While waiting for webinar to begin,

get a chair, preferably one

with no arms for

Sit-To-Stand-To-Sit Exercise

OSTEOPOROSISTHERE

ISSOMETHINGYOU CAN DO

ABOUT IT!Practical Applications for Practice

THE MEEKS METHOD

Sara Meeks, PT, MS, GCS

that, someday in this country and, indeed, around the world, any person, no matter their age, gender, lifestyle, ethnicity,

musculoskeletal condition or any other factor, can go into any environment where exercise and movement are being taught

and be given a program that is

Ideally, it will also be therapeutic. Although there is more awareness now than when I began

teaching in 1998, there is still a lot to be done. By taking this webinar, you will help me fulfill my dream.

As you learn more about movement that is

you can help me take the message of safety and therapeutic intent in movement and exercise into your own life and into

the lives of others.

Trabecular Fracture

BONES• At

• Inside

• Beyond

The Bones

FRONT

BACKBONE

OF

THE

Spinomed Online CEU Course July 2011

INSIDETHE

BONES

6

Milner, Colin. Making Bone HealthA Priority. The Journal on Active Aging.May June 2002.

OSTEOPOROTICBONE

NORMALBONE

9

BEYOND THE BONESANATOMICAL CONSIDERATIONS Boney Structure Intervertebral Discs Joints Ligaments Circulation Neurological Muscular Internal Organs

8

POSITIONINGOF

INTERNALORGANS

9

Loss of Body Height Can AffectSpeech

SwallowingBreathing

Heart RhythmDigestion

EliminationAny Internal Organ

Function

FUNCTION

FOLLOWS

FORM

IS THEKEY

©2000 SARA MEEKS SEMINARS

PATTERNS OF POSTURAL CHANGE

Prevent, Arrest or Reverse Function Follows Form

• Determine areas of restriction and weakness

ISOLATE

ACTIVATE

INTEGRATE

• Relieve restriction/strengthen weakness

• Put it all together into functional movement

ALIGNMENT

PERCH POSTURE HIP HINGE

STANDING

POSTURE

FOOT

PRESS

SIT-TO-STAND-TO-SITFUNCTIONAL MOVEMENT

Inability to stand up out of a chair unaided is linked to a 2 fold increase in hip fracture risk Cummings et al 1995

Weakness of lower extremities linked to impending physical frailty Judge et al 1996 Guralnik et al 1995

Low femoral neck bone mineral density is significantly associated with a low sit-to-stand performance assessed by measurement of maximum rising strength in healthy adult women. Blain et al 2008

SIT-TO-STAND CHAIR

Use Lift of a Lift-Recliner Chair in Home Care

Indicated for patients who need assist with Sit-To-Stand-To-Sit movement

www.endorphin.net

17

A musculoskeletal disorder with compromised bone strength

that predisposes an individual to increased fracture risk

(broken bone)

NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy.

JAMA 2001: 285:785-795

DEFINITION

•Bone Density•Bone Quality

•Architecture•Mineralization•Micro damage accumulation

BONE STRENGTH

PEAK BONE MASS•The amount of bone accumulated as a young adult (generally age 30-35)

•About 90-98% is accumulated by age 18-20

Reduction of bone mass, both quantity AND quality

so that the bones become fragile and easily fracture

Bone Health and OsteoporosisA Report of the Surgeon General October 2004

DETERMINANTS OFPEAK BONE MASS

•Heredity – up to 75%*

•Physical Activity •Nutrition

•Ethnicity • Hormonal Status

• Lifestyle Factors

http://www.niams.nih.gov/Health_Info/Bone/Osteoporosis/bone_mass.asp#aAccessed October 21, 2011

O to -1………………Normal Bone

-1 to -2.4…………….Osteopenia

-2.5 & Below………..Osteoporosis

Below -2.5 in presence of fracture………Severe Osteoporosis

T Score

WORLD HEALTH ORGANIZATION

DIAGNOSTIC CRITERIA for ADULT WOMEN

Used for

Pre-Menopausal Women Men <50 years old Children

Z Score

Vertebral Column

Bone DensityReport

A/P View

Patient E.W.

HipBone Density

Patient R.O.

OSTEOPOROSISIS A

PEDIATRICCONDITION

that manifests in

ADULTHOOD

• Also in childhood--babies are being born with osteoporosis• Osteoporosis affects all populations—women, men, young

adults, the elderly, patients in your clinics and classes, and anyone here in this room today

• It knows NO boundaries regarding age, gender, lifestyle, ethnicity or any other factor

• Some people are more at risk than others but no-one is totally immune

• Osteoporosis affects 60% of persons age 60+ (men and women)

• Total of 57 million age 60 + should be very concerned about their bone health

• Total # of people estimated to have low bone mass in the United States—48 million

• Osteoporosis is more prevalent than coronary heart disease (12.5 million), heart attack (1.1 million) & diabetes (17 million)

• It is more common than breast, uterine and ovarian cancer combined

PEAK BONE GROWTH

•In Utero •Adolescence

WHEN DOES

PREVENTIONBEGIN ?

BEFORE BIRTH?Evidence that fracture risk might be programmed during intrauterine life

Maternal smoking, diet (esp. Vit D deficiency) and physical activity appear to modulate bone

mineral acquisition during intrauterine lifeLow birth weight & poor childhood growth are directly

linked to later risk of hip fracture

Optimization of maternal nutrition and intrauterine growth should also be included within preventive

strategies against osteoporotic fracture

Cooper C et al. Review: developmental origins of osteoporotic fracture Osteoporosis International 2006

QUESTIONS?

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IN UTERO

o One of the peak times of bone growth

o Targeting healthy women to have healthy babies

o Human beings are designed to move right

from conception

o Fetal movement during pregnancy

o Skeleton formed by 7 weeks

STAGES OF BONE DEVELOPMENT

INFANCY

o Continuing with bone growth

o We are born to move

o Normal development – roll over, prone positioning,lifting head and upper body, crawling – hands/knees,walking etc.

o Prone to play/Back to sleep

STAGES OF BONE DEVELOPMENT

BABY BOOT CAMP&

STROLLER‐FIT

A, Photograph showing an infant asleep with the insert in position.

Tonkin S L et al. Pediatrics 2003;112:907-913

©2003 by American Academy of Pediatrics

INFANCY ‐ 2

How infant development is being affected by use of car seats/baby carriers/strollers etc

Oxygen deprivationDelayed developmentSkull deformitiesTorticollisGerdSensory deprivationLack of movement – more and more car seats are designedto keep the infant so safe that they cannot move – does thisaffect bone development too?Cutting off of the airway in cervical‐flexed positioningAnecdotal reports of deaths of babies in portable car seats

STAGES OF BONE DEVELOPMENT

CAR BED

RISK FACTORSfor

OSTEOPOROSIS

NON-MODIFIABLE RISK FACTORS

Female

Family History

Post-Menopausal – Natural or Surgical

Advanced Age

Caucasian or Asian

Delayed Puberty/Irregular Menstrual Cycles

Early Menopause

Men over age 75

Nulliparous-having had no children

Small Boned

MODIFIABLE RISK FACTORS

Smoking

High Alcohol Intake

Caffeine (more than 2-5 cups/day)

Sedentary Lifestyle/Over-Exerciser

Men-Low Testosterone

High Protein Diet (Meat)

Low Calcium Diet

Eating Disorders

AIDS/HIVAnkylosing spondylitisBlood and bone marrow disordersBreast cancerChronic obstructive pulmonary disease (COPD), including emphysemaCushing’s syndromeDepressionDiabetes Eating disorders, especially anorexia nervosaFemale athlete triad (includes loss of menstrual periods, an eating disorder and excessive exercise)GastrectomyGastrointestinal bypass proceduresHyperparathyroidismHyperthyroidismInflammatory bowel disease, including Crohn’s disease and ulcerative colitisKidney disease that is chronic and long lasting

DISEASES AND CONDITIONS

Liver disease that is severe, including biliary cirrhosisLupusLymphoma and leukemiaMalabsorption syndromes, including celiac diseaseMultiple myelomaMultiple sclerosisOrgan transplantsParkinson’s diseasePolio and post-polio syndromePoor diet, including malnutritionPremature menopauseProstate cancerRheumatoid arthritisScoliosisSpinal cord injuriesStroke ThalassemiaThyrotoxicosisWeight loss

NOTEThis list may not include all diseases and conditions that may

cause bone loss.

Aluminum-containing antacidsAntiseizure medicines (only some) such as Dilantin® or PhenobarbitalAromatase inhibitors such as Arimidex®, Aromasin® and Femara®Cancer chemotherapeutic drugsCyclosporine A and FK506 (Tacrolimus)Gonadotropin releasing hormone (GnRH) such as Lupron® and Zoladex®HeparinLithiumMedroxyprogesterone acetate for contraception (Depo-Provera®)

MEDICATIONS

Methotrexate

Proton pump inhibitors (PPIs) such as Nexium®, Prevacid® and Prilosec®

Selective serotonin reuptake inhibitors (SSRIs) such as Lexapro®, Prozac® and Zoloft®

Steroids (glucocorticoids) such as cortisone and prednisone

Tamoxifen® (premenopausal use)

Anti-rejection drugs in organ-transplant patients

Thiazolidinediones such as Actos® and Avandia®

Thyroid hormones in excess

NOTEThis list may not include all medicines that may cause bone loss.

FIRST SIGNS

• Fracture- minimal trauma(e.g., Colles Fracture, Compression Fracture, Rib Fracture. Any fall from standing body height is a fracture of minimal trauma)

• Hyper-Kyphosis • Loss of body height• Transparent skin• Periodontal disease• Back Pain• Protruding Abdomen

RISK FOR FRACTURE

History of Previous Fracture – Fracture Predicts Fracture

Vision Problems

Deconditioning/Hypokinesis

Balance Problems

Tall Slim Build

Hip Fracture Immediate Family-especially of the mother

Inability to get out of a chair unaided

Being on one’s feet less than 4 hours per day

• Occurs in 1 of 2 women; 1 of 4 men• Happens every 20 seconds• Can be immediately life-altering and life-

threatening• Annual Fracture Incidence

– Vertebral—700,000– Hip—300,000– Wrist—250,000– Other Sites—300,000

• Cost – >$46 million per day– By 2020– >$178 million per day

OSTEOPOROSIS-RELATED FRACTURE

More fragility fractures occur in women with normal bone or osteopenia than in

those with osteoporosisTherefore, when prescribing exercise,

it is important to consider bonehealth in all populations

Pasco JA, Seeman E, Henry MJ, et al. The population burden of fractures originates in women with osteopenia, not osteoporosis. Osteoporos Int (2006)17:1404Sornay-Rendu E, Munoz F, Garnero P, Duboeuf F, Delmas PD.. Identification of osteopenic women at high risk of fracture: the OFELY study. J Bone Miner Res. 2005 Oct;20(10):1813-9. Epub 2005 Jun 20.E. Siris & P. D. Delmas. Assessment of 10-year absolute fracture risk: a new paradigm with worldwide application. Osteoporosis International (2008);19:383-384

•Bones of spine usually first to show signs of osteoporosis•Primarily trabecular bone•Fractures occur during movement that includes

TRUNK FLEXION

VERTEBRAL BODY

•After one vertebral fracture, the risk for having a 2nd vertebral fracture increases 5 fold!•1 woman in 5 will sustain a 2nd vertebral fracture within 1 year•“The risk of death is 2.7 times higher than those with no fracture”1

•Only 20-30% of all compression fractures are symptomatic2

1 Too Fit To Fracture: Exercise recommendations for individuals with osteoporosis of osteoporotic vertebral fracture 2014

International Osteoporosis Foundation 2005Report of the Surgeon General on Bone Health Oct 2004

2www.nih.gov accessed November 30, 2011

CONTRAINDICATED/CAUTIONARYMOVEMENT

Movements that Flex

Sidebend and/or Rotate

theSpine

ACUTE COMPRESSION FRACTURE MANAGEMENTAdapted from work by Betsey Newcomb, OT and Denise Pontbriand, PTA

Start early – on day of fracture if possible UN-load the spine – position in supine or as close to supine as

possible, hips and knees bent and supported to relieve pull of leg muscles on the spine

Position from least to most compression – supine, side-lying, prone, standing (standing more likely to precede prone)

Pain relief with positioning, ice, moist heat, electrical stimulation along erector spinae muscles

Back Extensor, Gluteus Maximus, Abdominal Isometrics

NO OUT-OF-BED-TO-CHAIR ORDERS

If patient must be seated, use reclined chair. Avoid “hammock” effect with folded blanket on seat and back to provide flatter surfaces

Any head, neck or lumbar support should be minimal and used only as necessary.

Initiate weight-bearing with standing, weight shifting, gait training using rolling walker or other optimal-height-adjusted support as soon as possible

Consider bracing with Spinomed-Spinal Orthosis for Osteoporosis

Initial non-weight-bearing therapy is important for preventing vertebral body collapse in elderly patients with clinical

vertebral fractures. Kishikawa Y. Int J Gen Med 2012:5 373-380.

CONVENTIONAL RELATIVE REST

• Bedrest

• Soft brace wearing

• Minimization of weight bearing to spine

INITIAL NON-WEIGHT-BEARING

• Complete bed rest (2 weeks)

• No weight bearing to spine followed by soft brace wear

• Meals and voiding in bed

• At 12 wks body union 100%

• No back pain 37%

• Mild back pain 62%

• Moderate back pain 1%

• Length of stay 49.2 days

• At 12 wks body union 97%

• No back pain 12%

• Mild back pain 75%

• Moderate back pain 13%

• Length of stay 37.9 days

55

KUMMELL’S DISEASEdelayed post-traumatic osteonecrosis of the spine

• A rarely-reported clinical entity that likely occurs with higher frequency than recognized

• Treatment decisions are similar to osteoporotic compression fractures

• Relevant factors include patient comorbidities, level of disability and pain, degrees of kyphotic deformity and presence of neurological compromise

• Although early reports were centered on conservative management, more recent reports favor surgical intervention

Ma, Richard et al. Kummell’s Disease: delayed post-traumatic osteonecrosis of the vertebral body. Eur Spine J (2010) 19:1065-1070.

THE MEEKS METHOD

12-POINTINTERVENTION

FOROSTEOPOROSIS

PRE-ASSESSMENTASSESSMENT

EDUCATIONPatient

Advocacy****

Resources

QUESTIONS?

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SITE-SPECIFICEXERCISE

Target At-Risk Areas

Fountain-Of-Youth Muscles

Start with Re-Alignment Routine

Focus on Strengthening

of the Back

Extensors

PRINCIPLES OF THE MEEKS METHOD

DECOMPRESSION

FRONT of the Backbone

T E N S I L E F O R C E Single Best Exercise for Most Back Pain

UN‐LOAD the Vertebral BodiesSite-Specific Exercise

Strengthen Support Muscles

“Fountain of Youth” Muscles•Diaphragm & Intercostals

•Heart•Back Extensors

•Abdominals•Pelvic Floor

•Gluteus Maximus •Gluteus Medius

Decompression Exercise

ShoulderPress

Head Press

Leg Lengthener

Leg Press

Side-Lying Leg Lift*******************************

RE-ALIGNMENT ROUTINE

Wings of Collarbone

Uni- and Bi-Lateral

Press Bottom Leg Down To Initiate Movement

INDICATED EXERCISE - “CORE”

ABSIsometrics

PELVICFLOOR

Isometrics

DIAPHRAGMBalloon Breath

BACK EXTENSORS

Foot Press

INTERCOSTALSSegmental Breath

BODY MECHANICS

SAFEMOVEMENT

during ADL’S****

Hip HingeGolfer’s Reach

Weightlifter’s SquatLunge

Assistive Devices

POSTURAL

CORRECTION

Visual ImageryInternal Plumb Line

BALANCEFeet-TogetherSemi-Tandem

Tandem & Single-Leg

StanceEXPERIENCE

****Fall-Proofing

the Environment

WEIGHT-BEARINGEXERCISE

Not just for lower extremitiesWeight-Shifting

Assistive DevicesRandom Forces-Odd Impact

Exercise for the Heart

GaitWith

Exerstriders

MODALITIESPAIN CONTROL

Moist HeatIce

Ice MassageMassage

PositioningUltrasound

Myofascial ReleaseActive-Isolated Stretching

LIV (low intensity vibration)Constant, Calibrated .4 G

Electrical Stimulationalong Erector Spinae

Bracing is part of a comprehensive approach to the management of

patients with

osteoporosisand/or

compressionfracture

BRACING

Purposes of Bracing•Support and Protection

•Control of motion•Prevent Fracture

•Allow weight-bearing activities

Bracing usually associated with weakeningof body part it is designed to protect

SPINOMED Spinal Orthosis for Osteoporosis

Spinomed III

Spinomed IV

The Spinomed®

Spinal Orthosis for Osteoporosis

Is the only spinal orthosis

designed specifically for the management of osteoporosis and compression fracture and

backed up by a peer-reviewed study that shows it strengthens the body part it is designed to protect—namely, the back

BRACING (with the Spinomed® brace)

– 73% Increase Back Extensor Strength

– 58% Increase Abdominal Strength

– 11% Decrease Thoracic Kyphosis

– 25% Decrease Body Sway

– 7% Increase Vital Capacity

– 38% Decrease in Pain

– 15% Increase in Well-Being

– 27% Decrease in Limitations ADL’s

– Increase in Body HeightPfeifer, Begerow, and Minne 2004

After TreatmentNo Brace

After TreatmentClam Shell

After TreatmentSpinomed

Best PostureDay 1 – Brace

2 ½ Weeks No Brace

Thanks to Betsey Newcomb OTR/L

Physical Therapist’s PerspectiveoLightweightoCan be worn under clothing - inconspicuousoEasy to Don and DoffoStrengthens rather than weakens—even with

more wear time; begin slowly and increase as patients can experience discomfort from muscle activation

oCan fit to very severe thoracic hyperkyphosisoDo not cut the straps too earlyoFit is critical should conform exactly to curves of back pelvic strap below iliac crests abdominal support in lower abdomen serpentine strap DOES NOT pull shoulders back

Physical Therapist’s PerspectiveBacked up by a peer-reviewed research study

Michael Pfeifer, Bettina Begerow, Helmut Minne 2004

Ordered by Physician

Fit by Orthotist – orthotist should make sure patient understands how to don/doff Spinomed before leaving the office

Physician, Orthotist, Physical Therapist, & Patient work together for ultimate best fit and satisfaction of the patient

Combine with The Meeks Method Exercises for optimum results

Instruct patient that orthosis should be worn when he/she is up and active, can be worn when sitting but patient will not get the most benefit of it

BRACING WITH THE SPINOMEDSpinal Orthosis for Osteoporosis

“The Spinomed orthosis is the single, most significant advancement in the conservative

management of osteoporosis and compression fracture EVER.”

Sara M. Meeks, PT, MS, GCS

Use of the Spinomed is part of thecomprehensive approach of

The Meeks MethodGoal of Management is to Minimize

the Risk of the Next Fracture

QUESTIONS?

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BREATHINGAwareness

DiaphragmaticSegmental

Targeted AreasUmbrella

RELAXATIONConscious “Time-Out”

Contract-RelaxDoing “Fun” Things

Breathing

ADVANCED EXERCISE

Seated ClassesFitness CenterYoga -- Pilates

&More

Yoga Bone Campwith Sara Meeks, PT, MS, GCS, KYT

SAFE Pilates for Skeletal Healthwith Sherri Betz, PT, GCS

“Non-Compliant”Patients

STAGES OF GRIEFDENIAL

"No way - can't be!" “They’ve got my report mixed up with someone else’s”ANGER

"Darn! I am so angry: I did everything right and I get OSTEOPOROSIS anyway?!??!!!“

NEGOTIATING/BARGAINING"So ... it's not so bad (osteopenia, borderline) .. and, if I elongate

A LOT, I can still do those forward bends, side bends and twists right? Maybe just breathe and move more gently?“

DEPRESSION"I am so down about this ... I have this condition for the rest of my life. I

just won't move at all cause I could break a bone“ACCEPTANCE

"Ok, I have osteoporosis. Sucks. But I'm going to find a way to do yoga and exercise because I love it ...

Just have to find a way to do it safely"

o Health care workers may benefit from an individual approach

o Face-to-Face delivery more effective o Take time to explain benefits of physical activityo Give clear & personalized adviceo Message from providers should be more consistento Educate older patients that it takes time to adapt to

new physical activity (I usually say “give it 6-8 wks”)o Involve relatives, friends and important peerso Check regularly to see that older patients

understand what you are asking them to doBaeert V et al. Motivators and barriers for physical activity in older adults with osteoporosis. J Ger Phys Ther. Vol 38. Number 3. July –Sept 2015. PP105-114.

o Personalize your approach – consider clinical condition of the patient

o LISTEN to your patiento Engage your patient as a partner in their therapyo Give your patient something they CAN do and which

will make a difference right away and they will be more likely TO do it

o Keep instructions simple & modified for each patiento Err on the side of cautiono When in doubt, don’t

In the end—minimizing risk of injury is the “bottom line”

Habitual Posture Best Posture Best Posture–1 Hour Later

JAMESThoracic Kyphosis

The World’s Osteoporosis

is

Ticking

Chan et al. Bulletin of the World Health Organization 2003, 81 (11)

!! TAKE ACTION NOW !!

Best way to diffuse the world’s

OSTEOPOROSIS TIME BOMB

is to

THINK

BONEWHEN YOUR PATIENT

FIRST COMES THROUGHTHE DOOR

“BOTTOM LINE”

MINIMIZE

THE RISK OF THE

NEXT FRACTURE

WHATIS

YOURNEXTSTEP?

Rosie

Mikki

Raven

For information on the Spinomedspinomed@mediusa.com

Sit‐To‐Stand Chairendorphin.net

Exerstrider Walking Poleswalkingpoles.com

LivMD Low Intensity Vibration Unitmarodyne.com

For PDF’s of

The Re-Alignment Routine Pre-Assessment Form

PowerPoint (color) Presentation Slide on Compression Fracture Management

Kishikawa study

send email to

sara@sarameekspt.com

Check website www.sarameekspt.com for more education by Sara Meeks, PT, MS, GCS

For seminars, webinars, books, DVDs

and other products designed to enhance practice

please visit www.sarameekspt.com

DISCLAIMER

Sara Meeks receives no commission on sales of any products presented or mentioned in this webinar

She recommends only products that enhance practice.

WAITING FOR ME TO FEED THEM

ARCHIE

MOSES

BOBBSEY

JUGHEAD

QUESTIONS?

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