk are slightly different. They can make focus more on balance training, for example, on someone who's at high fall risk. So I think it's in your assessment is understanding their fracture risk and looking at their risk factors and what's contributing to their fracture risk, and then also thinking about their fall risk because that does also contribute to their fracture risk. And then the other thing is, you know, their history of fracture, which is part of their fracture risk because if they have had a history of fractures, they're probably at increased risk of future fractures. But if they have spine fractures specifically, having one spine fracture really increases your risk of subsequent fractures. And spine fractures can also cause, be a source of back pain. They can also, if you have multiple spine fractures, start to change your posture so you can develop hyperkyphosis. which then can contribute to other impairments, breathing impairments, digestion, you know, other things. So part of your assessment might include those other pieces. So for example, if sometimes lusteric cirrhosis, you might want to look at their posture and look, ask them about whether they've had fractures before and ask them that they have back pain, because you might then want to know, for example, if they experienced new back pain, distinguishing that from the back pain they had before, because that might be indicative of having a new fracture as well. So thinking about all these different pieces that might influence your treatment.

SPEAKER_02:

Definitely. So it's very multifactorial, isn't it? Rather than just looking at a patient, they have osteoporosis, it's far more in detail than looking at actually the person you have in front of you rather than just that diagnosis, which we hear all the time on this podcast about this, looking at a person, not just their diagnosis.

SPEAKER_00:

Well, and also I think, you know, it's probably not that common for someone to go see a physio for osteoporosis, right? They'd probably be going for another reason. but the osteoporosis might be part of their clinical picture. So you have to consider that. So it's probably much more like that you're seeing someone for fall risk or you're seeing someone for back pain or you're seeing someone for shoulder pain because they have hyperkyphosis. But I think it's understanding how their osteoporosis and these other factors influence your treatment.

SPEAKER_02:

Absolutely, definitely. So when we're treatment planning, I mean, if we've got a patient coming in with some back pain and we know they have a history of osteoporotic pain, fractures, say vertebra fractures, what sort of things might we consider with our exercise prescription? Is there anything that we need to bear in mind that we might consider with these patient groups?

SPEAKER_00:

Yeah, that's great. So we've actually been working with the Fragility Fracture Network on a care model for people with spine fractures and all the things you need to consider. And I think you need to, you know, like the first thing is pain management, right? So if they have pain due to their fractures, you want to give them strategies to manage that pain. You will want to then think about how it affects their physical functioning. And so you want to, your management strategy and exercises would address impairments in physical functioning or try to improve physical functioning. And part of that might be, and then sorry, and then the third element is fall and fracture prevention in future. So that might be trying to prevent falls and potentially trying to prevent bone loss or increase bone mass if that's possible. One thing that would fit under all of those categories is sort of the safe movement strategies. We call it spine safe movement. Some people say spine sparing, but the idea of like, you want to prevent falls because the vast majority of fractures occur due to falls, but there are some fractures that occur in the spine because of you know, the way that we move the spine. People are often said to don't lift it, don't move. And we want to avoid that because that can cause fear. But you do want to consider that it is possible that certain types of movements can potentially cause loads on the spine that can be risky. So fracture prevention, bone density and applied load. So a fracture is not going to happen unless the applied load exceeds the bone density. So we can sometimes modify the bone density with drugs or exercise to prevent bone loss or nutrition to prevent bone loss. But we can also affect the applied load side of the equation. So that's through fall prevention, hip protectors, if that's appropriate. And then also thinking about loads on the spine, which is the spine safe movement. So spine safe movement fits under the pain management because if someone's got pain due to vertebral fractures, giving them some movement strategies might help it be less painful. They improve physical functioning because they can do things better. And then it may also prevent fractures. So it kind of fits under all of those categories.

SPEAKER_01:

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SPEAKER_02:

in terms of the kind of conversation that sometimes comes up in terms of what shouldn't we do, how careful do we need to be with these patients? And you rightly said there, the last thing we want to be doing is putting fear into the patients and allowing them to worry about movements. But are there things that physiotherapists need to be aware of that they might not want to push certain movements or in certain ways?

SPEAKER_00:

Yeah, it's really tricky because you don't want to create like a movement avoidant person, right? Like you don't want to create fear. So I think the first thing I would say is that, you know, you want to be able to try to do the things that you normally do and the types of movements, like not all bending and twisting is bad. But the types of movements that tend to be a bit riskier is when we're either flexing our spine forward or laterally or twisting when it's fast, like rapid twisting. So not necessarily just twisting in general, but rapid or when it's repetitive or when it's weighted. So for example, if you're Bending forward and you're picking up really heavy groceries, you're flexed and you're holding something heavy and it's out in front. And then you're twisting to put it, you know, in your trunk, right? You know, the twisting and the bending that's combined or weighted, these are the scenarios. So when you're communicating, it's not saying you can never bend or twist, but how to... how to do it safely and giving examples of scenarios where it may be risky so like if you have to lift furniture like that's really heavy so maybe that's something you have to either hire someone or get some help with but when you bend tire shoes do it like this right so like you know thinking about framing the how to do the movement safely and what examples would be risky and so we would usually say that the rapid repetitive weighted sustained or end range forward or lateral flexion or twisting of the spine is the types of things that we want to either modify or avoid. But yeah, I like to give people examples so they can visualize what I mean by that. So I think about, for example, all of us who will carry our groceries, we have like five groceries in one bag in the keys or one hand and the keys in the other, right? Well, that's going to put a force on the spine that's going to want it to bend sideways. And then we have to have lots of muscle forces on the other side to kind of bring it back. So instead, divide and conquer. So you have grocery bags on either side, right? And then, you know, So thinking about giving people examples of how to do things safer and then what are the types of things that, you know, you may want to avoid. So some are more obvious, like shoveling. In Canada, shoveling is a reality. Shoveling still. And the, you know, sort of rapid, the repetitive, the weighted, the sustained, and then end range of motion, twisting of the spine or forward or lateral flexion. So those are the types of things that may be a bit risky. The reality is it's not like we have random trials, randomizing people to lateral flexion and not lateral flexion and seeing if they fracture. But it's kind of paying attention to the types of movements that often cause the fractures. And it's usually people moving quickly or not being careful about how they move or doing it with weight, right?

SPEAKER_02:

Absolutely. Okay, that's really interesting. A couple of things to ask around that then. We mentioned earlier a little bit about medications that may be supporting their bone health. Is that something that you would think to consider if you've got someone who's coming in with sort of a relatively new onset of back pain known vertebral osteoporotic fractures but haven't been put on any medications is that something that you would take into account at all?

SPEAKER_00:

Yeah so if someone is not on medication and they are at risk of fractures that they've been told they have osteoporosis I would usually ask, like, have you talked to your doctor about medication? And if not, then I encourage them to do so. Because I think it's really important that everyone has... the options explained to them. So some people will say, yes, I have, and I don't want to go on medication. I don't want to hear about it. And then at least you've done your due diligence, but there's the odd person who's said, no, no one's ever really talked to me about medication or I don't have a family doctor or whatever it is. And I think that's where it's, you know, encouraging them to have the conversation just so that they're aware of the potential benefits. And they can also discuss their questions about harms. We're all on the same team, right? We want everyone to get the right healthcare. So making sure that you encourage them to talk to their primary provider about medications. Medications do reduce the risk of fracture, but not completely. So I certainly would probably take similar precautions if someone is on medication or not, but I'm definitely a little bit more encouraged if they're on medication that they've sort of taken those steps to reduce the risk. But I would say that it's still probably take any... Any precautions I would take or any communications I would use related to safe movement, I would certainly do the same with people on medication or not. And the other thing you have to consider is that the people who are on medication are often the higher risk folks, right? So it's kind of like a continuum, right? You've got like people who are at high risk and then kind of intermediate risk and then lower risk, right? And often... the higher your risk, the more likely you're going to be convinced at some point to go on medication. So I wouldn't necessarily say, okay, we're all on medication, so they're in good shape and they're lower risk. They may actually be the highest for spokes.

SPEAKER_02:

Yeah, that's a good thing to take into account. And then going back into the movements you were talking about, suddenly I started thinking about some of the population that might actually still be playing some element of sport or certainly sort of more physically active and I'm thinking along lines of things like tennis and things like that which quite often we might see some of these populations still taking part in or wanting to. What are your strategies around that and advice that we might give to a patient? Does it differ to what you've already said?

SPEAKER_00:

Yeah I mean And I think this applies to most activities. So a lot of things that we do in life have risks and benefits. And I think it's important to talk to people about the activities that they want to do and the benefits they get out of them, and then the risks that are associated with those activities, and then help people understand that you can't predict whether someone's going to fracture during yoga or tennis or whatever it happens to be. Again, we don't have randomized trials, randomizing people to tennis and no tennis and seeing if they fracture. But what we can say is that there are inherent risks and you have to decide whether the benefits that you get out of playing this sport or doing this activity outweigh those risks. The higher risk you are... the likelihood that the risks outweigh the benefits. So again, it's about having the conversation. So a good example is pickleball, right? So pickleball has become, I don't know if it's popular where you are, but here it's very popular. And a lot of times it's pitched at people who are retirement age. Like there's these groups and people who do pickleball because it's supposed to be this like easier racket sport, but it's competitive and people get competitive and they're more likely to like do movements that are fast paced. And again, if you take someone who isn't maybe someone who's been playing racket sports all their life, and now you introduce this new sport that is competitive, you maybe have that potential that they're going to fall or twist suddenly to get at the pickleball thing. And then that's where your risk is. So I would say that I've known people with low bone mass who have fracture during pickleball. So it's not without risk. And I would say the same is true for tennis or any other sport. So I think it's just a conversation about the potential benefits and the reasons why they want to do it. And then the potential risks and the types of movements that can cause risk. And then people have to decide whether or not those benefits outweigh the risks. And I would say if someone is higher risk, I might be a bit more likely to say, I'm concerned about it for these reasons. I'd be a bit more nervous about people playing sports if they're high risk of fracture, if they've already had fractures.

SPEAKER_02:

As you say, it's a conversation, isn't it? And it's about information, being able to make an informed decision, or the patient being able to make an informed decision, knowing some of the information and the facts and the risks, but also the benefits, and then weighing it all up for themselves. Yeah.

SPEAKER_00:

Yeah, so we did a study, actually, where we looked at the data from the Canadian Multicenter Osteoporosis Study, and we looked at, like, what are the activities that caused fractures? And I would say probably 6% of them are related to sport. So it happens. And then a lot of the other ones are fall-related, you know, and some of them were during activities of daily life, as well as, you know, activities of leisure. So I would say that There's lots of different types of activities we do in our daily life that can increase our risk of fracture. And I think you can also talk about what are the strategies you can put in place to reduce the risk. So I got a question once, for example, you know, I have this patient. She has osteopenia. She wants to know if she can still do trail running. And I'm like, okay, well, you have to look at all the things that affect applied load and all the things that affect bone density. So, you know, are you taking adequate calcium and vitamin D? Are you on medication or not? Are you doing other things to... Maintain your bone strength, getting enough protein and calories, doing other types of exercise like resistance exercise. Are you doing exercises to improve your balance? Because now we go to the applied load section. So what are the risks? The risks are you're tripping, uneven surfaces, you know, those sorts of things. So are you doing balance exercises? You know, how much do you want to do the trail running? How fast are you running? So there's all these different things, you know, ground reaction forces, what type of footwear are you wearing? So again, it's about having a conversation about, you know, all the things that can improve your balance. And then what can you do to reduce the risk? If you want to go skiing, maybe if you are a very advanced skier and now you find that you have low bone density, like how important is skiing to you? If you want to continue doing it, how can we reduce the risk? Well, you could wear hip protector pads. You could, you know, stick to the blue and green runs and avoid the snowboarders. Like there's lots of strategies you could do to reduce your risk, but you have to also accept that that risk is there.

SPEAKER_02:

Absolutely. Laura, this is brilliant. Time has flown by and I'm really, really looking forward to the masterclass. And for those listening, a reminder, if you want to learn more about this topic and those patients which you will no doubt be seeing on a quite regular basis, potentially, depending on which area you're in, then please do check out the masterclass and there'll be a link in the show notes below. Laura, thank you so much for your time. And as I say, really looking forward to the masterclass and learning much more about this patient population that we do see a lot of. So thank you very much.

UNKNOWN:

Thank you.