Bone Health, Posture and Father Time
February 1, 2016
by Sandy Conran, PT, MHS, Cert TDN
Do you identify with the posture of the figure on the left, the middle, or the far right? Do you want to stay where you are at in this picture or move more to the left in this lineup?
This photo is an example of Patterns of Postural Change. (1) When posture begins to deteriorate; the first changes that are noted are a loss of height and the beginning of a swayback or lumbar lordosis. If it progresses, this lumbar sway becomes more pronounced and the abdomen begins to protrude with a corresponding forward displacement of the head. With continued postural changes, the upper thoracic spine becomes more rounded into the commonly called “Dowager’s Hump” and the hips and knees begin to become contracted or shortened. Unchecked, all these elements may continue to be accentuated until your ability to stand up straight is lost. The good news is that this process can be arrested, and even reversed, in many cases.
These Patterns of postural change happen as we age but not because of aging. They can be found in anyone who has progressive loss of functional mobility. While common in osteoporosis, these postural changes are not limited exclusively to cases of low bone density. Weakness develops in the spinal muscles, the gluteal muscles of the hips, and the quadriceps in the thighs. Tightness develops in the soft tissues of the chest, the front of the hips, and the back of the legs. By stretching what is tight and strengthening what is weak, it is possible to arrest these Patterns of Postural Change.
How does this relate to bone strength? Compression fractures of the spine may contribute to these postural changes. Extended periods of inactivity in the individual who is either frail or afraid of movement, for whatever reason, contribute to the very weaknesses and mobility restrictions that lead to these postural changes. So let’s look a little more at bone density or lack thereof; commonly referred to as Osteoporosis.
Osteoporosis, Osteopenia and More
Bones are like a bank. Up to age 30 we are primarily making deposits into the bank. This is the point in time where peak bone mass usually occurs. At that point, withdrawals begin to exceed deposits. When bone density falls below an established point, then osteopenia or osteoporosis is present. Osteoporosis is defined by the National Institutes of Health as “A systemic skeletal disorder with compromised bone strength that predisposes an individual to increased fracture risk.”(2) The current gold standard for measuring bone density is a DEXA scan. A DEXA report will include a T score that compares the individual’s test score against that of a 30 year old female. A T score of -1.0 and above is normal bone density. This means that the bone has 90-100% of peak bone mass. A score of -1.0 to -2.49 is called osteopenia. Bone density in osteopenia will be 75-90% of peak bone mass, the micro architecture is intact but thinner and the risk of fracture has begun to increase. Osteoporosis is when the DEXA score is -2.5 and below. In these individuals, bone mass has fallen below 75% of peak, the micro architecture has become disrupted, and the risk of fracture is high.
There are some limitations to the DEXA scan. A consumer is usually provided a composite score so one area may be osteopenic while an adjoining area is osteoporotic. Scoliosis can give false readings of higher than actual bone density. Finally, low bone density does not always correlate to low bone quality. A new test is on the horizon, called a Trabecular Bone Scan, which is theorized to provide a more accurate risk of fracture by assessing the quality of the micro architecture of the bone versus bone density.(4) Both tests are non-invasive and painless, very similar to getting an x-ray.
What factors contribute to peak bone mass? While heredity may be up to 75% responsible, it is also determined by levels of physical activity, nutrition, hormonal status, ethnicity, lifestyle factors, and even birth factors such as smoking, vitamin D deficiency, and inactivity of the mother, and low birth weight of the baby. Higher risk groups for low bone density include:
- Females by a 2:1 ratio over males
- Small boned
- Asian or Caucasian ethnicity
- Sedentary lifestyle
- Family history
- Never carrying a pregnancy
- Advanced age
Dietary considerations for risk factors include high amounts of alcohol, protein, and /or sodium; eating disorders; and low levels of either calcium or the Vitamin D which is needed to absorb the calcium.
There are medical conditions and medications that are also associated with lowered bone density. These include:
- Rheumatoid arthritis
- Malabsorption disorders
- Thyroid supplements
- Anticonvulsant medications
- Antacids containing aluminum
Early signs of bone loss are the aforementioned posture changes, a loss of body height, periodontal disease, transparent skin, fractures with low trauma; i.e. wrist, hip, or back without a significant fall, and persistent back pain from “silent” fractures. These fractures in the spine typically occur in the thoracic (middle) spine when stooping over to pick up something. The complications from repeated spinal fractures due to osteoporosis are numerous and include loss of independence, and increased nursing home admissions.(5) The risk of osteoporotic fracture is doubled in those who need their hands to push up from a chair to a standing position.
While there are risk factors that you cannot control, such as heredity and gender, there are many that can be influenced. The elements that you have influence over include: posture, body mechanics (how we move), strength, flexibility, and activity levels.
Posture: A variety of images can be used to promote positive posture changes. Some ideas:
- Pretend that you are 2″ taller than you think. Use your full height.
- Foot triangle of support: stand with weight evenly distributed on both feet with weight on your heels, along the outer bone on the bottom of the foot, and on the bony prominences just behind all of your toes.
- Golden thread or cable: Pretend a string or cable is pulling you up by the crown (back) of your head; like a puppet suspended on a support.
- Shelf or Tie High: Imagine a shelf (or tie) at collar bone height and that you are showing the tie off or keeping a coffee cup on the shelf; keep the breastbone “up.”
- Abdominal “set”: Imagine your pelvis is a bucket. The top of the bucket is at your waist line. Set the bucket so that it is not tipping forward or back so as not to spill any contents over the edge.
- Avoid thinking “shoulders back” as many individuals end up bending backwards in the low back due to motion restrictions in the upper back; thereby inadvertently increasing compressive loads on the spine.
Body mechanics is how we use our bodies in daily activities. Are you twisting, bending, lifting? The general rule of thumb is to imagine a straight line, like a long rod, from the back of the head to the tailbone. This straight line can tilt in any direction so long as it remains unbent or uncurved; like a letter “I” rather than a letter “C.” The following do’s and don’ts are a good rule of thumb for those with low bone density or history of spine/hip pain.
- Don’t bend over to tie shoes/ put on socks
- Do not do exercises in the gym that pull you forward
- Do not bend from the waist to pick up items/ brush teeth, etc
- Do not reach / twist unnecessarily
- Do not sit down when your back hurts (very compressive on spine)
- Do not engage in high impact activities like jumping
- Perform sit-ups or use abdominal machines
- Combine twisting or bending or lifting
- Bring your foot up or cross over other leg or place on step stool
- Hinge from the hips rather than the waist using the letter I image
- Practice good body mechanics
- Lie in decompression position; on back on floor with knees bent, feet on floor to unweight the spine
Strengthening and Stretching
Strengthening should be instituted prior to stretching. It is important to activate spinal muscles for stability before gaining flexibility that you have no control over! Strengthen what is weak; generally the spinal muscles, hip extensors (gluteals or buttocks), and thighs. Stretch what is tight: typically the chest, front of the hips, and back of the legs.
The single best thing you can do to preserve bone health is to perform weight bearing exercises. Walk. Walk forwards, backwards, sideways. Vary the terrain and the speed. Your bones will respond to the different demands by looking for bone building blocks in your bloodstream and depositing them, like a bank, into your bones. The pool and/or the bike are good cardiovascular exercises but your bones will not respond to them as they will with weight bearing. If your balance is less than stellar, consider hiking poles to help with balance and posture while you are walking. Yoga is generally safe for osteopenia but seek a provider who is knowledgeable regarding safe and unsafe yoga postures.
Adequate protein, limiting alcohol to 1 drink a day for females and two a day for males are definite contributors to bone health. Research on calcium is now contradictory. The body can only absorb 500 mg at a time so if you are taking more than that a day, break the dosage into 500 mg increments.(6) The research does affirm that Vitamin D is needed to help the body absorb calcium.(7) There are an increasing number of publications addressing pH balance in the body and suggesting that higher fracture rates in cultures that consume more dairy are actually correlated to diets that lean acidic, like the typical Western one. Intentionally eating a more alkaline diet, primarily vegetables, grains, and fruits; may help prevent the leaching of calcium and phosphorus from the bones that the body is using to neutralize the acidic environment in the blood stream.(8)
- Know your T scores if you are over the age of 50,
- Monitor your height annually (ask for a height measurement when your weight is measured at your annual physical exam),
- Avoid compressive movements,
- Alignment (posture correction) is key,
- Bear weight by standing 10 minutes every hour and 4 hours of every day,
- Strengthen what is weak,
- Stretch what is tight,
- Practice good body mechanics,
- Work on leg strength so that you are able to get up from a chair without the use of your hands and
- Make deposits into your bone bank with good nutrition and physical activity.
If you identified yourself as being in the middle or right side of the Patterns of Postural Change photo at the top of the article, you may need site specific exercises to assist you in getting started. Consider physical therapy to help you on your journey to improved bone health. The Meeks Method for Osteoporosis and Postural Management can provide site specific exercises, instruction in proper body mechanics or movement during activities of daily living, breathing exercises, and recommendations on bracing when appropriate.
- Sara Meeks, Patterns of Postural ChangeTM
- Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Statement. 2000 March 27-29; 17(1): 1-36.
- Notelovitz, MD, Morris. (1982) Stand Tall. Triad Publishing. Gainesville
- Pothuaud, L, Barthe, N; Krieg, M; Mehsen, N; Carceller, P; and Hans,D. Evaluation of the Potential Use of Trabecular Bone Score to Complement Bone Mineral Density in the Diagnosis of Osteoporosis: A Preliminary Spine BMD–Matched, Case-Control Study. Journal of Clinical Densitometry. April-June 2009. Vol 12, Issue 2, pp 170-176.
- Old JL. Vertebral Compression Fractures in the Elderly. American Family Physician. Jan 2004
- Committee to Review Dietary Reference Intakes for Vitamin D and Calcium, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.
- Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.
- Brown, Susan and Trivieri, Larry. (2003) The Acid-Alkaline Food Guide – Second Edition: A Quick Reference to Foods & Their Efffect on pH Levels. Square One Publishers. NY http://www.trans4mind.com/nutrition/acid-alkaline.html
National Osteoporosis Foundation www.nof.org
NIH Osteoporosis Consensus https://consensus.nih.gov/2000/2000osteoporosis111html.htM
Sara Meeks website for further information on Meeks Method including consumer information and S.A.F.E. Skeletally Appropriate For Everyone Yoga videos www.sarameekspt.com
Meeks, Sara. (1999) Walk Tall! An Exercise Program for the Prevention & Treatment of Back Pain, Osteoporosis and the Postural Changes of Aging, Second Edition. Triad Publishing Company
Numerous books on pH diet; alkaline-acidic balance available in local library systems.