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OsteoStrong Review: What’s Wrong With OsteoStrong?

Margaret Martin — Thu, 31 Jul 2025 01:28:49 +0000

July 31, 2025

As a Physical Therapist and licensed health professional, I frequently receive questions about OsteoStrong from my patients. Many women in their 40s, 50s, 60s, and 70s are understandably concerned about maintaining or improving their bone density, especially as the risk of osteoporosis increases with age. They specifically ask: Is OsteoStrong safe? Is it effective? Is there credible research supporting their claims?

As a clinician, I will only recommend a modality when it can demonstrate that it is an effective and safe way to improve bone health. Recently, Osteostrong identified a study out of Greece that it claimed supports that their devices improve bone health.

In the past, I’ve been hesitant to speak openly about the company. There was an unpleasant OsteoStrong lawsuit with a client who experienced a compression fracture (1) (2). However, a recent development has encouraged me to share my professional insights with you.

What is OsteoStrong?

Before diving further into the topic, let’s clarify what OsteoStrong actually is. OsteoStrong is a private company offering membership-based gym services specifically targeting individuals with osteoporosis. They operate through a franchise model, with “OsteoStrong Centers” located throughout the US, Canada, Europe, and other parts of the world.

The company claims their protocol involves “bone strengthening” through brief (12-minute), weekly, low-impact, high-intensity osteogenic loading sessions. This certainly sounds appealing, especially for those seeking efficient ways to improve bone health.

Review and Evaluation of The Recent OsteoStrong Study

In February 2025, a team of researchers in Greece published a study on OsteoStrong in the Journal of Clinical Endocrinology and Metabolism (3). This study, which was funded by OsteoStrong, claimed that the OsteoStrong protocol effectively increases bone mineral density, improves bone quality, and delivers other health benefits.

However, Dr. Lora Giangregorio, a leading researcher in osteoporosis and exercise from the University of Waterloo in Canada, has published a thorough review of this study (4). Dr. Giangregorio has published numerous studies on osteoporosis and exercise and is highly respected in her field. Her analysis reveals several concerning issues that anyone considering OsteoStrong should be aware of.

Major Shortcomings of the OsteoStrong Study

Dr. Giangregario identified seven significant shortcomings in the OsteoStrong study.

1. Failure to Meet Basic Scientific Standards

According to Dr. Giangregorio, the OsteoStrong study fails to meet even the most fundamental standards expected in scientific research:

No clear objectives or hypotheses
Inadequate information about ethical approval
No clear statistical analysis plan describing how results were analyzed
Incomplete description of how data was collected and analyzed for many outcomes
No clear information about what the control group actually did

Scientific research follows internationally accepted standards and checklists for reporting. Alarmingly, this study is missing most of these essential elements.

2. Lack of Trial Registration

The scientific community agrees that all clinical trial protocols should be registered in a widely available online registry to ensure transparency. This registration number should be included in the published study.

Without a registered protocol, no one can confirm whether the researchers followed their original plan or if they changed their analysis or reporting methods to align with desired outcomes.

Interestingly, there is no information confirming that the OsteoStrong trial was registered. Dr. Giangregorio contacted both the authors and the university’s ethics board to determine if it was registered but received no response.

3. “Low Quality Study” with High Risk of Bias

From what Dr. Giangregorio could determine, this appears to be a very low-quality study with no efforts made to reduce the risk of bias.

Rather than using a randomized controlled trial (the gold standard in research), participants were allowed to choose whether they wanted to be in the control group or the OsteoStrong group. This self-selection creates an immediate bias, as people eager to participate in OsteoStrong may have had different health status or habits than those who opted out.

Additionally, there’s no indication that the study blinded the assessors – meaning the people evaluating outcomes knew which participants were in which group. This knowledge can significantly influence results, whether consciously or unconsciously.

4. Confounding Factors: Osteoporosis Medications

Dr. Giangregorio noted it was unusual that the study enrolled participants who were taking osteoporosis medications. These medications increase bone mineral density on their own, which confounds the results – especially if:

The types of medications varied among participants
Duration of medication use differed
The number of participants was too small to separate medication effects from OsteoStrong effects

The study provides very little information about the types of osteoporosis medications participants were taking, how long they had been on them, or whether they took them consistently. This means the study wasn’t designed to accurately test the effects of OsteoStrong independent of medication effects.

5. The Crucial Question: Does OsteoStrong Improve Bone Density Scores?

For many women considering OsteoStrong, the most important question is whether the study demonstrated that OsteoStrong increases bone mineral density compared to the control group.

Surprisingly, we don’t know the answer because the authors didn’t report any analyses of between-group differences in bone mineral density at the hip or spine. Instead, they reported other statistics that aren’t typically used or accepted in clinical trials, such as:

Changes in bone mineral density within each group (but not compared between groups)
T-scores
The percentage of people who experienced an increase in bone mineral density

The scientific standard is to focus on whether the bone mineral density change in one group is statistically different from the other group. Without this comparison, we cannot draw conclusions about effectiveness.

6. Lack of Proper Statistical Analysis

The study reported changes within each group but did not report statistical analyses comparing between the groups. Without this critical between-group analysis, it’s inappropriate to make conclusions about the effectiveness of OsteoStrong compared to the control.

Dr. Giangregorio points out that the average bone mineral density was already different between groups at the start of the study – something that shouldn’t happen if the groups are properly balanced. There’s also no information about how the researchers handled:

Baseline differences between groups
Missing data
Outliers (unusually large individual changes that can skew averages)

Some participants showed changes that seem implausibly large. Including these outliers can falsely increase the average change reported. Dr. Giangregorio noted several errors and outliers in the paper, suggesting that a closer examination of the data and statistical analysis is warranted.

7. Follow the Money: Who Funded the Study?

Just as we might be skeptical of research funded by pharmaceutical companies, it’s important to note that this study was funded by a private company that owns OsteoStrong franchises.

Although the authors disclosed this funding, there remains significant potential for conflict of interest that could influence how the study was designed, conducted, analyzed, and reported.

8. Scientific Community Response

Dr. Giangregorio believes that the peer reviewers who evaluated this paper before publication may have missed several critical issues. She notes that the paper doesn’t even meet all of the journal’s own authorship guidelines.

The Bone Health and Exercise Science Lab at the University of Waterloo and other scientists globally have made the journal editors aware of their concerns about this paper and have called for its retraction. Several researchers from multiple countries, including researchers at Harvard, have written letters calling for its retraction.

Importantly, the senior author of the study is an editor for the journal where it was published, raising additional questions about the review process.

Exercise and Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

But what exercises should you do and which ones should you avoid? What exercises build bone and which ones reduce your chance of a fracture? Is Yoga good for your bones? Who should you trust when it comes to exercises for osteoporosis?

A great resource on exercise and osteoporosis is my free, seven day email course called Exercise Recommendations for Osteoporosis. After you provide your email address, you will receive seven consecutive online educational videos on bone health — one lesson each day. You can look at the videos at anytime and as often as you like.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Enter your email address and I will start you on this free course. I do not SPAM or share your email address (or any information) with third parties. You can unsubscribe from my mail list at any time.

OsteoStrong Review: July 2025

Previously, we examined the “research” OsteoStrong promotes as evidence for its claims on increasing bone density and improving health. We highlighted how Dr. Lora Giangregorio from the University of Waterloo identified significant shortcomings in that research, concluding that its cornerstone—the “Greek study”—is not credible evidence.

Now, I want to guide you through a far more definitive OsteoStrong review and analysis. The research team, including Dr. Giangregorio, published a comprehensive paper in the July 2025 issue of the prestigious journal Osteoporosis International (5). Titled “OsteoStrong and bone health: a scoping review,” this paper examines the available scientific literature to answer the critical questions that patients and their healthcare providers have about the program’s efficacy and safety, such as:

Does OsteoStrong work?
Are there any OsteoStrong side effects?

Let’s start with a discussion of how the research team approached these questions.

OsteoStrong Review Methodology

The research team cast a wide net to find all available evidence. They systematically searched five scientific databases for any study involving OsteoStrong machines. Their goal was to find any data related to the outcomes that matter most to bone health: changes in bone strength, risk of falls, and fracture rates.

OsteoStrong Review: General Concerns

The OsteoStrong review identified several significant methodological issues with the research:

Conflicts of Interest: Of the four studies for which full texts were available, three have evidence of conflicts of interest. The first author of one study was also the sole participant in the study, and the third author of the same study was the inventor and medical science advisor of OsteoStrong.
Publication Issues: One study was identified from a journal whose publisher appears on Beall’s list of predatory publishers, which are not typically indexed in major bibliographic databases.
Small Sample Sizes: Most studies included 26 or fewer participants, limiting the ability to draw meaningful conclusions about effectiveness or safety.

Does OsteoStrong Work?

The research team examined the research to see if OsteoStrong does work as promised by the company. The evaluated OsteoStrong on several dimensions. Let’s discuss each one.

Fractures

The fracture data from OsteoStrong studies is extremely limited and concerning. None of the studies had sufficient sample size to properly test fracture outcomes, yet some troubling findings emerged.

In one of the studies, researchers identified multiple vertebral compression fractures in the OsteoStrong group:

One T8 wedge fracture progressed from grade 1 (mild) to grade 2 (moderate)
Five new incident wedge fractures at 8 months: T5 grade 1, T6 grade 1, T8 grade 1, and T9 grade 1

In contrast, no incident fractures were reported in the high-intensity resistance training (HiRIT) or control groups.

Another study reported three vertebral fractures in the OsteoStrong group compared to one in the exercise group.

Falls

Only one study reported comprehensive fall data. While the authors found no significant between-group differences in the number of falls or people who fell, the sample sizes were too small to draw meaningful conclusions.

Bone Mineral Density (BMD)

The research team evaluated OsteoStrong as it relates to effect on bone mineral density (BMD). They examined the results by area of anatomy.

Lumbar Spine BMD

Studies examined lumbar spine BMD with highly inconsistent results.

Femoral Neck BMD

Several studies reported femoral neck BMD outcomes but found no statistically significant between-group differences.

Total Hip BMD

Several studies examined total hip BMD but found no statistically significant between-group differences.

Femoral Neck and Total Hip Volumetric BMD (vBMD)

Femoral Neck vBMD: No significant between-group or within-group differences were found for total, trabecular, or cortical vBMD at the femoral neck.
Total Hip vBMD: Similarly, no significant differences were observed between groups for total hip vBMD measurements.

Bone Material Strength Index

The researchers used bone material strength index (BMSi) but found no significant difference was found between exercise and OsteoStrong groups.

OsteoStrong Side Effects and Adverse Events

The OsteoStrong side effects and adverse event reporting across studies was inadequate, but several concerning patterns emerged.

In one study, the OsteoStrong group experienced:

Right knee discomfort during leg press
Left shoulder muscle discomfort during chest press (caused 3 weeks of missed sessions)
Low back discomfort after vertical lift (participant refused to perform vertical lift for four subsequent sessions)

Study Limitations in Safety Assessment

The researchers emphasized that none of the studies had sufficient sample sizes to properly assess safety, particularly for low-frequency but serious events like fractures. The small sample sizes make it difficult to determine the true safety profile of OsteoStrong interventions.

The Verdict: Is OsteoStrong a Hoax? Is OsteoStrong Legitimate?

While the authors do not question the legitimacy of the business venture, they do share their concerns with the potential for conflict between client care and profit maximization.

OsteoStrong is a for-profit company that sells franchises where members pay to access OsteoStrong proprietary equipment. The company and franchisees stand to benefit from being able to point to research that their intervention is effective while keeping research questioning the efficacy of the modality.

The company’s social media channels and website highlight published research that aligns with claims on their website but does not include the independent trials that reports incident fractures and no between-group differences in favour of OsteoStrong.

This does not suggest that OsteoStrong is hoax or is not legitimate. OsteoStrong is not a hoax, by any measure.

However, the review is more of warning for you, the reader, and that you should tread cautiously with OsteoStrong and their claims.

Individuals considering OsteoStrong as a treatment should be cautioned that claims that it has been shown to be safe or that it increases bone mineral density have not been substantiated by well-designed, published randomized controlled trials.

Discussion

The research on OsteoStrong is mainly limited to small observational studies that are at risk of bias because of conflict of interest, imprecision, publication in a predatory journal, participants on anti-resorptive medications, or poor-quality research reporting. The effects of OsteoStrong on bone strength outcomes are inconsistent, and currently there is little data on safety of this intervention.

The researchers emphasize that individuals considering OsteoStrong as a treatment should be cautioned that claims that it has been shown to be safe or that it increases bone mineral density have not been substantiated by well-designed, published randomized controlled trials.

OsteoStrong Efficacy and Effectiveness

If you’re a woman concerned about your bone health and considering OsteoStrong, what does all this mean?

In Dr. Giangregorio’s professional opinion – which I share – it is not possible to draw any meaningful conclusions from this study regarding the efficacy and effectiveness of OsteoStrong or from any of the published research on OsteoStrong to date.

The Bone Health and Exercise Science Lab and their international colleagues do not recommend making decisions to participate in OsteoStrong based on this new study. The serious methodological flaws, potential conflicts of interest, and lack of proper statistical analysis mean that the reported benefits cannot be trusted.

Conclusion: Looking Forward

There are reportedly two other studies about OsteoStrong that have not been published yet. These may provide more insight into whether OsteoStrong is truly effective. Until then, I recommend approaching claims about OsteoStrong with healthy skepticism.

Bone health is too important to entrust to interventions without solid scientific backing. As we learn more about OsteoStrong through future research, I’ll continue to share updates and insights with you.

Remember, improving and maintaining bone health is a long-term commitment that typically involves multiple approaches working together.

There are no quick fixes or miracle solutions, but there are evidence-based strategies, such as my Exercise for Better Bones program, that can help you maintain your bone density and reduce fracture risk as you age.

Margaret Martin

Margaret Martin is a Physical Therapist with 40 years of clinical experience. Her expertise is in the treatment and prevention of osteoporosis through exercise, safe movement and fall prevention. For the last 20 years, she has concentrated on bone health and has treated thousands of patients for their osteoporosis, osteopenia and low bone density.

References

Oliveri v. Osteostrong, 2021 Ohio 1694, 171 N.E.3d 386 (Ohio Ct. App. 2021), Casetext. https://casetext.com/case/oliveri-v-osteostrong
“Anguish” Failed to be an Effective Substitute for “Negligence” in Ohio Case, Doric Cotten, Sport Waiver July 21, 2021 https://www.sportwaiver.com/anguish-failed-to-be-an-effective-substitute-for-negligence-in-ohio-case/
Nektaria Papadopoulou–Marketou, Anna Papageorgiou, Nikolaos Marketos, Panagiotis Tsiamyrtzis, Georgios Vavetsis, George P Chrousos, Effective Brief, Low-impact, High-intensity Osteogenic Loading in Postmenopausal Osteoporosis, The Journal of Clinical Endocrinology & Metabolism, 2025;, dgaf077, https://doi.org/10.1210/clinem/dgaf077
Osteostrong and Osteoporosis: BonES lab review of new study. https://youtu.be/fI3s_bbqrKQ?si=cNS4CwmGYZr4iXj5
Kabra A, Katzman WB, Lane NE, Giangregorio LM. OsteoStrong and bone health: a scoping review. Osteoporos Int. 2025 Jul 21. doi: 10.1007/s00198-025-07614-x. Epub ahead of print. PMID: 40691713.

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Can Osteopenia Be Reversed?

Margaret Martin — Thu, 15 May 2025 14:54:31 +0000

May 15, 2025

If you’ve recently received a diagnosis of osteopenia following your DEXA scan, you likely have questions about what this means for your future bone health. Like many people diagnosed with this condition, you want to know if osteopenia can be reversed, and whether you can avoid progressing from osteopenia to osteoporosis.

As a physical therapist specializing in this area, I can assure you that with proper intervention, many people can improve their bone density and bone quality. They can slow the process of bone loss and, potentially, reverse their osteopenia. Let’s get you started on the path to building better bones.

Can Osteopenia Be Reversed?

Thankfully, you can be proactive and prevent your osteopenia diagnosis progressing to osteoporosis. The key is to follow a program that improves bone density and bone quality.

Patients often ask me if osteopenia is reversible. While some people manage to regain bone density and reverse osteopenia, I encourage clients to set realistic goals and focus on slowing down bone loss and preventing osteoporosis. I advise them to consider the diagnosis of osteopenia as a wake up call as well as an opportunity to improve their bone health before things get worse.

Most are never told by their doctor that they have osteopenia. Many physicians have limited time and are unable to give you the attention you need to manage osteopenia. For most physicians osteopenia is not seen as a red flag. So they do not raise it with their patients.

Sadly, many physicians wait until the diagnosis of osteoporosis to take action. The tools they have at their disposal is pharmaceutical intervention.

Before we dive into all of the great things we can do for the health of our bones, let’s cover the definition of osteopenia so that we’re all on the same page.

What Is Osteopenia?

The “gold standard” for diagnosing osteopenia is a bone mineral density test using a machine called a densitometer, commonly known as a DEXA scan. These tests became available in 1987 and have been our main tool for assessing bone health ever since.

When you get your results, you’ll see the bone density of your spine, hip and femoral neck (the upper part of your hip) measured in g/cm², but what doctors focus on is your T-score. This score compares your bone density to that of a healthy 30-year-old woman.

Since 1994, here’s how we categorize these scores based on standard deviations away from normal:

Normal: T-score above -1
Osteopenia: T-score between -1 and -2.4
Osteoporosis: T-score below -2.5

There’s also a newer assessment tool called Echolight REMS that similarly provides T-scores for your spine, hip and femoral neck.

Your BMD score is just one piece of information about your bone health. It tells you the density but not the quality of your bones. More on bone quality later.

Evidence Based Guidelines for Treatment for Osteopenia

The diagnosis of osteopenia is NOT necessarily an indication for pharmaceutical intervention. I suggest that it is a great opportunity to make your bones as resilient as possible.

Many clients with osteoporosis or who have already fractured wish that they knew they could have made changes sooner. Don’t wait until your doctor tells you that you have osteoporosis and that you need medication! You can start making your bones stronger today and reduce your risk of developing osteoporosis and potentially reverse osteopenia.

Effective osteopenia treatment guidelines include the following major components.

Targeted Osteoporosis Exercise Program for Osteopenia

Weight-bearing and strength training exercises are crucial for stimulating bone formation:

Weight bearing exercises: Activities like walking, jogging, dancing, and stair climbing force your body to work against gravity, which stimulates bone-strengthening cells.
Strength training: Using resistance bands, free weights, or weight machines helps build muscle strength and stimulates bone growth at the attachment sites of muscles to bones.
Balance training: While this doesn’t directly build bone, improving balance reduces fall risk—a critical factor in preventing fractures.

The most effective exercise programs include progressive strength training 2 to 3 times per week combined with regular weight-bearing activities. Research shows that site-specific exercises can improve bone density in targeted areas, particularly the spine and hip. Shorter high-intensity activities are more beneficial for bone strength.

Optimal Nutrition Program for Osteopenia

Your bones need specific nutrients to build and maintain strength:

Calcium: Women aged over 50 need daily food sources rich in calcium like dairy products, fortified plant milks, leafy greens, and fish with edible bones.
Vitamin D: Essential for calcium absorption, aim for 800-1,000 IU daily. Your body produces vitamin D when exposed to sunlight, but supplementation is often necessary, especially in northern climates.
Protein: Adequate protein intake supports bone matrix formation.
Magnesium, vitamin K, potassium: These nutrients work synergistically to support bone health and are found in fruits, vegetables, nuts, and seeds.

Whole foods provide the best combination of these nutrients in forms your body can efficiently use.

Lifestyle Modifications

Several lifestyle factors significantly impact bone health:

Limiting alcohol consumption: Keep alcohol intake to one drink or less per day.
Avoiding smoking: Smoking impairs blood flow to bones and interferes with the production of bone-forming cells.
Maintaining healthy weight: Being underweight increases fracture risk, while excess weight puts additional stress on bones.
Controlling blood sugar levels.

Osteopenia Prevention and Treatment

Your goal should not be to reverse osteopenia by achieving a specific T-score, but rather to build stronger, more resilient bones that reduce your overall fracture risk. Don’t wait until osteoporosis develops and medication becomes necessary. Start implementing these bone-strengthening strategies today. Your future self will thank you for the foundation of support you’re building now.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Osteopenia, Bone Density and Bone Quality

Most of us never think about our bones until we break one. We assume they’ll be there as our foundation of support for life.

But here’s what’s important to understand: a bone density test tells you just that—the density of your bones. What about the QUALITY of your bone and why does this matter?

The combination of bone density and bone quality determines your overall fracture risk.

Osteopenia and Fracture Risk

This is where the Fracture Risk Assessment (FRAX) calculation comes in. It measures fracture risk when you have osteopenia. (1)

The FRAX should accompany any bone mineral density test result for someone in the osteopenia range, as it provides insight into bone quality and overall fracture risk. Many of the questions on the FRAX are risk factors you cannot control. Let’s take a look at these next.

Risk Factors of Osteopenia Outside Your Control

Here is a list of risk factors of osteopenia you CANNOT control:

Genetics, if your parent had a hip fracture this is a red flag
Previous fragility fractures, where your bone breaks from a slip or fall from standing height or less
Having a fragility fracture in the last year
A history of eating disorders, malabsorption or nutrient deficiencies
Menopause younger than age 50 and long periods of amenorrhea (skipping menstrual periods)
Glucocorticoid use for longer than five months

Sadly, you cannot go back in time and change any of these things that may have led to lower bone quality and density. You can however, still make changes to a number of factors in your life that can have a significant impact on the health of your bones. Let’s take a look at these below.

Risk Factors of Osteopenia Within Your Control

Here are the risk factors of osteopenia (and bone health) you CAN control:

Diet: Rich in protein, vegetables and fruit, adequate vitamin D, calcium and other essential minerals.
Reducing and/or eliminating highly processed foods, including many “fast foods”
Smoking.
Alcohol intake. Moderating your alcohol intake to one a week.
Controlling your blood sugar
Participating in regular, safe and progressive strength training
Incorporating daily weight bearing exercises and activities appropriate for your fracture risk

Your bones build more easily when you are in the osteopenia range rather than osteoporosis range. Studies have shown that women with osteopenia who did the exact same exercises as the women with osteoporosis were able to make greater gains, all else being fairly equal.

A 2023 meta-analysis on jumping showed that women with osteopenia gained bone at the hip and spine whereas those with osteoporosis only gained at the hip. (2)

Osteopenia and Fractures

Here’s the surprising fact that your doctor may not tell you: Most fractures occur in people who have osteopenia, not osteoporosis. (3)

A 2024 paper titled Osteopenia: a target for fracture prevention (3) highlights that “the importance of the osteopenia label for diagnosis and treatment is often unclear and misinterpreted.”

Many individuals who have experienced bone loss with bone density scores in the osteopenia range are simply told “all is good” without being informed that their bone loss can increase their risk of a fracture.

Osteopenia: Hip, Femoral Neck and Spine

Many of my clients ask me for specific exercises for their hips, femoral neck and spine because osteopenia is detected in one or more of those areas. I encourage all my clients to have a well rounded program that takes all their bones into consideration.

Our skeleton is made up of two types of bone: cortical and trabecular. The cortical bone is hard and more resistant to fracturing. Trabecular bone is softer and composed of thousands of trabecular or cross links. As such, trabecular bone can fracture more easily.

A DEXA test measures your hip and spine because those bones are composed of a relatively high percentage of trabecular bone. Having osteopenia or osteoporosis increases your risk of fractures of the spine (vertebral body) and the femoral neck (part of the hip).

Along with the ends of the long forearm bones, the bones of your hip and spine are more vulnerable to breaking if your fracture risk is elevated. Testing your hip and spine is a leading indicator of overall bone health. Bone density and bone quality scores provide early warning that something needs to change to stop your bones from becoming further at risk of fracturing.

In the next section we discuss an overlooked modality to improve bone health in women: hormone replacement therapy or HRT.

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HRT and Osteopenia

Women have a lot going on in their lives around menopause. Hormonal changes can reduce your sex drive, cause vaginal dryness, weight gain and hot flashes. Mood swings and sleep problems are also on the list of issues that our hormones influence.

Unfortunately, one of the least spoken symptoms of menopause is bone loss. Due to the drop in estrogen and progesterone, women will rapidly lose bone in the first five years after menopause. Studies have shown that fifty percent of bone loss that will occur between the start of menopause and age 80 happens in the first 5 years after the start of menopause.

Hormone Replacement Therapy and Osteopenia

Hormone replacement therapy, HRT, has come a long way in the past 25 years. HRT is an option that can help reduce many of the symptoms mentioned above, including bone loss. The dosage may change as you age but clinical data have shown that women can maintain more robust and resilient bodies while on hormone replacement therapy into their 90s.

Armed with this knowledge you may wish to connect with a gynecologist, endocrinologist or any doctor in your community versed in hormone replacement therapy (HRT). So long as you do not have a family history of estrogen dependent breast or ovarian cancer, hormone replacement therapy is a safe and effective option for your bones. For those of you at risk for cancer there is another option.

Selective Estrogen Receptor Modulators (SERMS) and Osteopenia

The most widely used SERMS is Raloxifene (Evista). It selectively mimics estrogen’s beneficial effect to bone and not to our breasts of ovaries.

Over the last quarter of a century few North American doctors received training in HRT while in medical school. Today doctors around the country are coming to realize the harm this has caused women. Some have taken extra training to be able to understand and prescribe HRT.

If you are unable to start HRT or use SERMS, remember there are still many things you can do to reduce your risk of having a fracture.

Monitoring Your Progress

Following your osteopenia diagnosis, your physician will likely provide the following medical advice:

Repeat DXA scans every 1 to 2 years to monitor changes in bone density
Regular check-ins to assess your osteoporosis exercise program and nutrition
Height measurements to detect any compression fractures

Success looks different for each person. For some women, completely reversing osteopenia and returning to normal bone density is possible. For others, success means halting bone loss and preventing progression to osteoporosis.

Osteopenia and Sarcopenia

Both osteopenia and sarcopenia can affect us as we age. However, they are very different. Sarcopenia affects muscle mass, specifically it is the gradual loss of muscle mass and strength that occurs as we age. Osteopenia, on the other hand, affects our bone health.

I do not need to elaborate more on sarcopenia in this post because I have written blog posts on preventing sarcopenia and exercises for sarcopenia elsewhere on my site.

Conclusion

An osteopenia diagnosis represents an opportunity to take control of your bone health before more serious problems develop. With a comprehensive approach that includes targeted exercise, optimal nutrition, healthy lifestyle choices, and appropriate medical intervention when necessary, many women can improve their bone density and reduce fracture risk.

Remember that consistency is key—the bone remodeling process takes time, and improvements in bone density may take 12 to 18 months to appear on scans. Stay committed to your bone health program, and work closely with your healthcare team to optimize your results.

Your bones support you every day—now is the time to support them.

Margaret Martin

References

Zerikly R, Demetriou EW. Use of Fracture Risk Assessment Tool in clinical practice and Fracture Risk Assessment Tool future directions. Womens Health (Lond). 2024 Jan-Dec;20:17455057241231387. doi: 10.1177/17455057241231387. PMID: 38529935; PMCID: PMC10966972.
Florence G, et al. Skeletal site-specific effects of jump training on bone mineral density in adults: a systematic review and meta-analysis. Journal of Sports Sciences. 2023 Dec;41(23):2063-2076. doi: 10.1080/02640414.2024.2312052. Epub 2024 Feb 2
Reid IR, McClung MR. Osteopenia: a key target for fracture prevention. Lancet Diabetes Endocrinol. 2024 Nov;12(11):85

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Sarcopenia Exercise Program to Reverse Muscle Loss in Seniors

Margaret Martin — Thu, 03 Apr 2025 16:25:56 +0000

April 3, 2025

Today I’m going to cover a sarcopenia exercise program for older adults and seniors. It will help you combat muscle loss as you age.

What many people don’t realize is that sarcopenia begins earlier than we thought – often in our 40s – and accelerates after 50.

The European consensus on the definition and diagnosis of sarcopenia (1) states that sarcopenia has multiple contributing factors such as:

The ageing process itself
The developmental influences from your younger years,
A less-than-optimal diet,
Having an episode of bed rest or a sedentary lifestyle,
Chronic diseases and certain drug treatments

Sarcopenia creates a cascade of problems including:

Weaker muscle contractions
Reduced coordination
Slower reaction times
Compromised balance

Sarcopenia Exercise to Reduce Muscle Loss

All of these factors contribute to an increased fall risk and accelerated muscle loss.

A 2023 paper titled Exercise for sarcopenia in older people: A systematic review and network meta-analysis (2) showed that resistance exercise and the combination of resistance exercise with weight bearing exercise and balance training were the most effective interventions for improving quality of life.

So today I want to share my top five exercise choices to increase muscle strength and muscle mass for older adults with sarcopenia.

Exercise for Sarcopenia: Walking

Let’s start with an aerobic exercise that most everyone has access to: walking.

My oldest patient, Babs, at 97 would make sure she would reach her daily target number of corridor lengths.

Even when she transitioned to using a walker, she succeeded to keep it up until the day before she died.

Walking is not only functional, it is great for improving circulation, helps you with your blood sugars and increases opportunities to meet others.

Here are some walking tips:

Establish your baseline. Be it the number of times you walk the hallway or blocks in your neighborhood.
Time yourself.
Gradually increase your distance and your pace, but not both at the same time.
Keep track of your success. Write it down where others can see it and encourage you along.

Four Resistance Exercises for Sarcopenia

The next four exercises are resistance exercises for sarcopenia. These strength training exercises can be done at your kitchen counter:

Butterfly Wings
Heel Raises
Push Ups
High Knees for Your Core and Hip Flexor

How many should you do is very dependent on your current strength and function.

Start with one set of 5 of each exercise.
Gradually build to 3 sets of 10.

Exercise for Osteoporosis Course

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Bonus Sarcopenia Exercise: Balance

As promised, I have a bonus balance exercise for you to try.

Pause the video if you need to sit for a minute or two before you do the balance exercise.

Also, if you are comfortable removing your footwear, I encourage you to do so. It will help you strengthen the smaller, intrinsic foot muscles.

Stand between your counter top and chair.
Bring your feet together. Keep your hands just above your support surfaces and when you are comfortable you can close your eyes.
Hold this position for 20 seconds. If it feels too easy you can progress to stepping forward, holding the position.
If you feel stable look from side to side. Repeat this with your other leg forward.

Conclusion to Sarcopenia Exercise

Sarcopenia may be a natural part of aging, but as we’ve seen, it’s not something we have to passively accept. By incorporating these five key exercises into your routine – walking, high knees, pushups, butterfly wings, and heel raises – plus our bonus balance exercise, you’re taking powerful steps toward maintaining your independence and quality of life.

Remember that consistency is more important than intensity. Start where you are, track your progress, and gradually build up your strength and endurance. Even small improvements can lead to significant gains in your daily functioning and confidence.

The research is clear: combining resistance training with weight bearing exercises and balance exercises provides the most comprehensive approach to combating sarcopenia. Each exercise we’ve covered targets different muscle groups and aspects of fitness that work together to keep you strong, stable, and mobile.

If you’re just beginning your journey to combat muscle loss, be patient with yourself. Celebrate each small victory – whether it’s walking an extra hallway length like Babs at 97, or progressing from one set to three sets of your strength exercises.

Most importantly, know that it’s never too late to start. Your body has an amazing capacity to respond to exercise at any age. By taking action today, you’re investing in a stronger, more capable tomorrow.

Margaret Martin

References

Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16-31. doi: 10.1093/ageing/afy169. Erratum in: Age Ageing. 2019 Jul 1;48(4):601. doi: 10.1093/ageing/afz046. PMID: 30312372; PMCID: PMC6322506.
Shen Y, Shi Q, Nong K, Li S, Yue J, Huang J, Dong B, Beauchamp M, Hao Q. Exercise for sarcopenia in older people: A systematic review and network meta-analysis. J Cachexia Sarcopenia Muscle. 2023 Jun;14(3):1199-1211. doi: 10.1002/jcsm.13225. Epub 2023 Apr 14. PMID: 37057640; PMCID: PMC10235889.

The post Sarcopenia Exercise Program to Reverse Muscle Loss in Seniors appeared first on MelioGuide.

How to Prevent Sarcopenia and Muscle Loss

Margaret Martin — Thu, 13 Mar 2025 21:21:09 +0000

March 13, 2025

As a physical therapist working with adults over 45, I’ve seen firsthand how maintaining muscle strength and balance becomes increasingly important—and challenging—with age. Unfortunately, most people lose muscle mass during the aging process. Some individuals lose at a much greater extent than others. This is commonly called sarcopenia, the progressive loss of muscle mass and strength that occurs as we age. But there are things you can do to reverse age-related sarcopenia.

Many of my patients ask about effective, evidence-based ways to prevent sarcopenia (muscle loss) and reduce their fall risk. Historically, I have recommended a combination of an exercise program that includes strength training, balance exercises, and weight bearing exercises, as well as a nutritional program that includes protein and Vitamin D.

Today, I want to share promising research (1) about low intensity vibration therapy (LiV) and its role in sarcopenia prevention and balance improvement.

Sarcopenia: Muscle Loss Associated with Getting Older

Before we dive into low intensity vibration therapy, let’s understand what we’re fighting against. Sarcopenia is the progressive loss of muscle mass and strength that occurs as we age. This isn’t just about looking less toned—it’s a serious health concern that affects your:

Ability to perform activities of daily living independently
Balance and stability
Risk of falls and fractures
Overall quality of life

What makes sarcopenia particularly concerning is that it begins earlier than most people realize—often in our 40s—and accelerates after 60. Even more troubling is that sarcopenia affects more than just muscles. Recent research (1) shows it’s linked to the deterioration of neuromuscular junctions (NMJs), the critical connections between our nerves and muscles.

A Key to Sarcopenia Prevention: The Neuromuscular Connection

The recently published research in Aging Cell (1) reveals something fascinating: the deterioration of these neuromuscular connections (or junctions) actually precedes the onset of sarcopenia and that sarcopenia prevention is possible if you can preserve these crucial connections.

Think of these junctions as the electrical outlets where your brain’s signals plug into your muscles. When these connections degrade, the communication becomes less effective, and muscles don’t respond as quickly or powerfully.

This degradation creates a cascade of problems:

Weaker muscle contractions
Reduced coordination
Slower reaction times
Compromised balance

All of these factors contribute to an increased fall risk and accelerated muscle loss. But here’s the good news: research suggests that you can prevent sarcopenia if you can preserve these crucial connections.

In the diagram below you see a motor nerve. These motor nerves communicate with skeletal muscle fibers called myofibrils. The specific node through which they communicate is the neuromuscular junction.

Exercise and Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

How to Prevent Sarcopenia: The Promise of Low Intensity Vibration

Low-intensity vibration therapy, similar to what is delivered with the Marodyne LiV, involves standing on a platform that delivers gentle, controlled vibrations throughout your body. The vibrations used in this therapy are much gentler than what you might associate with heavy machinery or intense exercise equipment.

The research shows that LiV treatment operates at about 35 Hz (cycles per second) with only 0.3g of force (where 1g is the force of gravity). The intensity is so mild that it feels like a gentle hum rather than a vigorous shake.

What the Research Tells Us

The study from The Chinese University of Hong Kong published in Aging Cell (1) explored how LiV affects both muscle health and the critical neuromuscular junctions in aging subjects. The findings are compelling:

Improved muscle performance: At just 4 months of treatment, participants managed to increase muscle mass and demonstrate an increase in grip strength and muscle force.
Preserved neuromuscular junctions: LiV helped maintain the structure and function of these crucial nerve-muscle connections.
Reduced muscle atrophy markers: The therapy decreased the expression of genes associated with muscle breakdown.
Beneficial muscle fiber changes: The treatment helped maintain more of the fast-twitch muscle fibers that are typically lost with age.

Perhaps most importantly, the Centers for Disease Control and Prevention (CDC) now recommends LiV as an effective fall prevention intervention for older adults. This endorsement appears in the 4th Edition of their Compendium of effective fall interventions (2).

How Low Intensity Vibration Works: The Science Behind the Benefits

What makes this therapy particularly fascinating is how it works at the cellular level. The research reveals several mechanisms:

Increased Dok7 expression: The therapy increases a protein called Dok7 that’s crucial for maintaining healthy neuromuscular junctions.
Reduced enzyme activity: LiV decreases acetylcholinesterase activity, which helps improve nerve signal transmission to muscle cells.
Enhanced muscle receptor health: The treatment helps maintain acetylcholine receptors, ensuring muscles remain responsive to nerve signals.
Suppressed ERK1/2 phosphorylation: This molecular change helps preserve neuromuscular junction structure.

In simpler terms, the low intensity, gentle vibrations seem to “wake up” the communication pathways between your nerves and muscles, keeping them healthier and more functional as you age.

Practical Benefits for Women Over 45

If you’re over 45 years of age, the potential benefits of LiV are particularly relevant:

Fall prevention: The improved neuromuscular function translates to better balance and stability.
Maintained independence: By preserving muscle strength and function, you’re more likely to remain able to perform daily activities without assistance.
Better quality of life: Stronger muscles and better balance contribute to more confidence in movement and activity.
Non-invasive approach: Unlike medications that might have side effects, LiV is a gentle, non-pharmacological intervention.

How to Access Vibration Therapy

If you’re interested in trying LiV, here are some practical steps to consider:

Sarcopenia can affect your whole musculoskeletal system. As a result, I recommend the use of a LiV platform (that you stand on) that propagates the vibration signal through the whole body. A vibration belt only provides local vibration signals and will not reach the neuromuscular connections of your legs.
Look for physical therapy clinics: A number of Physical Therapy clinics now offer vibration therapy as part of their treatment options. Be sure it is low intensity vibration.
Specialized fitness centers: Some fitness centers focused on active aging have vibration platforms available for members.
Home options: While professional-grade platforms can be expensive, there are now more affordable options designed for home use. Just be sure to research carefully to ensure you’re getting a device that delivers the appropriate frequency and amplitude. The only vibration platform I trust for my clients is the Marodyne LiV.

Comprehensive Sarcopenia Prevention: Strength Training, Vibration and Nutrition

While LiV shows remarkable promise, it’s most effective as part of a comprehensive approach to healthy aging. Consider combining it with:

Resistance exercise: Regular strength training (resistance training) remains one of the most effective ways to help prevent sarcopenia.
Adequate protein intake: Your muscles need sufficient protein to maintain and rebuild.
Vitamin D: Ensuring proper levels helps support muscle tissue.
Regular movement: Even gentle activities like walking and gardening help maintain muscle health.

I recently published a post with a sarcopenia exercise program for older adults.

How to Prevent Sarcopenia: Conclusion

Low intensity vibration therapy represents an exciting advance in our approach to sarcopenia prevention and balance issues. The research shows it works not just at the muscular level, it preserves the critical nerve-muscle connections that begin deteriorating earlier than we previously realized.

Readers will also know that it stimulates bone cells, building both bone quality and bone density. As a result the effects of osteoporosis, osteopenia and sarcopenia can be reduced by a combination of exercise, nutrition and potentially, low intensity vibration.

As with any intervention, individual results will vary, and LiV isn’t a magic solution. However, the evidence suggests it’s a valuable tool in our arsenal in the prevention of sarcopenia and fall risk—one that’s non-invasive, relatively accessible, and now backed by CDC recommendations.

If you’re concerned about maintaining your strength, balance, and independence as you age, discussing vibration therapy with your healthcare provider could be a worthwhile conversation. The gentle vibrations that seem so subtle might just help keep you stronger, more stable, and more independent for years to come.

Margaret Martin

References

Bao Z, Cui C, Liu C, Long Y, Wong RMY, Chai S, Qin L, Rubin C, Yip BHK, Xu Z, Jiang Q, Chow SK, Cheung WH. Prevention of age-related neuromuscular junction degeneration in sarcopenia by low-magnitude high-frequency vibration. Aging Cell. 2024 Jul;23(7):e14156. doi: 10.1111/acel.14156. Epub 2024 Mar 27. PMID: 38532712; PMCID: PMC11258441.
Burns, E., Kakara, R., & Moreland, B. (2023). A CDC compendium of effective fall interventions: What works for community- dwelling older adults (4th ed.). Centers for Disease Control and Prevention.

The post How to Prevent Sarcopenia and Muscle Loss appeared first on MelioGuide.

Osteoporosis Bone Markers

Margaret Martin — Tue, 03 Dec 2024 15:22:58 +0000

Osteoporosis bone markers are valuable tools that help your doctor assess and monitor your bone health. Your access to bone turnover marker testing may vary depending on several factors: where you live, what type of insurance you have, and whether your physician is familiar with and comfortable using these tests.

To help you understand bone markers better, I spoke with Dr. Stuart Silverman, an expert in bone health. Dr. Silverman runs a private rheumatology practice and serves as a clinical professor of medicine at both Cedar-Sinai in Los Angeles and UCLA. His passion for understanding and treating osteoporosis spans decades – he even helped develop and launch nasal spray calcitonin in its early stages.

Osteoporosis Bone Markers

As an experienced practitioner, Dr. Silverman regularly uses osteoporosis bone markers in his practice and considers them invaluable diagnostic tools. His expertise extends beyond clinical practice – he has contributed to important bone turnover marker research with the International Osteoporosis Foundation (IOF). The IOF has worked to standardize these markers and make them more practical for both patients and their doctors.

But before we dive into what bone turnover markers are, let’s understand something fundamental: how your bones constantly rebuild themselves through a process called bone turnover.

Bone Loss and Formation: How Bone Turnover Works

Your bones are alive and constantly renewing themselves through two key bone remodeling processes: resorption and formation. Think of it as your body’s natural renovation project.

During bone resorption, special cells called osteoclasts act like tiny demolition crews. They create small pits in your bone by breaking down old or damaged bone tissue.

Next comes bone formation, where builder cells called osteoblasts get to work. These cells fill those pits with fresh bone material called osteoid, which then hardens with calcium. It’s like pouring and setting new concrete to repair a damaged sidewalk.

This continuous cycle of breakdown and rebuilding serves two important purposes:

It repairs tiny cracks in your bones
It helps your bones adapt to physical stress

A complete renovation of any bone area takes about three months. In healthy bones, this process stays balanced – your body removes and rebuilds the same amount of bone tissue. However, in conditions like osteoporosis, this balance tips: your body breaks down more bone than it rebuilds, leading to weaker bones over time.

What Are Bone Turnover Markers?

Doctors can measure how quickly your bones are remodeling by checking specific substances in your blood called bone turnover markers. These markers show up during bone breakdown and bone formation, giving your doctor valuable clues about your bone health.

Think of these markers as leaving footprints in your blood – they reveal how active your bone remodeling process is. Your doctor can track these markers through various blood tests, also called assays.

Let’s explore the different types of osteoporosis bone markers and what they can tell us about your bone health.

Which Serum Level Indicates the Rate of Bone Turnover?

Leading medical organizations have joined forces to recommend specific tools for measuring bone turnover. The International Osteoporosis Foundation (IOF), European Calcified Tissue Society (ECTS), and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) all agree on using two key serum level (blood) tests:

P1NP (N-terminal propeptide of type one collagen) for measuring bone formation
CTx for measuring bone breakdown

Let’s examine this further :

When your bone-building cells (osteoblasts) are at work, they release P1NP into your bloodstream
When your bone-breakdown cells (osteoclasts) are active, they release CTx

By measuring these markers in your blood, your doctor can tell whether your bones are building up or breaking down too quickly.

How Do Postmenopausal Osteoporosis Bone Markers Measure Bone Formation and Resorption?

How do doctors measure bone formation and breakdown using osteoporosis bone markers? The secret lies in tracking specific proteins in your blood that appear during bone remodeling.

Think of it this way:

When new bone forms, it leaves behind fragments of collagen in your blood
When bone breaks down, pieces of amino acids get released into your bloodstream

Doctors focus on two key markers to monitor these processes:

P1NP (N-terminal propeptide of type one collagen)
- This appears when new bone is being built
- It’s like finding sawdust that shows where construction is happening
CTx (C-terminal telopeptide)
- This shows up when bone is being broken down
- It’s similar to finding debris from a demolition site

Exercise and Osteoporosis

Dr. Silverman told me that a well constructed exercise program therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Osteoporosis Bone Marker P1NP: Bone Formation Marker

Let’s explore how your bone-building cells (osteoblasts) create bone markers we can measure. When these cells are working, they produce two types of substances:

Special enzymes and proteins that show osteoblast activity
Type 1 collagen, which we track through P1NP (marker of bone formation)

The collagen story is particularly fascinating. Think of building bone like crafting a rope:

First, your body creates strands of collagen (called procollagen)
Before these strands can be twisted together into their final form (the triple helix), they need trimming
The trimmed pieces don’t go to waste – doctors can measure these fragments to understand how much new bone you’re building [1]

Osteoporosis Bone Marker CTx: Bone Resorption Marker

Just as we can track bone building, we can also measure bone breakdown by watching what osteoclasts (your bone breakdown cells) leave behind. The key marker doctors look for is CTx.

Think of your bones’ collagen structure like a tightly woven fabric. When osteoclasts break down bone:

The collagen fibers begin to unravel
Small pieces break free
These fragments (called CTx) float into your bloodstream

When your doctor tests your blood for CTx levels, a marker of bone resorption, they’re essentially measuring how quickly your bones are being broken down. It’s like finding threads from a unraveling sweater – the more threads you find, the more the sweater is coming apart.

Clinical Use of Bone Markers in Osteoporosis Treatment

While bone turnover markers help doctors understand how osteoporosis medications work [2], using them to guide individual treatment can be tricky. Why? The test results can vary between laboratories, and doctors are still learning the best ways to interpret these results.

Dr. Silverman has developed a practical approach to overcome this challenge. He uses a three-point diagnostic triangle that combines:

Bone markers (showing dynamic bone activity)
DEXA scans (measuring bone density)
Trabecular Bone Score (TBS) (assessing bone quality)

Before considering any medications, Dr. Silverman starts with the basics:

A tailored osteoporosis exercise program
Proper nutrition guidance

Think of the diagnostic triangle like a three-legged stool:

Two legs (bone density and quality) give you a snapshot of your current bone health
The third leg (bone markers) shows how quickly your bone tissue is changing

Let’s explore each of these measurements in detail and understand how they work together to create a complete picture of your bone health.

Source: Dr. Stuart Silverman

Static Measures of Bone Health

The health history of your bones can be told through two key snapshots:

Bone Quantity: The DEXA Score
- Think of this like measuring bone mass or how much bone material you have
- It’s similar to weighing your bones
Bone Quality: The Trabecular Bone Score (TBS)
- This reveals your bone’s internal architecture
- Imagine it as examining your bones’ internal scaffolding

Together, these static measurements form the foundation of Dr. Silverman’s diagnostic pyramid. They’re like reading the history book of your bones – telling the story of how your bones have changed over time.

Dynamic Measures of Bone Health

At the top of Dr. Silverman’s diagnostic pyramid sits the most dynamic measure: bone turnover markers. While DEXA and TBS tell us about your bone’s past, these markers give us a glimpse into its future.

Think of it this way:

DEXA and TBS are like looking at a photograph of your bones
Bone markers are more like watching a live video of what’s happening right now

These markers help Dr. Silverman answer crucial questions about your current bone health:

Are you actively losing bone tissue?
Is your medication working to stop bone loss?
Is your treatment successfully building new bone?

It’s like having a real-time monitor of your bone activity s, helping guide treatment decisions when they matter most.

Blood or Urine Test for Bone Turnover Markers?

Dr. Silverman explained several options for testing biochemical markers of bone turnover. While you can measure N-telopeptide (NTx) through a urine test, he recommends following the International Osteoporosis Federation’s (IOF) preferred method of blood or serum tests.

These tests, which measure serum CTx and P1NP, provide more reliable results than urine tests like NTx, which can show significant variability. Though some healthcare providers still use the NTx urine test, Dr. Silverman follows the IOF guidelines and uses the CTx serum test for more consistent results.

How Dr. Silverman Uses Bone Markers for the Treatment of Osteoporosis

To assess a patient’s complete bone health, Dr. Silverman combines three key measurements:

Bone density (DEXA)
Bone quality (TBS)
Bone markers

This comprehensive approach helps him identify patients who need treatment, even when some test results appear normal. For instance, a patient might show:

Moderate bone loss (osteopenia) on their DEXA scan
Normal bone quality on their TBS test
BUT their bone markers reveal rapid bone loss

In these cases, Dr. Silverman may recommend starting medication to prevent future fractures, rather than waiting until more serious bone loss occurs. By tracking all three measurements, he can catch and treat bone loss early, helping patients maintain their bone health.

Exercise Recommendations for Osteoporosis

Dr. Silverman told me that a well constructed exercise program therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Clinical Applications of Bone Markers

Dr. Silverman uses bone turnover markers in five important ways to monitor and improve patient care:

Tracking Response to Bone-Building Medications. When patients take bone-forming medications like teriparatide or abaloparatide, Dr. Silverman monitors their P1NP levels. A rise in this bone formation marker indicates the treatment is working effectively.
Confirming Treatment Adherence. The CTx bone marker helps Dr. Silverman verify that patients are taking their prescribed medications. Following IOF guidelines, he looks for a drop in CTx levels when patients start medications like oral bisphosphonates – a clear sign they’re following their treatment plan.
Managing Drug Holidays. For patients taking oral bisphosphonates, Dr. Silverman uses bone markers to:
- Monitor treatment effectiveness during the typical 3-5 year treatment period
- Determine when medication effectiveness begins to decline
- Guide decisions about continuing or pausing treatment
Adjusting Treatment Frequency. When managing treatments like IV zoledronic acid (an infusion form of bishophonate), bone markers help Dr. Silverman:
- Monitor effectiveness of preventive doses given every two years
- Detect declining effectiveness
- Decide whether to adjust treatment intervals to one or two years
Enhancing Fracture Risk Assessment. Dr. Silverman combines bone marker results with DEXA scans to create a more complete picture of bone health. This dual approach helps him:
- Identify patients who need treatment even when their DEXA scores fall just below treatment thresholds
- Better assess fracture risk in patients with high bone turnover
- Make more informed treatment decisions

Important Note: While bone markers provide valuable insights, Dr. Silverman emphasizes that they should not be used alone to make treatment decisions. The management of osteoporosis and metabolic bone disease is more complex than that. Instead, they work best when combined with bone density and quality measurements and other clinical factors to guide patient care.

Preparation for Bone Turnover Marker Test

Your CTx blood test preparation can affect the accuracy of the results. It is extremely important to take the CTx blood test in the early morning after a night of fasting and before you take any supplements. Do not take biotin or collagen supplements 48 hours before the blood draw.

Your P1NP blood test should follow a similar protocol. Take the test in the early morning after a night of fasting and before breakfast or taking supplements.

Understanding Bone Marker Test Variability

Bone marker tests have become more reliable as clinicians better understand how to control various factors that affect test results. Dr. Silverman contributed to this advancement through his work with the 2012 National Bone Health Alliance project [3], which helped standardize sample collection procedures and establish reference ranges for P1NP and CTx tests.

Factors You Can Control Before Testing:

Fast for 8-10 hours before the blood draw
Avoid exercise before the the blood draw
Schedule blood draws at the same time of day to account for circadian rhythm
Stop taking supplements as directed before the blood draw

Factors Beyond Control:

Age
Sex
Ethnicity
Recent fractures (which increase bone turnover and marker levels)
Kidney or liver function

Laboratory Considerations:

Your test results will be most reliable when you:

Use the same accredited laboratory for all tests
Ensure the lab follows proper reference standards

Insurance Coverage for Bone Marker Tests:

Before scheduling regular bone marker tests:

Check with your health insurance provider about coverage
Ask how frequently they will cover these tests
Confirm which specific tests are included in your plan

This careful attention to testing conditions helps provide more accurate results that your healthcare provider can use to guide your treatment decisions. While past variability issues limited the use of bone marker tests, today’s standardized procedures make them a valuable tool for monitoring bone health.

How to Measure Changes in Bone Markers

Clinicians use a concept called “least significant change” to determine meaningful differences between test results, be it positve or negative. Here’s what they look for:

Urine NTX test: A 50% decline between readings to indicate changes in fracture risk
Serum CTx and P1NP tests: A 30% decline between scores

Understanding What Bone Markers Tell Us

Bone markers serve as valuable predictors of:

Rate of bone loss
Future fracture risk

However, it’s important to note that bone markers alone cannot diagnose osteoporosis. Research supports their predictive value – for example, the 2005 OFELY study [4] that Dr. Silverman often references identified three independent factors that increase fracture risk:

Low bone mineral density (BMD)
Elevated bone markers
History of prior fractures

This research helps explain why doctors, like Dr. Silverman, use bone markers alongside other measurements and patient health history to assess a patient’s overall bone health and fracture risk.

Bone Turnover Markers Reference Range

The C Telopeptide CTx reference range for premenopausal women is 34 to 635 pg/mL (picograms per millilitre) and for postmenopausal women is 34 to 1037 pg/mL. While reference ranges can vary depending on the lab and medical institution doing the test and analysis, when the results are above the threshold, it can indicate loss of bone. Clinicians pay particular attention to changes over time.

The reference range for P1NP test is 30 to 50 µg/L (micrograms per litre). When the score is low, it might indicate insufficient osteoblastic activity to keep pace with osteoclast activity. A high P1NP score, on the other hand, might indicate excessive bone turnover, thus raising concern about increased risk of osteoporotic fractures.

Current Use of Bone Turnover Markers

Dr. Silverman explains that the use of bone marker tests varies significantly among medical providers. While he regularly uses them in his Los Angeles clinic, adoption depends largely on a specialist’s training and experience.

Who typically uses bone marker tests:

Endocrinologists
Rheumatologists
Specialized bone health clinics

Who rarely uses bone marker tests:

Primary care physicians
General practitioners

This limited adoption highlights that bone marker testing remains a specialized tool, primarily used by doctors who focus on bone health and metabolic disorders. As understanding of these tests grows and standardization improves, their use may become more widespread in general medical practice.

Bone Markers and After Discontinuing Prolia/Xgeva (Denosumab)

When patients stop taking Prolia, they face a unique challenge: rapid bone loss that can lead to spinal fractures in as little as seven months after their last injection, from my clinical observation. While all osteoporosis medications show some bone loss after Prolia discontinuation, Prolia’s effects are particularly swift and severe compared to other treatments like Fosamax, which may take five years to show significant decline.

Current Treatment Protocol

For patients completing five years of Prolia treatment, doctors typically prescribe an antiresorptive medication, usually IV Reclast (zoledronic acid) as a follow-on agent. The recommendations regarding the usage of bone markers to monitor bone loss, however, vary from region to region.

The European Calcified Society (ECTC) [5] recommends the following:

Use zolendronic acid as a follow-on agent
Three to six months after the IV injection, monitor changes in bone activity with bone markers

Using Bone Markers to Prevent Fractures

Dr Silverman states that bone markers, particularly CTx, can play a vital role in monitoring patients after Prolia discontinuation. He recommends:

Check bone markers six months after last the last Prolia injection to assess treatment response
Test again at six months later to confirm continued effectiveness
Consider a second IV zolendronic acid injection if CTx levels indicate ongoing bone loss

Why This Matters

This monitoring strategy helps doctors:

Identify patients who aren’t responding well to IV zolendronic acid
Catch dangerous bone loss before fractures occur
Adjust treatment plans promptly when needed

This new approach using bone markers represents an important advance in protecting patients during the critical transition period after stopping Prolia.

Getting Bone Marker Tests in the United States

Major commercial laboratories offering bone marker tests include:

Quest Diagnostics
LabCorp

Cost and Ordering Process

The CTx test typically costs around $200
Doctors can order the test on standard laboratory requisition forms
No special laboratory arrangements needed – your doctor can use their regular lab service provider

Making Testing Easier

This straightforward testing process means your doctor can:

Order bone marker tests alongside other routine blood work
Use their existing relationship with commercial labs
Monitor your bone health through established testing networks

Remember to check with your insurance provider about coverage for these tests, as policies vary regarding bone marker testing frequency and reimbursement.

Conclusion and Summary

Osteoporosis bone markers provide a dynamic view of bone health, complementing static measures like DEXA and TBS. While variability has historically limited their use, advancements in standardization and interpretation are expanding their role in osteoporosis care.

By integrating bone markers into a broader diagnostic framework, Dr. Silverman exemplifies how these tools can guide personalized treatment decisions, improve medication adherence, and reduce fracture risk. For patients, understanding the factors that influence test results and staying informed about treatment options are crucial steps toward maintaining bone health.

Margaret Martin

References

Lumachi F, Ermani M, Camozzi V, Tombolan V, Luisetto G. Changes of bone formation markers osteocalcin and bone-specific alkaline phosphatase in postmenopausal women with osteoporosis. Ann N Y Acad Sci. 2009 Sep;1173 Suppl 1:E60-3. doi: 10.1111/j.1749-6632.2009.04953.x. PMID: 19751416.
Naylor KE, Jacques RM, Paggiosi M, et al. Response of bone turnover markers to three oral bisphosphonate therapies in postmenopausal osteoporosis: the TRIO study. Osteoporos Int 2016;27, 21–31.
Bauer D, Krege J, Lane N, Leary E, Libanati C, Miller P, Myers G, Silverman S, Vesper HW, Lee D, Payette M, Randall S. National Bone Health Alliance Bone Turnover Marker Project: current practices and the need for US harmonization, standardization, and common reference ranges. Osteoporos Int. 2012 Oct;23(10):2425-33. doi: 10.1007/s00198-012-2049-z. Epub 2012 Jul 14. PMID: 22797491; PMCID: PMC4011662.
Sornay-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. doi: 10.1359/JBMR.050609. Epub 2005 Jun 20. PMID: 16160738.
Tsourdi E, Zillikens MC, Meier C, Body JJ, Gonzalez Rodriguez E, Anastasilakis AD, Abrahamsen B, McCloskey E, Hofbauer LC, Guañabens N, Obermayer-Pietsch B, Ralston SH, Eastell R, Pepe J, Palermo A, Langdahl B. Fracture risk and management of discontinuation of denosumab therapy: a systematic review and position statement by ECTS. J Clin Endocrinol Metab. 2020 Oct 26:dgaa756. doi: 10.1210/clinem/dgaa756.

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What is Bone Remodeling?

Margaret Martin — Sat, 30 Nov 2024 16:53:39 +0000

Did you know your bones are constantly rebuilding themselves? This amazing process, called bone remodeling, works around the clock to keep your skeleton strong and healthy. When everything’s working properly, your bones can handle everyday stress and recover from injuries without any special treatment.

In this post, we’ll explore four key topics:

How the bone remodeling cycle works.
What can throw this natural process off balance.
What causes bone loss.
How you can keep your bones in top shape.

To help us understand this better, I spoke with Dr. Theresa Guise from the MD Anderson Cancer Center in Houston. As a professor in the Department of Endocrine Neoplasia and Hormonal Disorders, she’s an expert in skeletal health.

What is Bone Remodeling?

Inside each bone lies a complex network of cells and essential components known as the bone microenvironment. This specialized environment serves as the foundation for bone remodeling, the natural process of bone formation and bone resorption that keeps our bones healthy and strong. In the next section, we will discuss the bone microenvironment (and specifically each of these bone cells) in detail.

How Osteoblasts and Osteoclasts Remodel Bone

The process of bone remodeling relies on three specialized cell types, each performing distinct but interconnected roles in maintaining bone health. Here’s how each type functions:

Osteoclasts: The Cells That Remove Bone

Osteoclasts are large cells that originate in the bone marrow. Their primary function is bone resorption, the process of breaking down and removing old or damaged bone tissue. While this may sound destructive, osteoclasts play an essential role in bone health. They not only clear away old bone tissue but also stimulate bone-forming activity and help maintain a balanced remodeling process.

Osteoblasts: The Bone Formation Cells

Osteoblasts are responsible for bone formation, the process of creating new bone tissue. These cells develop from mesenchymal stem cells and typically remain active for about two weeks. During their lifecycle, some osteoblasts take on a unique role: instead of dying off, they embed themselves within the bone matrix they’ve created. These embedded cells then release enzymes that help maintain healthy bone tissue and transform into a third cell type called osteocytes.

Osteocytes: Cells That Manage The Regulation of Bone

Osteocytes function as the bone’s monitoring system. They manage bone formation and bone resorption. These long-lived cells can survive for up to 25 years within the bone matrix. Their primary role is to detect microscopic damage and stress in bone tissue. Upon detecting these changes, osteocytes send signals to both osteoclasts and osteoblasts, coordinating their activities to maintain proper bone structure and strength.

The Bone Matrix

The bone microenvironment also includes the mineralized bone matrix – the hard outer portion of bone that gives bone its strength. This matrix is built primarily from type 1 collagen, a special protein that forms strong fibers. Beyond providing structural support, the bone matrix serves another vital function: it acts as a storage depot for growth factors, which are important proteins that help maintain bone health.

The Bone Resorption and Formation Process

Your bones are continuously renewing themselves through a remarkable process that involves bone formation and bone resorption. Every time you move, jump, or make sudden movements, you create tiny stress points in your bones that can develop into microscopic cracks, called microfractures.

Bone Resorption

As we mentioned above, special cells called osteocytes act as the bone’s surveillance system and regulate bone formation and bone resorption. They detect stress points and locate these microfractures in your bones. When damage is found, at a remodeling site osteocytes signal another type of cell, called osteoclasts, to remove the damaged bone tissue.

Bone Formation

After the osteoclasts (that originate from your bone marrow) finish removing damaged bone, they signal yet another type of bone cell, called osteoblasts, to begin their work. These cells arrive at the site and build new, healthy bone tissue to replace what was removed.

This continuous cycle of removal and rebuilding keeps your entire skeleton healthy and strong. The complete process takes about 120 days and occurs simultaneously throughout all parts of your skeleton.

Growth Phase and Bone Remodeling

Your bones are living, changing parts of your body that grow and transform throughout your life. Let’s look at how they change as you age.

From birth until about age 18, your long bones (like those in your arms and legs) gradually get longer. This growth doesn’t happen at a steady pace – sometimes it speeds up, like during growth spurts, and other times it slows down.

Osteoblasts make and lay down bone while the osteoclasts break bone down. The two cell types work in concert.

Peak Bone Mass

Your bones also get wider and their walls grow thicker until you’re about 30 years old when you achieve your peak bone mass. Think of it like a tree trunk getting thicker over time. At the same time, your bones are becoming denser as they pack in more minerals, especially calcium. This process peaks when you’re in your late twenties to early thirties.

How Adulthood Affects Bone Remodeling

While your bones stop getting longer by your early adult years, they never completely stop changing. Think of it like a tree – even though it might reach its full height, its trunk can still get thicker over time.

Throughout your entire life, your bones continue to adapt their shape and structure based on how you use them – like how exercise can make them stronger or how lack of activity can make them weaker. After that peak, bone density naturally starts to decrease, especially in women after menopause. [1]

How Mechanical Stress Impacts Bone Remodeling

When you engage in strength training, your muscles contract against the weight you’re lifting. All skeletal muscles are connected to your bones, either directly or through tendons. Each muscle contraction sends a mechanical signal to your bones that triggers two responses: it activates bone-building cells (osteoblasts) while reducing the activity of bone-removing cells (osteoclasts).

This physical stress also stimulates special cells called mesenchymal stem cells. These remarkable cells can develop into different types of tissue, including muscle, bone, cartilage, and ligaments. They respond particularly well to physical movement and mechanical forces. [2]

As we age, two significant changes occur: we naturally lose muscle mass, and the connections between our muscles and nerves become less efficient. This combination results in weaker muscles, which in turn leads to weaker bones.

However, there’s good news: your bones maintain their ability to strengthen themselves through physical activity at any age. This is why I strongly recommend staying active throughout your life. Whether you’re in your twenties or your sixties, your skeleton can still respond positively to regular exercise. [3]

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, a therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

What Role Does Estrogen Play in Bone Remodeling?

Estrogen, an essential sex hormone, plays a crucial role in maintaining bone health by regulating how bones maintain and rebuild themselves. The most important form of estrogen for bone health, called estradiol ), works in harmony with three types of bone cells: the bone-building osteoblasts, the bone-removing osteoclasts, and the coordinating osteocytes.

During menopause, women experience a dramatic decrease in estrogen production. This decline disrupts normal bone maintenance by reducing the activity of osteoblasts, the cells responsible for building new bone tissue. When osteoblasts become less active, the delicate balance of bone renewal is disrupted, which can result in decreased bone density and strength.

While researchers have established estrogen’s importance in bone health, they continue to study the precise mechanisms behind this relationship. Current research suggests that estrogen may influence how certain stem cells develop into bone-building cells, though this theory requires further scientific verification.

Factors That Disrupt Bone Remodeling

Various factors can disrupt the natural process of bone remodeling. Hormonal changes significantly impact bone health, particularly in women. The decline in estrogen levels during menopause is a major factor that can disturb this delicate process.

Similarly, when women experience amenorrhea—the absence of one or more menstrual periods—their bone remodeling process can be disrupted. When bone remodeling becomes unbalanced (the bone resorption and bone formation processes become uncoupled), it may lead to decreased bone density and, potentially, osteoporosis.

Fortunately, many factors affecting bone health can be managed through lifestyle choices. Two critical areas where positive changes can make a significant difference are:

Nutrition: The foods we eat, especially during our bone-building years, play a vital role in bone health. Poor nutritional choices during these crucial periods can have long-lasting effects on bone density.
Physical Activity: Regular exercise is essential for maintaining healthy bones. An inactive lifestyle fails to provide the necessary stimulation for bone building. Without consistent physical activity, the bone remodeling process becomes less effective.

Finally, cancer can disrupt bone remodeling and cause a decline in bone density. The next section discusses this in detail.

Cancer and Osteoporosis

Cancer and osteoporosis share a complex and significant relationship. When cancer cells invade the bone environment, they actively disrupt the natural bone remodeling process. These cells achieve this disruption either through direct invasion of the bone or by secreting substances that manipulate osteoclasts and osteoblasts, the cells responsible for bone maintenance.

Cancer cells initiate a destructive process by releasing factors that trigger excessive bone breakdown. As osteoclasts multiply on the bone surface, they accelerate bone destruction. Additionally, cancer cells can force osteoblasts to produce structurally weak bone tissue. This combination of accelerated destruction and compromised bone formation significantly increases fracture risk.

To put it simply, cancer cells commandeer healthy bone cells to serve their destructive purpose. This process becomes particularly dangerous when cancers like breast or prostate cancer metastasize to bone tissue, leading to rapid bone deterioration and eventual fractures.

Bone Matrix, Cancer, and Growth Factors

The mineralized bone matrix serves as a reservoir for crucial growth factors. When cancer triggers excessive bone destruction, it not only weakens the bone but also releases these stored growth factors. As osteoclasts break down bone tissue, the released factors create a dangerous cycle by stimulating cancer cells to grow more aggressively and produce additional bone-destroying factors.

This self-perpetuating cycle creates an environment where tumors thrive in bone tissue. Patients face severe consequences, including painful fractures, elevated blood calcium levels (hypercalcemia), and other serious complications resulting from disrupted bone remodeling.

Cancer Accelerates the Normal Bone Remodeling Process

Cancer dramatically speeds up bone remodeling, causing destruction that outpaces the body’s ability to form new bone tissue. While osteoblasts attempt to compensate, they cannot match the rate of destruction. The new bone they manage to create is structurally inferior, further compromising bone strength.

The impact extends beyond the bones themselves. Cancer cells in bone tissue trigger systemic effects throughout the body, with muscle weakness emerging as a particularly significant concern. This occurs through a specific mechanism: cancer cells stimulate factors that activate osteoclasts, which then release stored growth factors like transforming growth factor beta (TGF beta) from the bone matrix.

Recent research demonstrates that TGF beta can travel through the bloodstream to affect multiple organs, including muscles, heart, brain, and pancreas. The resulting muscle weakness occurs even before visible muscle wasting (cachexia) develops. This weakness increases fall risk, potentially leading to fractures and creating a cycle that increases patient suffering and mortality rates.

Medical science now recognizes the importance of blocking bone resorption not only to maintain bone strength but also to prevent systemic effects like muscle weakness. Research in mouse models shows promising results using bone-protective drugs to prevent muscle weakness, and human trials are on the horizon.

Breast cancer treatment introduces several unique challenges for postmenopausal women. These are covered, in detail, in our post on aromatase inhibitors and bone loss.

Cancer and Osteoporosis: Summary of Key Points

Cancer cells actively disrupt normal bone remodeling by manipulating bone-maintaining cells
This disruption creates a destructive cycle that weakens bones and promotes tumor growth
The effects extend beyond bone health, causing system-wide complications
Muscle weakness develops through the release of growth factors from damaged bone
Current research focuses on blocking bone destruction to prevent both skeletal and systemic effects

Bone Remodeling: Best Practices

While the hormonal changes of menopause and their effects on bone health are a natural part of aging for women, you can take proactive steps to maintain strong, healthy bones. A well-planned strategy can help keep your bone remodeling process functioning effectively.

Four key approaches can help protect your bone health:

First, following a comprehensive osteoporosis exercise program helps maintain bone strength.
Second, proper nutrition provides the essential building blocks your bones need to stay healthy.
Third, low intensity vibration therapy can assist the bone remodeling process by stimulating mesenchymal stem cells (MSEs) to produce osteoblasts, the cells responsible for bone formation.
For those whose bone density has decreased significantly, placing them at higher risk for fractures, medical professionals may recommend pharmaceutical treatments as a third line of defense.

Conclusion and Summary

Bone remodeling is a remarkable and continuous process (involving bone resorption and bone formation) that keeps our skeleton strong and healthy throughout our lives. This complex system involves three main types of cells—osteoclasts, osteoblasts, and osteocytes—working together in a carefully orchestrated cycle of removing damaged bone tissue and building new bone.
While this process occurs naturally, various factors can influence its effectiveness. Age-related diseases and many medications can have a significant impact on bone remodeling. However, understanding these changes allows us to take proactive steps to maintain our bone health.

Through regular physical activity, proper nutrition, and medical intervention when necessary, we can support our body’s natural bone remodeling process and maintain strong, healthy bones at any age.

Whether you’re in your twenties or your sixties, it’s never too late to start taking care of your skeletal health. By making informed lifestyle choices and working with healthcare professionals when needed, you can help ensure your bones remain strong and resilient for years to come.

Remember: your bones are constantly rebuilding themselves—give them the support they need to do their job effectively.

Margaret Martin

References

Duren DL, Seselj M, Froehle AW, Nahhas RW, Sherwood RJ. Skeletal growth and the changing genetic landscape during childhood and adulthood. Am J Phys Anthropol. 2013 Jan;150(1):48-57. doi: 10.1002/ajpa.22183. PMID: 23283664; PMCID: PMC3539213.
Rubin J, Styner M. The skeleton in a physical world. Exp Biol Med (Maywood). 2022 Dec;247(24):2213-2222. doi: 10.1177/15353702221113861. Epub 2022 Aug 19. PMID: 35983849; PMCID: PMC9899984.
National Cancer Institute. SEER Training Modules. Anatomy & Physiology. Skeletal System. https://training.seer.cancer.gov/anatomy/skeletal/growth.htm
Cheng CH, Chen LR, Chen KH. Osteoporosis Due to Hormone Imbalance: An Overview of the Effects of Estrogen Deficiency and Glucocorticoid Overuse on Bone Turnover. Int J Mol Sci. 2022 Jan 25;23(3):1376. doi: 10.3390/ijms23031376. PMID: 35163300; PMCID: PMC8836058.

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Bone Quality vs Bone Density

Margaret Martin — Wed, 13 Mar 2024 01:08:09 +0000

Bone Quality vs Bone Density

The stronger your bones, the greater their ability to withstand fracture. However, what’s the best way to assess the strength of your bones? What do we mean when we compare bone quality vs bone density?

This article will answer these questions, discuss how we measure bone quality, provide guidelines on how to improve bone quality, and explore the relationship between bone quality and osteoporosis.

Bone Quality and Bone Density

The National Cancer Institute defines bone density as a “measure of the amount of minerals (mostly calcium and phosphorous) contained in a certain volume of bone.” The DEXA exam measures bone mineral density (BMD).

Health professionals use the BMD score to evaluate and classify bone health into one of several classes, including osteoporosis and osteopenia. Bone mineral density (BMD) tests are generally easily accessible, inexpensive, and safe. Later in this post, we describe the advantages and shortcomings of using bone density to evaluate bone health.

Bone quality refers to the material properties and architecture of the bone. It has to do with how bone is made, the cortical margin, the fabric of the trabeculae inside the bone, and porosities in the cortical part. A bone with “higher quality” is better able to withstand stress and potentially fracture. There are several ways to measure bone quality. We discuss these options later in this post.

In general, bone quality is a better way to evaluate bone health compared to bone density.

Bone Density and Bone Health

Medical professionals often use bone density to assess bone health. They use Dual Energy X-ray Absorptiometry (DEXA) that measures bone mineral density (BMD).

They frequently use this score to estimate your risk of fracture, select your best treatment options, and determine whether you should or should not take osteoporosis medication.

However, it has been known for over a decade that the DEXA test is not as reliable a measure of bone strength as originally thought. (1)

Bone Mineral Density (BMD) and Fracture Risk

In fact, several studies have shown that many fractures occur in people with only moderately decreased bone mineral density. (2,3)

Further, half of all postmenopausal fractures occur in women with bone mineral density (BMD) test results that indicate that their bone density levels are not low enough for them to be categorized as having osteoporosis. (4)

In addition, the results of the BMD test often determine whether you end up on medication or not. The most popular osteoporosis medications, both bisphosphonates and Prolia, are frequently prescribed to increase the density of bone.

These medications increase bone density, but do not necessarily improve the quality of bone.

Bone Strength and Bone Health

In his review, Bone Quality: The Determinants of Bone Strength and Fragility (5), published in Sports Medicine in 2013, Dr. Helder Fonseca defines bone strength as “the maximal amount of load tolerated before structural failure occurs.”

Dr. Helder explains the relationship between bone strength and the risk of fracture: “Failure gradually builds within the [bone] material as micro-cracks develop. Strains [eventually] reach an unbearable critical limit. Bone strength and toughness are therefore highly dependent on the ability of the bones to dissipate the stresses that lead to increases in strain, as well as on the micro-structural properties that prevent crack propagation.”

This explains why a vertebral compression fracture is the result of the buildup of small micro-cracks that develop over time and eventually lead to a fracture.

The next section throws light on how bone strength, and in particular, bone structure, influence frailty and eventually the chance of fractures. including compression fractures and femoral neck fractures.

Bone Strength and Fracture Risk

In 2016 Dr. Georg Osterhoff and colleagues published a report in the journal Injury, entitled Bone mechanical properties and changes with osteoporosis (6), that examined the relationship between bone quality and osteoporosis. Dr. Osterhoff reported several important findings.

Bone Fragility and DEXA

First, Dr. Osterhoff states: “The assessment of bone mineral density (BMD) as a surrogate marker of bone strength using non-invasive methods like dual-energy X-ray absorptiometry (DEXA) is widely regarded as the gold standard for diagnostic screening and as a guide prior to therapeutic decisions.

However, BMD accounts for only 60% of the variation in bone fragility because it is unable to depict differences in bone material composition and structural design. Both characteristics influence bone strength to a large extent.”

In other words, while DEXA evaluation of BMD is seen as the “gold standard,” it can only account for 60% of the measure of bone fragility. Bone fragility reflects the ability of your bones to resist fracture (discussed in more detail later in this post.)

As a result, you could receive a good BMD score, but there is still a risk of a fracture because the DEXA cannot evaluate “bone material composition and structural design,” or bone structure.

Bone Fragility and Movement Patterns

Second, Dr. Osterhoff notes that when we evaluate bone, we should consider its ability to withstand different movement patterns, such as rotation and lateral movements. He explains this here:

“The unique mechanical properties of bone reflect the need to provide at the same time strength and lightweight design, stiffness and elasticity, the ability to resist deformation, and the ability to absorb energy.”

These dynamic movements happen in everyday life when you exercise, work in your garden, pick up your grandchildren, or shop for groceries.

Bone is both strong and pliable. It is not a rigid structure.

Bone Fragility and Trabecular Connectivity

Third, Dr. Osterhoff reports that: “aging and other factors like estrogen deficiency can affect these components and eventually result in decreased bone strength and fracture toughness.”

He also states that “osteoporotic fractures are the macroscopic result of a sequence of multiple nano- and micro-structural events.”

The source of these osteoporotic fractures is the inability of our bones to withstand different types of loads.

Later in this post, we will talk about the different types of bone and their role in resisting fracture. However, at this time, I should point out that trabecular (also referred to as cancellous) bone composition plays a critical role in whether you experience a fracture or not.

Dr. Osterhoff states in his report that “trabecular connectivity inside a bone contributes more to the bone’s biomechanical strength than the trabecular thickness or the bone mineral density.”

Recent medical research demonstrates that good bone structure (or bone quality) is more important than the density of your bones when determining the strength of your bones (and their ability to resist fracture.)

Unfortunately, the BMD test or DEXA does not provide information on the quality of your bone or any insight into the architectural structure of your bones.

What is Bone Quality?

I asked Dr. Janet Rubin to define bone quality. Dr. Rubin is the Sarah Graham Kenan Distinguished Professor and Vice Chair for Research at the Department of Medicine of the University of North Carolina in Chapel Hill. She is also the Professor of Medicine in the Division of Endocrinology and Metabolism, a Joint Professor in Pediatrics and Pharmacology, and an Adjunct Professor for Bioengineering.

In the interview, Dr. Rubin explains that “bone quality is the architecture of the bone. It has to do with how bone is made, the cortical margin, the fabric of the trabeculae inside the bone, and porosities in the cortical part. Bone quality represents the material properties, where the materials are, and the architecture of the materials.”

Bone quality is an essential ingredient in bone structure and strength, as well as the bone’s ability to resist fracture. A major challenge is how to easily measure bone quality.

Dr. Helder explains in his paper (5) that “bone mineral density (BMD) is only able to provide insight regarding the quantity of bone tissue. It is insufficient as a measure of bone quality, given that bone strength is dependent on a large variety of interconnected factors.”

Bone Quality and Osteoporosis

To gain a better understanding of the relationship between bone quality and osteoporosis, we need to cover bone anatomy in some detail.

Bone tissue (or osseous tissue) refers to the bone. There are two types of bone tissue: cortical bone and cancellous (trabecular) bone.

An individual bone can be composed of both cortical and cancellous bone, and the relative mix of the two types varies from bone to bone in your body.

Cortical Bone

Cortical bone (sometimes referred to as compact bone) forms the cortex or outer shell of most bones. It is much denser, rigider, and stronger than the other type of bone tissue, cancellous bone.

Cancellous Bone

Cancellous bone (also referred to as trabecular or spongy bone) appears at the end of long bones, at the points of attachment of joints, and within the interior of the vertebrae. It has a greater surface area and is more porous, softer, less dense, and less stiff than cortical bone. As a result, cancellous bone is more affected by osteoporosis than cortical bone.

Bone Quality and Vertebral Body

Because the vertebral (spinal) area is largely composed of cancellous (trabecular) bone, it is at a greater risk of osteoporotic fracture when compared to other parts of the body.

The image to the right shows a cross-section of the vertebral body.

The vertebral body is the portion of the spinal column facing into the body. Note how the porous structure of the trabecular bone varies depending on the quality of the bone.

The vertebral body at the top of the spinal column is healthy. This is indicated by the dense trabecular bone.

The vertebral body at the bottom of the spinal column segment has been compressed (a compression fracture) because of the reduced trabecular bone. The bone quality in this case has been compromised.

Cancellous bone is composed of many individual and interconnected trabecula.

Trabecula is a small, microscopic tissue element.

They look like beams (“trabecula” is Latin for “small beam”) and are often in the form of small rods or plates. The plural of trabecula is trabeculae.

What is the Trabeculae?

When we talk about bone quality and osteoporosis, we are specifically referring to the quality of the cancellous or trabecular bone. Bone quality is defined as the sum of the structural and material properties of the trabecular bone.

Think of trabecular bone as similar to the scaffolding that holds a building up.

A building composed of concrete is solid but rigid and inaccessible. Instead, the building should have support beams, struts, and strong interconnected pieces that allow the building to stand tall and flexible at the same time.

Either through ageing, disuse, or disease, the interconnected trabecular bone interconnections begin to break down. Even with anabolic therapy, it’s very rare that trabeculae reconnect. Although there may be a buildup of bone density, there can still be a loss of bone quality.

Trabecular Bone and Bone Structure

Bone structure is the composition of the trabecular bone inside the bone. Trabecular or cancellous bone is made up of many interconnected trabeculae, either in the shape of a rod or a plate.

The illustration above shows a microscopic view of a trabecular bone. Note the mix of flatter, plate-like trabecula interweaved with the narrower, rod-like trabecula in the top left of the image.

The more of the thicker plate-like trabeculae present in the structure as compared to the thinner, rod-like trabeculae, the better the quality of the bone.

The better the bone quality, the stronger the bone.

Trabecular Bone

Trabecular bone that has been replaced by rod-like trabecula is weaker, osteoporotic, and more at risk of a fracture. This change can occur over time and is dependent upon the individual’s family history as well as exercise and nutritional history.

Note the higher frequency of plate-like trabecula in the bone structure of the normal trabecular bone (top left of the image) when compared to the bone structure of the osteoporotic trabecular bone (bottom right of the image). In addition, the osteoporotic trabecular bone has more rod-like structures.

The material properties refer to substances or matter such as collagen and minerals that make up the bone.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

Topics Covered in Course

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Age, Bone Loss and Localized Fractures

Trabecular bone, due to its lesser density when compared to cortical bone, accounts for approximately 20% of the skeletal bone mass. However, trabecular bone is responsible for most of the bone turnover during the early stages of osteoporosis (in people under the age of 65).

As a result, Dr. Fonseca (5) states, “vertebral compression fractures, being ‘trabecular fractures’, are more common in individuals aged less than 65 years.”

Conversely, as we age, cortical bone becomes more and more porous and weaker. Dr. Fonseca notes that “with increasing cortical bone loss after the age of 65 years, hip fractures, being ‘cortical fractures’, become more frequent.”

Bone Location and Fracture Risk

Bone is subject to a number of forces as we move, specifically compressive and shearing loads.

In his paper (6), Dr. Osterhoff points out that “each bone’s location in the body and the forces acting on it determine its characteristic microstructure and composition.”

He points out that “vertebral bodies must resist high and repetitive axial compression loads.” Further, they “experience much less shear or tension loads. If the trabecular bone is reduced in a vertebral body, this leads to increased cortical shell stresses and a disproportionate decrease in the vertebral bone’s ability to withstand compression forces.”

In other words, if the trabecular struts within the vertebral body diminish, pressure is placed on the cortical bone to support the compressive forces through the spinal column.

“The femoral neck, on the other hand, is mainly subjected to shear forces and bending — the latter of which creates a combination of compression, tension, and shear.”

This makes intuitive sense. The hip area must support every day movements that include bending and squatting. As the bone quality diminishes in the femoral area, the risk of a femoral fracture increases correspondingly.

Bone Quality and History of Physical Activity

Your history of physical activity throughout your life can affect the quality of your bones in different locations.

In March 2020, Dr. Carrie Anne Ng (and colleagues) at Monash University published a paper (7) in the journal Osteoporosis International entitled Associations between physical activity and bone structure in older adults: does the use of self-reported versus objective assessments of physical activity influence the relationship?.

In the paper, Dr. Ng examined the effects of physical activity (during different periods) on bone locations. Dr. Ng stated: “In postmenopausal women with low bone mineral density (BMD), current physical activity (PA) was positively associated with femoral neck BMD and microarchitecture. Past PA was positively associated with tibial microarchitecture.”

In other words, current thinking is that physical activity you do today (or recently) can positively influence the BMD in your femoral neck area. Whereas, the BMD in the tibial microarchitecture (located near the ankle and a reasonable proxy for trabecular bone in the spine) is mostly influenced by physical activity you did in your early years (including your youth).

Study Details

Fifty community dwelling postmenopausal women were recruited for the study and subjected to physical activity. Bone structure was assessed by lumbar spine and hip dual-energy X-ray absorptiometry (DEXA), 3D modelling algorithms (3D-SHAPER) of hip DXA scans, and distal tibial high-resolution peripheral quantitative computed tomography (HR-pQCT) scans. We will define HR-pQCT in the next section of this post.

After examining the data, Dr. NG concluded that “past physical activity [had] lasting benefits for trabecular microarchitecture, and current physical activity [was] positively associated with cortical bone.”

If you are young, you can influence the bone structure of your spine (specifically the trabecular bone) through physical activity. Fortunately, you can influence the cortical bone in your femoral neck area with physical activity today.

Bone Quality vs Bone Density Measurements

The follow sections describes the various ways we measure bone density and bone quality. We will start with measuring bone density.

Bone Mineral Density (BMD)

Bone mineral density (BMD) tests are today’s most recognized tests to diagnose osteopenia and osteoporosis. However, as the name implies, BMD tests only measure bone density, not bone quality.

A second issue with BMD tests is the variability within the machines and even the same manufacturer over time. Several factors can influence your BMD test and t-score. A 2022 study from Sweden looked at this problem and identified several factors explaining the variability in the BMD and T-scores. (8)

Lack of information on bone quality is a problem. More than half of individuals who have low trauma fractures have BMD scores that are in the range of osteopenia.

Until recently, the average individual did not have access to bone quality testing. A high-resolution quantitative computed tomography test was the most common way of obtaining information on bone quality.

High-resolution peripheral Quantitative Computed Tomography (HR-pQCT)

High-resolution peripheral quantitative computed tomography (HR-pQCT), as the name implies, generates a high-resolution, three-dimensional monitoring of the architectural structure of bone. The word peripheral stands for our limbs as opposed to our torso. This microscopic view makes it good at determining the quality of bone in your forearms and lower legs.

HR-pQCT imaging is not practical for frequent use because it exposes people to higher amounts of radiation and costs more to operate. For these reasons, these tests are usually used for research or study in large hospitals.

Bone quality information is a key part of the decision-making process when someone is diagnosed with osteoporosis or osteopenia. The World Health Organization recognized the need for access to this information and created the Fracture Risk Assessment Tool, known as FRAX.

Fracture Risk Assessment (FRAX)

Some centers that provide DEXA testing will include FRAX scores with your BMD results. Your FRAX score is based on age, sex, weight, height, and other specific risk-related questions to determine your 10-year probability of a major osteoporotic fracture and a hip fracture.

To complete the FRAX questionnaire, you need the DEXA BMD result for your femoral neck. The FRAX does not take into account the BMD of your spine. If you have not received a FRAX score, you can follow MelioGuide’s tutorial to complete your FRAX.

If your spine score is lower than your femoral neck, you may be at a higher risk for fracture than predicted by FRAX.

Not all countries or clinicians use FRAX, but it should be considered one of many tools available to predict your fracture risk. A bone quality test on the market for the past nine years is the Trabecular Bone Score, or TBS.

Trabecular Bone Score (TBS)

What is a TBS test? TBS is a noninvasive, computer-generated calculation obtained via a software package that analyses the DXA scan. Having a test done feels and looks the same as having a DXA test.

The TBS indirectly estimates the microarchitecture of the trabeculae in the vertebral bodies of your lumbar spine and provides you with a score similar to the DXA BMD score.

Trabecular Bone Score testing has evolved to be important in assisting clinicians in making the right treatment decisions for their patients and monitoring the effectiveness of treatment on the quality of their patients’ bones.

In 2023, a panel of international experts concluded that TBS was a helpful tool for managing high fracture-risk women, men, and those with osteoporosis caused by secondary causes. (9)

There are a growing number of facilities around the world that provide this service. Unfortunately, access to TBS measurements is still relatively limited and expensive.

The newest test to enter the market originated in Italy and is called the Radio-frequency Echo-graphic Multi Spectrometry, or REMS for short.

Radio-frequency Echo-graphic Multi Spectrometry (REMS)

Radio-frequency Echo-graphic Multi Spectrometry (REMS) is a non-ionizing technology that uses ultrasound to assess the bone density and fracture risk of the neck of the femur and lumbar spine.

Unlike DEXA, it has been pre-programmed to recognize and exclude things that can skew the results, such as aortic calcifications, bone spurs, and other common artifacts that falsely raise DEXA scores.

Studies have shown REMS to be diagnostically accurate in comparison to DEXA. (10)

I had a lot of questions about the REMS technology, so I reached out to Echolight REMS in Italy on two occasions but never received a response. Fortunately, Nick Birch, Consultant Spine and Bone Health Specialist and co-owner of Ostescan UK, generously answered many of my questions about the technology.

The REMS is not a bone quality test. It is, however, considered in certain populations (i.e., petite women) to provide a more accurate bone density test. Nick Birch, cofounder of Osteoscan UK, told me that individuals with very arthritic spines or degenerative scoliosis can obtain more accurate readings with REMS than DEXA.

There is one thing that bothers me about the REMS test. The image of the spine in the report is a generic representation of a healthy spine.

No one has ever mentioned to my clients that the image on the report does not represent their spine.

Nick agreed that it was unfortunate that the company had an image representing a healthy spine and mentioned that he makes sure that his clients know it does not represent their spine.

Clients with known thoracic compression fractures have felt emboldened to take risks based on the REMS results of their lumbar spine. Please be aware of this issue.

What is Bone Fragility?

A DEXA can indicate that you have a good bone mineral density score. However, your risk of a fragility fracture might be elevated, largely due to your reduced bone quality.

Conditions such as diabetes, chronic kidney disease, amenorrhea, and eating disorders can deteriorate bone quality.

Some clinicians use the FRAX in concert with the DEXA results to estimate fracture risk.

In the video interview above, I asked Dr. Rubin to describe bone fragility.

Factors That Affect Bone Quality

In this section, we cover the numerous health conditions and pharmaceuticals that can negatively impact your bone quality.

Co-morbidities, Pharmaceuticals and Bone Health

The following medical conditions can affect the quality of your bones:

Diabetes (Type 1 or type 2)
Hormone deficiencies (estrogen, testosterone, thyroid, parathyroid)
High doses of thyroid medication
Malnutrition or malabsorption diseases
Cancer and cancer treatments
Organ transplants

In addition, there are numerous secondary causes of osteoporosis and a surprising number of prescription medications and over-the-counter pharmaceuticals that can negatively impact your bones. Speak to your doctor/pharmacist about possible alternatives if you are currently taking a pharmaceutical that has been linked to a lower BMD.

Genetics and Bone Health

We cannot control everything in life. We don’t get to choose our parents, however, genetics play a big role in the quality of our bones.

If you have a parent who has sustained a hip fracture (or if you have had a low trauma fracture on one of your vertebras or the long bones of your arms or legs while under the age of 45), you will likely be more susceptible to future fractures.

How to Improve Bone Quality

In this section, I identify steps you can take to improve bone structure and the quality of your bones. Let’s start with exercise.

Resistance Exercise and Bone Health

In their 2018 publication, Effects of Resistance Exercise on Bone Health (10), Hong and Kim state that “resistance exercise (RE) is known to be highly beneficial for the preservation of bone and muscle mass.”

They define resistance exercise (RE) as “a physical conditioning program that enhances fitness, health, and sports performance, using a variety of training modalities such as free weights, weight machines, medicine balls, elastic bands, and different movement velocities.”

Hong and Kim conclude that “based on the available information, RE, either alone or in combination with other interventions, may be the most optimal strategy to improve the muscle and bone mass in postmenopausal women, middle-aged men, or even the older population.

In particular, resistance exercise seems to be beneficial for the cortical bone.”

Studies dating back to 1984 (11) show that the type of exercise is equally important to protect from fractures.

Lifestyle choices and Bone Health

Your lifestyle choices can affect your bone quality.

If you currently smoke, do your best to stop smoking.
Do not exceed 2 alcoholic drinks a day.
Reduce your intake of processed foods such as pastries, pizza, french fries, snacks, and refined grains.
Reduce your intake of protein from cheese and processed meat.
Build your diet around vegetables, fruit, whole grains, and healthy protein choices.
Maintain a healthy body weight to ensure you maintain regular menstrual cycles.

Nutrition and Bone Health

In the article, Nutrients and Dietary Patterns Related to Osteoporosis, the authors write that “overall, adherence to a healthy dietary pattern including fruit, vegetables, whole grains, poultry, fish, nuts and legumes, and low-fat dairy products and the avoidance of processed food products will be beneficial for bone health, decreasing the risks of osteoporosis and fractures.” (12)

The article is a must-read for those looking to optimize their diet for their bones. Here are a few highlights:

Magnesium

Magnesium is important for bone health. It is involved in osteoblast proliferation.

Magnesium deficiency is associated with reduced bone formation (12). It is necessary for the activation of vitamin D, and it affects bone quality through its influence on the hydroxyapatite crystal size and formation.

Protein

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends a dietary protein intake of 1.0–1.2 g/kg body weight/day, with at least 20 to 25 g of high-quality protein at each main meal.” (12)

The authors go on to say that “adequate protein intake is imperative for bone matrix formation and maintenance.” (12)

Consumption of adequate protein when strength training has been shown to improve the accretion of protein.

Ensuring adequate protein intake while strength training is an “important contributor to the maintenance of bone strength.

Other Nutrients and Foods

A bone-healthy diet includes a number of other nutrients and foods, including Vitamin K2, calcium, prunes, among others. A healthy gut microbiome that improves the absorption of nutrients can play an important role in bone health.

Conclusions

High resolution computer imaging technology has helped researchers learn more about bone strength, the importance of bone quality, and the limitations of solely relying on bone density to determine bone strength.

From these developments, we can conclude the following:

Bone Quality vs Bone Density

First, remember that your DEXA score is one variable in the overall equation for determining your bone strength. But it is not the be-all and end-all.

If you get a bone density score that is less than optimal, consider it an early warning signal indicating symptoms of osteoporosis. Unfortunately, for many people, the first sign of poor bone quality is a fracture.

Use the BMD score as an opportunity to take stock of all the variables that can affect your bone health.

Bone Quality, Bone Strength and Exercise

Second, the quality of your bone structure is very important in determining the strength of your bones and their ability to resist fracture.

It appears that people who are physically active have better quality bone structure. Create opportunities for safe movements and effective exercise that can influence the quality of your bones.

Balance Training

Third, your exercise plan should include balance training along with strength training.

Better balance leads to fall reduction. A lower fall risk leads to a reduced incidence of fracture.

Nutrition, Lifestyle Choices and Bone Quality

Fourth, make dietary and lifestyle choices that help your skeleton support you for your lifetime.

Low-Intensity Vibration Therapy

Lastly, if you are limited in your exercise regimen, consider low intensity vibration therapy as a surrogate for an exercise program.

Bottom line: bone quality matters. Eat well and incorporate physical activity into your bone health regimen. Consult with a qualified professional knowledgeable in movement and bone health to ensure safety and efficacy.

References

Beck TJ et al. Confounders in the Association between Exercise and Femur Bone in Postmenopausal Women. Med & Sc in Sports & 2011 Jan;43(1):80-9. doi: 10.1249/MSS.0b013e3181e57bab.
McDonnell et al. Ann Biomed Eng 2007
Delmas PD et al. J Bone Miner Res 2005
Schuit SC et al Bone 2004
Fonseca H, et al. Bone Quality: The Determinants of Bone Strength and Fragility. Sport Medicine. October 3, 2013
Osterhoff G et al, Bone mechanical properties and changes with osteoporosis. Injury. 2016 Jun; 47(Suppl 2): S11–S20.
Ng C-A, et al. Associations between physical activity and bone structure in older adults: does the use of self-reported versus objective assessments of physical activity influence the relationship? Osteoporosis International. 2020 Mar;31(3):493-503. doi: 10.1007/s00198-019-05208-y. Epub 2019 Nov 13.
Karolina Lundstam, Kristin Godang, Mikkel Pretorius, Paul Markwardt, Mikael Hellström, Jens Bollerslev, Ansgar Heck, The Influence of DXA Hardware, Software, Reference Population and Software Analysis Settings on the Bone Mineral Density and T-Score Relationship, Journal of Clinical Densitometry, Volume 25, Issue 1, 2022
Shevroja, E., Reginster, J-Y., Lamy, O., et al. (2023). Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging. Osteoporos Int (2023). Published online: July 01, 2023: https://link.springer.com/article/10.1007/s00198-023-06817-4
Adami G, Arioli G, Bianchi G, Brandi ML, Caffarelli C, Cianferotti L, Gatti D, Girasole G, Gonnelli S, Manfredini M, Muratore M, Quarta E, Quarta L. Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study. Bone. 2020 May;134:115297. doi: 10.1016/j.bone.2020.115297. Epub 2020 Feb 21. PMID: 32092480.
Sinaki M, et al. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Physical Med Rehabilitation. 1984 Oct;65(10):593-6.
Muñoz-Garach A, García-Fontana B, Muñoz-Torres M. Nutrients and Dietary Patterns Related to Osteoporosis. Nutrients. 2020;12(7):1986. Published 2020 Jul 3. doi:10.3390/nu1207198

The post Bone Quality vs Bone Density appeared first on MelioGuide.

The Sleep Solution

Richard Martin — Tue, 18 Jan 2022 16:00:41 +0000

If you have sleeping problems you should read The Sleep Solution — Why Your Sleep is Broken and How to Fix It by Dr. Chris Winter. Most nights my sleep is “fragmented” — meaning that for more nights than I like, I wake up and experience problems getting back to sleep. I suffer from sleep maintenance insomnia.

The Sleep Solution helped me understand why my sleeping pattern was broken and what I need to do to improve the quality my sleep. I describe my personal journey to fix my sleep using Dr. Winter’s book.

I also discuss the relationship between quality of sleep and bone health — something that should interest most readers. In December of 2021 I completed a sleep study to determine if there were issues that affected my sleep. I report on that experience in this post and provide recommendations (not provided by my health provider) that will make your sleep study more successful.

Later in this article, I cover two other important sleep training books, Why We Sleep by Dr. Matthew Walker and The Effortless Sleep Method by Sasha Stephens.

I also discuss a 2018 book on the importance of circadian rhythm, The Circadian Code, by Satchin Panda, PhD. One of the interesting findings in Dr. Panda’s book was how circadian rhythm affects bone health. I cover this later on the blog post and encourage readers to review this.

Sleep, Osteoporosis and Low Bone Density

This site is dedicated to bone health and osteoporosis prevention and management. As a result, before I get into the book reviews, I should discuss the relationship between osteoporosis and sleep. When it comes to keeping our bones strong, sleep plays a very important role in at least five ways.

High quality sleep:

Improves the absorption of nutrients and reduces gastrointestinal problems.
Changes our food choices. When we are sleep deprived, we crave high calorie foods.
Enhances our gut bacterial community.
Leads to better balance and reduces our injury and fall risk.
Reduces cortisol production.

Each of these is covered in detail in Why We Sleep.

Shortened Sleep Associated with Low Bone Mineral Density and Osteoporosis

A study published in the Journal of Bone and Mineral Density in November of 2019 identified a link between short sleep and low bone mineral density and osteoporosis (1). The research team examined “a sample of 11,084 postmenopausal women from the Women’s Health Initiative. They performed a cross-sectional study of the association of self-reported usual hours of sleep and sleep quality (WHI Insomnia Rating Score) with whole body, total hip, femoral neck, and spine BMD using linear regression models.” (1)

The study stated that women reporting 5 hours or less per night had:

22% and 63% higher risks of experiencing low bone mass and osteoporosis of the hip, respectively. Similar results were seen with the spine.
Lower BMD at all four sites assessed—whole body, total hip, neck, and spine—compared with women who reported sleeping 7 hours per night.

The main author, Heather Ochs-Balcom, PhD of the University of Buffalo, stated: “Our study suggests that sleep may negatively impact bone health, adding to the list of the negative health impacts of poor sleep. I hope that it can also serve as a reminder to strive for the recommended 7 or more hours of sleep per night for our physical and mental health.”

Later in this article, the section on The Circadian Code, I discuss the relationship between the circadian rhythm.

Clearly, sleep plays a critical role in our health. We are now starting to see that there is a relationship between sleep and osteoporosis.

The Sleep Solution by Chris Winter

The Sleep Solution is much needed, especially for those of us in search of better sleep. I have read many blog articles on sleep and, for the most part, I find them repetitive and uninformative. They tell you that your health is at risk if you do not sleep, that you need a certain number of hours of sleep per night, and finally that you should sleep in a dark, cool room and not take your computer or iPhone to bed with you.

The problem is that the people who read these articles usually have sleep problems, often follow all of these guidelines and still cannot sleep. The reader is left with a sense of failure and anxiety — which furthers the sleeping problem!

The Sleep Solution Approach

Dr. Winter does not take this approach. He insists that you read the book from beginning to end so that you learn the basics of sleep and understand what is happening to your sleep. Instead of simple and obvious rules, he challenges the reader with two facts.

First, many of us dysfunctional sleepers insist that they do not sleep and have not slept for years. How can that be true? If, every night, you did not sleep, you would likely be dead — but you are here, reading this article I have written, and very much alive.

Second, we have an emotional relationship with our sleep. Most of the problems we have with sleep stems from the dysfunctional relationship we have with our sleep. (Sleep problems cause by physical issues such as apnea are different from emotional issues and demand specific treatment protocols). As a result, Dr. Winter encourages the reader to come to terms with this relationship and, like any relationship having a rough patch, put some effort into making it work.

The Sleep Solution: Reference Guide for Sleep Disorders

Dr. Winter has treated thousands of patients for various sleep disorders. He spends a significant amount of his time educating patients on the basics of sleep and this book was written as a reference guide for his patients.

We are fortunate that he published The Sleep Solution and made it available to you and I, the general public. For a modest price, you can access much of the information he shares with individual patients.

The Sleep Solution Deliverables

In The Sleep Solution, Dr. Winter achieves the following:

Delivers a comprehensive explanation of how sleep works. He covers the stages of sleep and why they matter, how circadian rhythms work, and the chemical foundations of wakefulness and sleepiness and how the two states compete with each other to keep you awake or put you to sleep.
Addresses many of the myths and misunderstanding about sleep that confuse many of us with sleep problems and the physicians who treat people with sleep problems.
Clarifies the difference between sleep deprivation and insomnia. This is one of the most important parts of the book. Instead of attempting to explain the difference in this blog post, I will leave it to you, the reader, to read his book to learn about this topic. Dr. Winters does a far better job than I ever will explaining this complex issue.
Asks the difficult questions about their sleep and challenges many of their beliefs. I feel that this discussion is one of the most important contributions of this book. The better understanding you have of your sleep behaviour, the greater the chance that you will fix your sleep problems.
Presents the latest research available on sleep and, where pieces are missing, he fills in with his own informed opinions.

A Sense of Humour

One more thing before I cover the book in more detail: Dr. Winter presents the material in a friendly and accessible manner. He is self deprecating and has a goofy sense of humour. Here is a gem from the chapter on snoring and apnea:

“When I turned thirty, I remember Ames (Dr. Winter’s wife) telling me that if I rolled over on my back, I sawed some logs. For years, like most men who come to my clinic, I assumed my wife was lying. Everyone knows that women have nothing better to do than to accompany their husbands to doctors’ appointments and make up stories about their spouses’ breathing at night.”

Introduction to Sleep Medicine

The Sleep Solution is broken into two major sections. The first section is an introduction to sleep medicine and the second section (after an “intermission”) addresses sleep problems and how to deal with them.

Dr. Winter provides a thorough explanation of sleep in the first section of the book. By now most of us know that sleep is important to our health and that poor sleep can detrimentally affect our heart, mood, immune system, and brain, can lead to weight gain, and has been linked to cancer. He covers each of these issues but, thankfully, he does not overdo the message.

On the other hand, he does point out several important new findings from recent research on sleep and the brain. For example, in 2015, University of Helsinki researchers Antoine Louveau and Aleksanteri Aspelund found that the brain has a system for removing waste called the glymphatic system (2). This system is 60% more productive when we sleep as compared to when we are awake. Removal of waste products in the brain plays an important role in long term cognitive well-being.

Sleep is Essential and Will Happen

Sleep is essential to our survival. Dr. Winter points out that our brain insists that we sleep. Eventually, no matter how poor the quality of your sleep or how sleep deprived you are, you will fall asleep. You might find the road to sleep to be a rocky one, but sleep is something that happens to all of us (even Rolling Stones guitarist Keith Richards).

Dr Winter points out that most people he sees do not grasp this simple concept. Many insist that they “haven’t slept in years.”

Really? You might have restless nights, you might not like the quality of your sleep, but you do sleep.

Some individuals, on the other hand, are sleep deprived. People who work night shifts are often sleep deprived. There are sleep tests that allow you to determine if you are sleep deprived and Dr. Winter provides several in the book. I completed each of these self-assessments and learned that I do, in fact, sleep at night. I just needed to work on improving the quality of my sleep.

Sleep Deprivation, Fatigue and Poor Sleep

This book made me think about the difference between sleep deprivation, fatigue, and poor sleep. Understanding these differences is essential to the sleep remedies described later in the book.

The chapter entitled Sleep Stages delivers an excellent overview of the structure of sleep and why it is important that your transition between the different sleep stages in the correct order. I appreciated the explanation of the different sleep stages when, later in the book, Dr. Winter discusses sleep studies.

During a sleep study, the sleep technician generates a reading of your sleep pattern called a polysomnogram. I was able to leverage my learning from the Sleep Stages chapter to interpret the output from a polysomnogram.

How to Treat Sleep Problems

Once you have a firm understanding of your sleep, Dr Winter moves onto how to treat sleep problems. This is the second section of the book. Like many sleep specialists, he discusses the importance of sleep hygiene. He also covers treating insomnia, sleep schedules, napping, snoring, apnea, sleep medications, sleep studies, sleep efficiency, sleeping aids and other sleep conditions.

I have read several books on sleeping, including Say Goodnight to Insomnia by Dr. Gregg Jacobs, and feel that The Sleep Solution is the most comprehensive, practical, pragmatic and realistic of them all.

Two other books require mention.

Why We Sleep by Dr. Matthew Walker is the latest addition to the sleep reading list.
The Effortless Sleep Method published in 2010 by Sasha Stephens is another important contribution to this field.

I discuss both books, in detail, later in this blog post.

Trazadone

As well as tips, self assessments and directions, it includes a number of surprises. For example, I was alarmed to learn in the chapter on sleep medications that the most common sleep medication prescribed by physicians is not even a sleep medication! It is an FDA approved anti-depressant: Trazadone. This is concerning.

As Dr. Winter points out in The Sleep Solution: “There is no real literature supporting their [anti-depressants] off-label use in helping patients fall asleep faster or even stay asleep. To me, these drugs epitomize the haphazard, misinformed, and dangerous practices of some doctors who do not understand sleep or how to treat it.”

Did The Sleep Solution Solve My Sleep Problems?

Several months have passed since I first wrote and published this review in July of 2018. The section you are now reading was added in September 2018 to update you on my personal journey with The Sleep Solution.

Since publishing the review in July, a number of people have asked me if reading the book and employing the techniques provided by Dr. Winter improved my sleep. In other words, was The Sleep Solution the solution to my sleep problems?

The answer is yes. The Sleep Solution worked because it did two things for me.

The Sleep Solution Helped Me Understand Sleep

First, the book gave me a better understanding of sleep. I learned that I sleep during the night. Unfortunately for me (and most problem sleepers), my sleep patterns are dysfunctional and my sleep quality is poor. Just knowing I do sleep at night (although it does not feel like I do) reduced my ongoing anxiety about my sleep.

Sleep Restriction Therapy (The Ice Bucket Sleep Challenge)

Second, I learned that dysfunctional sleep can be fixed through Cognitive Behavioural Therapy (CBT). Dr. Winter discourages the use of pharmaceuticals and advocates CBT as the path to good sleep. There is an abundance of clinical research supporting the effectiveness of CBT and, as a further bonus, CBT means you do not need to take medications or supplements to fix your problematic sleep.

Dr. Winter recommends a protocol that is part of CBT he amusingly calls the “Ice Bucket Sleep Challenge”. No need to worry. No-one will be dumping ice water on you. The clinical name for it is sleep restriction therapy (SRT). It is very effective but, I should warn you, it is not fun and requires serious commitment.

The objective is to increase your sleep efficiency. I was spending too much time in bed and not enough of that time was spent sleeping. In other words, my sleep was inefficient.

How Sleep Restriction Therapy Worked For Me

Here is how sleep restriction therapy worked for me. I restricted the duration of my time in bed to five hours and thirty minutes a night. I would go to bed a 12:30 AM and get up, whether I liked it or not (and most time I did not like it), at 6:00 AM. Although I felt groggy each day and wanted to nap, I didn’t. This protocol trains the brain’s clocking system, the suprachiasmatic nucleus, that a new sleeping pattern is in town.

I followed this protocol every night — without exception. It took a week to 10 days until my brain and body capitulated and I eventually slept through my first full night of uninterrupted sleep in years. It took another 20 to 25 days before I settled into a regular healthy sleeping pattern. In total, it took over a month to regain control of my sleep.

Those first 10 days were complete misery. When I take a dislike to people, I recommend they try this exercise. (Just kidding.)

Once I felt confident that my brain was retrained and healthy sleep was established, I added 15 to 30 minutes to my nightly sleep.

How to Succeed With Sleep Restriction Therapy

I found it very difficult staying awake each night until 12:30 AM. I like to read at night but found with this protocol I was unable to read because I fell asleep before my prescribed sleeping time. To stay awake, I went out late each evening for long, long walks. I not only fixed my sleeping problem, I added some extra exercise to my day. Pretty good deal!

I recommend you do this protocol during the spring, summer or fall seasons when walking at night is accessible and pleasant. Also, I found it relatively easy to stay awake through the long and sunny days of July and August.

Following this protocol during January and February in northern climates when the days are short and the light is low could be a challenge, unless you have access to a treadmill or exercise bike at home. If you are one of the lucky ones who gets away from the winter weather, perhaps now is your opportunity to fix your broken sleep while enjoying the nice weather!

One more point regarding time of year. I think it’s best to do sleep restriction therapy when the days are long and warm and the evenings are cool. Cooler temperatures at night are more conducive to good sleep.

If you experience dysfunctional sleep and you know that the cause is not a physical impairment such as apnea, I encourage you to try this approach. I think that you’ll find that, as the French say, ca vaut la peine.

Where to Purchase The Sleep Solution

You can purchase The Sleep Solution on Amazon in paperback. Please note I receive small commission from Amazon if you purchase the book.

About Dr. Chris Winter

Dr. Winter is a physician, a board certified sleep-medicine specialist, and a board-certified neurologist. He has been involved in sleep medicine and sleep research since 1993 and is the owner of Charlottesville Neurology and Sleep Medicine clinic in Charlottesville, Virginia where he has been practising sleep medicine since 2004.

Conclusion to The Sleep Solution

Dr. Winter has done the poor sleepers of the world a great service with the publication of the book, The Sleep Solution. I encourage you to read it so that you can learn more about your sleep and how to make it better.

The Sleep Solution is now available on Amazon in paperback.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Richard’s Overnight Sleep Study (Polysomnogram)

In late 2021 I asked my physician if I could have an overnight sleep study (known as a polysomnogram). My sleep has improved since using Dr. Winter’s protocols but it was still fragmented.

I wondered if there were other issues at play — physical impairments such as sleep apnea — that were affecting my sleep quality.

My physician was able to arrange an overnight sleep study at a hospital near my home. The following is a summary of my experience and the outcome, as well as tips and suggestions that could make your sleep study experience a success.

The Sleep Study Process

Once the sleep study was scheduled, I received instructions from the sleep lab at my local hospital on how to prepare for the event.

They recommended that I:

Avoid sleeping (napping) during the day of the study.
Not consume medications or alcohol before the sleep study and to take any medications to the session for the technician to review.
Limit (or eliminate) caffeine during the day of the study.
Bring comfortable pyjamas.
Optionally, bring my own pillow.

My session was scheduled to start at 10:00 PM and the staff member told me to be at the hospital at 9:30 PM for registration. I arrived, registered and within 10 minutes a sleep technician welcomed and invited me into the secure sleep lab area. The technician showed me where the bathroom was and escorted me to the room I would sleep in that night.

She showed me room layout and identified the call button I could use to request her attention. I was told that the session would start when I was ready to go to sleep and that it would end at 5:45 AM the next morning. If I was still asleep at that time, they would wake me at 5:45 AM and ask me to leave.

At this point, she asked me a series of questions:

Do I snore?
Am I on medication?
Do I have restless legs when I slept?
What was my typical night of sleep?

Once that was out of the way, she said she would leave the room and asked me to put on my pyjamas while she was away. After I got into my pyjamas, I used the call button next to the bed to have her return.

Polysomnogram Set Up

When she returned she wired me for the pleasant night of sleep ahead. The configuration included the following items:

Chest strap that measured my breathing pattern.
Series of electrodes taped to my scalp to measure electrical activity on my brain.
More electrodes [electro-oculogram (EOG)] positioned near my eyes to measure eye movements.
Electrocardiogram connectors attached to my chest to measure heart rhythm.
Nose cannula to monitor air flow.
Microphone attached to my chest to monitor snoring.
Electromyography connectors attached to my shins to monitor muscle activity.
A peripheral capillary oxygen saturation monitor (clipped to my index finger) to measure continuous oxygen saturation.

All of the cables (from all of the attachments) terminated into a small red box. The small red box, in turn, had cables leaving it that terminated into a large wall panel. The data would be sent during the night to the technician for monitoring.

The image above is a selfie of me in the bed with the connectors and cables. You can see the small red box in the top right hand corner of the image. The cables attached to my body terminated in the box. The box had a cable that connected into the wall panel.

How Much Sleep Data Do They Need?

As she attached all of the connectors I asked my technician how much continuous sleep I needed to provide so that she could give my physician a usable sleep report. She told me she needed two continuous hours of sleep.

I was concerned because I usually do not sleep well in a new setting, and this setting was particularly uncomfortable. I anticipated that I might “fail” the test and not deliver the required amount of sleep data.

She told me that quite a few people are unable to provide adequate sleep data and, in some cases, people are so uncomfortable that they leave the premises shortly after putting their head on the pillow.

When everything was set up, the technician left the room and went to her lab position. She spoke over the speaker into my room and asked if we could do a series of tests. She asked that move my eyes in different positions to calibrate the electro-oculogram (EOG) attached near my eyes. I was also asked to vary my breathing pattern.

The Sleep Study Experience

When the sleep technician finished the configuration and test process, I was ready to settle down into sleep.

I brought a book to read and lasted about ten minutes; at which point I asked the technician to shut off the lights. What followed was one of the worst sleeps I have ever experienced.

It struck me as ironic that you go to a sleep lab to study your sleep (because you are a bad sleeper), only to find that you are trying to sleep in the most uncomfortable setting possible. If you are a bad sleeper (at the best of times), expect to have an even badder sleep at a sleep lab.

This is an important fact bad sleepers should know before they go to a sleep bad. Make sure you do everything you can beforehand to cause you to fall and stay asleep. More on this later.

A Challenging Night

These are the things that challenged my sleep that night:

The cables attached to my head, chest, shins and the tip of my finger were very uncomfortable. I could move around, and shift to sleep on my side, but I have to move the cables and reposition them with each change. Not fun.
I do not sleep well in new locations and while the hospital tries its best, the room is very sterile and, well, like a hospital bed.
Hospital sounds. Several times during the night, a voice came over the PA system with an announcement. “Code Blue on Floor 3. Code Blue on Floor 3.” I didn’t know what a Code Blue was and I hoped I was not the cause.
At one point during the night, I had to go to the bathroom. I called the technician. She disconnected the small red box (that terminated all of the connectors) from the wall panel, strapped the box over my shoulder and told me I was free to go to the bathroom. When I returned she reconnected the small box to the wall panel.
My sleep continued to be disjointed and eventually at 5:00 AM, I threw in the towel. I tried my best but was unsure whether I generated two hours worth of sleep data. The technician came in, quickly detached all the connectors, whereupon I dressed gathered my things and headed home.

How to Prepare for a Sleep Study

If you are challenged to have a good night’s sleep at home, you will find the experience at a sleep lab to be difficult. You do not want to have to go back and have another test.

To improve your chances of providing two continuous hours of sleep data, I recommend the following:

The most important thing you can do is to reduce the amount of sleep the night before the event. The stronger the urge to sleep (because you are sleep deprived), the better the chance you will give them their two hours of sleep data. I cannot emphasize this enough.
Have a coffee-free the day of the sleep test.
You probably will not know the temperature of the room until you get there. I suggest you bring two pairs of pyjamas, a light pair for warmer ambient temperatures and a heavy pair for cooler sleeping conditions.
Bring warm socks. Just in case.
Your pillow will make the environment more familiar. I suggest you bring your own.

Results From My Sleep Study

Two weeks after my sleep test, my physician called to tell me that they managed to get the data they needed to assess my sleep.

The good news was that my sleep is normal.

The bad news is that my sleep is normal and I know less about why my sleep is fragmented.

I realized that I am as not a disciplined with my sleep as I need to be.

Sleep comes naturally to some people. I am not one of those people and so I need to be a bit more attentive to how much I sleep, when I go to bed, and when I get up.

The Winter protocol showed me that I only need seven hours of sleep. I need to be respectful of that and limit my sleep to what I need so that I reduce the fragmentation of sleep.

Why We Sleep by Matthew Walker

Matthew Walker is a leading expert on sleep. He is a professor of neuroscience and psychology at University of California (Berkeley) and director of its Sleep and Neuroimaging Lab. His book, Why We Sleep, provides new insights (based on the latest scientific research) into the role of sleep, how we have disrupted our sleep, and what we can do (at both the individual and societal level) to get it back to its natural order.

In his book, Dr. walker states that the latest research into sleep has “an unequivocal message: sleep is the single most effective thing we can do to reset our brain and body each day — Mother Nature’s best effort yet at contra-death.” His concern is that this message has not gotten to the public and his book “is intended to serve as a scientifically accurate intervention addressing this unmet need.”

Much of the book covers why sleep matters to our health and well being. This may not be of interest to people who already know that they have poor sleeping patterns and may add to their existing anxiety. However, the book does provide insights into what could be wrong with your sleep and what you should do to fix it. Because it is based on the latest research presented by an expert in the field of sleep and since education is a key component of CBT-I, I recommend that people who want to improve their sleep read Dr. Walker’s book.

In the book’s opening chapter, Walker states that you do not have to read the book in its entirety and should freely read chapters that interest you. I found this to be liberating since his approach to each topic is very accessible.

Why Our Sleep is Dysfunctional

Walker explains that the easy availability of incandescent light, blue light, caffeine, and alcohol and rigid work (and school) schedules has disrupted the gift of sleep — a natural therapeutic that took Mother Nature millions of years to perfect. All of this happened in the last 100 years — the blink of an eye in evolutionary terms. Walker points out that daily sleep duration in the developed, western world has decreased by about 25% since 1930 — from about 8 hours a day to 6.5 hours.

Sleep, The Circadian Rhythm and Adenosine

Walker does a wonderful job describing the relationship between our circadian rhythm (our internal clock that orchestrates many of our biological activities, including wakefulness) and adenosine levels in the brain (the chemical that creates sleepiness). These two systems are independent and play a critical role in when we sleep. When the relationship between the two systems gets out-of-whack, the outcome is a dysfunctional sleep pattern.

For more on circadian rhythm, I encourage you to read the review of The Circadian Code later in this article.

Are You Getting Enough Sleep?

There are more than a hundred undiagnosed sleep disorders. The most common is insomnia. This is followed by sleep disordered breathing (sleep apnea).

Dr. Walker states that a clinical sleep assessment is the correct way to determine if you are getting enough sleep, the probate cause and best solution. He recommends that if you suspect that you or a loved one has a sleep disorder, that you consult your physician and request a sleep assessment.

However, in the absence of this tool, he does provide some rough guidelines that can help you answer this question. If either of the following are true, you are likely not getting adequate sleep:

You could easily fall asleep at ten or eleven a.m. after a night of sleep.
You need coffee before noon to function optimally.

In addition, Dr. Walker provides another resource, a questionnaire called SATED developed by the American Academy of Sleep Medicine (AASM), that you can use to evaluate your sleep. I have included it here.

Insomnia

Dr. Walker devotes a chapter to sleep disorders. I will not cover all of these in this post. Instead, I’ll quickly cover the key points on insomnia.

As I mentioned earlier, insomnia is the most common sleep disorder. There are two types of insomnia. Onset insomnia refers to difficulty falling asleep. Maintenance insomnia refers to difficulty staying asleep. Some unfortunate individuals suffer both conditions. Dr. Walker notes the diagnosis of insomnia as:

Dissatisfaction with either quantity or quality of sleep.
Daytime impairment.
Three nights each week of insomnia for a period of three months.
Absence of co-existing mental disorders or medical conditions that could be causing sleep disruption.

These are not meant to encourage self diagnosis but act as a signpost indicating insomnia. You should consult a sleep professional if you suspect you have insomnia.

Five Things That Could be Stopping You From Having a Good Night’s Sleep

A number of variable can affect (and disrupt) your sleep. Broadly, sleep hygiene and your attitude towards your sleep have considerable impact on the amount and quality of sleep. Sleep therapy is designed to address these two forces. Besides these two categories, Dr. Walker discusses five things he believes have a detrimental affect on sleep.

Caffeine

Dr. Walker devotes a lot of time to how caffeine disrupts our sleep. He describes how the daily buildup of a chemical in the brain, adenosine, creates “sleep pressure” – the desire to sleep. Caffeine mutes adenosine and makes us feel more awake and alert. It competes with adenosine for access to receptors in the brain that trigger sleepiness. While it occupies the receptors, the desire to sleep diminishes.

Caffeine has a half life of five to seven hours. Half life refers to the time it takes the body to remove 50% of a chemical’s concentration. Dr. Walker uses the following example to illustrate caffeine at work. Say you have a cup of coffee at 7:30 pm — after evening dinner. Fifty percent of that caffeine dose is still in your brain and blocking sleep receptors at 1:30 am. That concentration can be enough to disrupt your sleep. Further, it takes another 7 hours to remove 50% of that 50% concentration. In other words, you will wake up with 25% of the caffeine you consumed after dinner last evening still in your system and actively suppressing adenosine.

Some people are more effective at “burning off” the caffeine dose than others. You might or might not be one of those. Regardless, if you have sleeping problems and you are a consumer of caffeine, you should consider only drinking a small amount first thing in the morning or eliminate it altogether.

Caffeine Little Known Facts

Dr. Walker encourages the reader to keep in mind a few more important items related to caffeine.

There are many sources of caffeine including coffee, colas, tea, and some medications.
De-caffeinated does not mean non-caffeinated. It means a reduction in caffeine concentration.
When the caffeine finally wears off, the adenosine (that has been building up during the time the caffeine is active) can cause a “crash” or sudden urge to sleep. This crash could happen at inopportune times like during a meeting, which could be embarrassing, or while driving, which could be fatal.

How Much Caffeine Can You Drink?

If you are a coffee drinker and enjoy the caffeine experience you will probably not like what Dr. Walker says about the relationship between caffeine consumption and quality of deep sleep.

Dr. Walker acknowledges the existence of rapid metabolisers — individuals who are able to quickly process and break down caffeine because of an enzyme. You know someone like that! Rapid metabolisers are less sensitive to caffeine and can sleep after having coffee.

For many people, caffeine is “wake promoter” and can slow the arrival of sleep. For most people, Dr. Walker states that caffeine affects sleep quality — particularly deep sleep. So while you may be able to drink coffee and easily fall asleep, your deep sleep is compromised.

Dr. Walker points to two studies to make his point.

In the first, a standard 180 mg dose of caffeine is given to a group of research subjects in the evening. They fall asleep but the amount and electrical quality of deep sleep is compromised. A 20% reduction in deep sleep quality was experienced by the participants — equivalent to adding 25 years to your age!

In the second study out of Surrey UK, the research team gave participants a standard caffeine dose in the morning (7:20 AM, on average), provided no caffeine during day, and asked the participants to go to bed by 11:00 PM.

The researchers reported that even the early morning only caffeine dose disrupted deep sleep quality — to the effect of a 10 to 12% drop in deep sleep quality.

My Personal Caffeine Experience

Since learning Dr. Walker’s position on coffee consumption and sleep, I decided to eliminate coffee from my day. It was not easy. I love a cup of coffee!

Initially I reduced my coffee intake and limited it to a 7:00 AM dose. But within a few days of stopping completely I noticed that my sleep was much, much better. Maybe Dr. Walker is right, after all.

Modern Light

We can thank Thomas Edison for making modern incandescent light broadly available. Blue light, used by electronic devices including TVs, computers, mobile phones and tablets was developed and introduced in the 1990s. Unfortunately, these artificial light sources have convinced our brains that daylight is around longer than it actually is and that we need to stay awake longer than we need.

The effects of blue light exposure are particularly pernicious in that they stay long after the blue light is turned off. Dr. Walker points to a study where participants were exposed to 90 minutes of iPad usage and the “lingering aftereffect” of the blue light on brain sleepiness was several days.

Alcohol

While some people think that alcohol helps their sleep, it is actually a sedative. It puts you out but does not put you to sleep. That is why you feel groggy even though you “slept” through the night. Further, alcohol consumption has a detrimental affect on REM sleep which plays an important role in memory formation.

Dr. Walker’s advice is if you want to sleep soundly, eliminate alcohol altogether from your life. Sorry!

Ambient Temperature

Your circadian rhythm triggers a number of changes in your body throughout the day. One of these changes is the lowering of your core temperature as the day comes to end. This is a signal to the body that sleep is coming soon. As a result, your best sleep occurs when the ambient temperature is cool since this is conducive to keeping the core body temperature low.

This is something that we have had for many many years. Our long-ago ancestors lived in environments that had warm days and cool nights. Our resettlement in different parts of the planet and the introduction of innovations like central heating have potentially disrupted this ancient pattern.

Alarms, Wake Up Calls and Other Disturbances

Dr. Walker points out that we are the only “species that demonstrates an unnatural act of prematurely and artificially terminating sleep.”

The standardization of work times during the industrial revolution caused us to start our days with alarms, whistles and loud bells. Dr. Walker points out that a sudden, unexpected wake up “spikes our blood pressure” and accelerates the heart. Neither of these is good for our health. While sudden sleep termination might not the source of your dysfunctional sleep, it is certainly not good for your overall health and well being.

While a regular wake up time is seen as part of good sleep hygiene, sudden and artificial sleep interruptions should be avoided. Try to wake up at the same time each morning without an alarm clock.

Fixing Your Sleep: Medication or Therapy

Dr. Walker is no fan of sleeping medication. Repeated use can affect mortality rates and withdrawal leads to a rebound effect. He would like to see sleep medications that aid sleep but, to date, none exist.

The scientific evidence, on the other hand, supports therapy as the path to fixing sleep, specifically Cognitive Behaviour Therapy for Insomnia (CBT-I).

I’ll let Dr. Walker present the case in his own words. “So powerful is the evidence favouring CBT-I over sleeping pills for improved sleep … and so limited or nonexistent the safety risks associated with CBT-I that in 2016, the American College of Physicians made a landmark recommendation.”

This recommendation was based on an extensive study presented in the Annals of Internal Medicine. The study results stated clearly to physicians that “CBT-I must be used as the first line of treatment for all individuals with chronic insomnia, not sleeping pills.”

Conclusion to Why We Sleep

While much of Dr. Walker’s book is devoted to understanding the role of sleep and he delves into the societal issues associated with the sleep epidemic, I still believe the average sleep sufferer will benefit from this book. His explanation of how sleep works is well worth the read and will help you understand and manage your sleep problems.

Dr. Walker’s book is not only a significant contribution to our understanding of sleep and why we sleep, it has stimulated much-needed and overdue dialogue and lead to a mindset change with how we, as a society, see sleep. In fact, Bill Gates recommends Why We Sleep on his Gates Notes website.

Where to Purchase

You can purchase Why We Sleep on Amazon. Please note I receive small commission from Amazon if you purchase the book.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

The Effortless Sleep Method by Sasha Stephens

Sasha Stephens’ book, The Effortless Sleep Method, is more of a prescription to better sleep from someone who was a chronic poor sleeper than the deep dive into sleep that Dr. Walker and Dr .Winters do in their books.

Ms. Stephens argues that sleep medications and sleep restriction therapy (SRT) are not effective because they are a crutch that inhibit the person with chronic dysfunctional sleep from getting control over their sleep.

She sees drugs as very problematic. First they are sedative and do not induce natural sleep. Second, the sleep hangover (or groggy state) that they cause coupled with sleep deprivation, create misery for their user. Third, they have a terrible rebound effect so that when the patient stops using them, the insomnia returns in a worse form than before.

Twelve Promises to Yourself

She believes that SRT is too difficult for people to follow and, as a result, most people fail. Instead Ms. Stephens recommends that people follow her program (or method) that includes twelve promises. These promises are evenly split between sleep hygiene and belief modification.

While I generally agree with her recommendations (probably because they resemble the techniques used in CBT-I), I don’t agree that SRT is perceived as a crutch by the practitioner. I agree that it is hard to complete SRT until it resets your internal sleep mechanism. However, if you practice SRT while following a strict sleep hygiene, you improve your overall chance of achieving your goal: better sleep.

If you are unable to access a qualified sleep therapist, I recommend the book solely because it does provide a clear step-by-step framework to improving your sleep. Her book was written in 2010 and is not as up-to-date or research-based as the The Sleep Solution or Why We Sleep. As a result, I would take her prescription and add some of the points made by Winters and Walker, specifically those associated with alcohol, caffeine and modern light.

Where to Purchase

You can purchase The Effortless Sleep Method on Amazon in paperback. Please note I receive small commission from Amazon if you purchase the book.

The Circadian Code

Your sleeping problems (as well as your weight and other health issues) could be caused by an out-of-rhythm circadian rhythm. In his book, The Circadian Code, Satchin Panda, PhD discusses the latest research on circadian rhythm, presents a number of surprising facts about it, and identifies ways you can get your circadian groove back to where it should be.

Dr. Panda is a leading researcher on circadian cycles and has unearthed many of the major findings regarding our circadian rhythm. He is well versed on the topic. For example, Dr. Panda was one of the researchers who discovered melanopsin — the light-sensing protein in the eye that calibrates the sleep-wake cycle from the presence of light.

While the other books presented in this post specifically address sleep and how to fix dysfunctional sleep, this book aims wider. It looks at your circadian cycle and how it affects your sleep, your weight, and your overall well being. If you want a deeper understanding of your health, I encourage you to read Dr. Panda’s book.

What is the Circadian Rhythm?

Wikipedia provides a good definition of the circadian rhythm.

“The term circadian comes from the Latin circa, meaning ‘around’ (or ‘approximately’), and diēm, meaning ‘day’. A circadian rhythm is a roughly 24 hour cycle in the physiological processes of living beings, including plants, animals, fungi and cyanobacteria.

In a strict sense, circadian rhythms are endogenously generated, although they can be modulated by external cues such as sunlight and temperature.

Circadian rhythms are important in determining the sleeping and feeding patterns of all animals, including human beings.

There are clear patterns of brain wave activity, hormone production, cell regeneration and other biological activities linked to this daily cycle.”

Dr. Panda points out in his definition that the circadian rhythm “optimizes biological functions. Every function in the body has a specific time because the body cannot accomplish all it needs to do at once.” In other words, biological functions are spread out throughout the 24 hours of the day.

Why Your Circadian Rhythm Matters

Dr. Panda opens his book with a statement: “To have rhythm, to be in sync, is to be healthy. But not just any rhythm will do.”

With this, Dr. Panda spends the remainder of the book explaining how your circadian rhythm should work and how to get it back in sync. Your circadian rhythm is the clock that sets and modulates the tone of your life and well being. Every organ, every physical activity, and every bodily function is set by your circadian rhythm. If these are out of sync, then your overall health and well-being are compromised.

In his book, Dr. Panda provides excellent resources to help you determine if your circadian rhythm is off and how to correct it.

We Are All Shift Workers

Dr. Panda provides a number of interesting insights into the circadian rhythm. The first is that all (or at least most) of us are, one way or another, shift workers.

As you likely know, shift workers work through the night and try to sleep during the day. This runs counter to the natural rhythm of our circadian clock. With that aberration, comes health problem such as early dementia, heart attacks, weight gain, and diabetes.

Dr. Panda suggests that the advent of several modern phenomenon that shift and disrupt our circadian clock make all of us, to a degree, shift workers. Examples he provides are life style changes like long work hours, jet lag from travel, and season time changes that shorten our days.

How the Circadian Rhythm Works

Dr, Panda indicates that every organism (including humans) spends its 24 hour day getting food, protecting itself, repairing itself, reproducing.

All of bodily functions are dictated by the circadian rhythm. The circadian rhythm is influenced by the lifecycle of each day. As the day becomes night, the circadian clocks in our body respond accordingly.

Dr. Panda points out that every organ has a circadian clock operating in its own time zone, activated by different stimuli.

The master circadian clock is the suprachiasmatic nucleus (SCN) in the brain (mentioned in the book by Dr. Winters). SCN is the “link between light and timing because is receives information about light from the outside world and shares it with the rest of the body.”

There are three core rhythms that influence our circadian code: sleeping, eating, and physical activity. If these are out-of-whack, so is our circadian rhythm.

When You Do Things Matters

One of the most important insights Dr. Panda makes in the book is that “when” you do things associated with sleeping, eating, and physical activity matters as much as “what” you do. This is because the “when” affects the timing of the circadian clock.

Dr, Panda wants you to “focus not so much on the what of a healthy lifestyle but on the when. A healthy lifestyle includes what and when you eat, when and how much you sleep, and when and how often you move.”

The events you should monitor are:

When and how you wake up.
The time you take your first bite or sip of the day.
End of your last meal or drink.
When you go to sleep.
What time you shut off all screens.
What time you exercise.

Sleep and The Circadian Rhythm

Dr. Panda points out that the combination of timing, light and food affect your sleep. He pays particular attention to the affects of light on our circadian pattern and sleep. Blue light is fine during the day, but will cause problems during the evening. As we age, our circadian rhythm weakens, so those of us of advanced age should be careful and avoid our iPhones, iPads, TVs, and high temperature lights after 6:00 PM.

Eating and the Circadian Rhythm

While light affects the circadian rhythm timing in the brain, eating affects the circadian rhythm timing in other organs. Dr. Panda states that “eating the same time every day is one of the most powerful ways to maintain a strong circadian rhythm. This is true for breakfast and dinner especially. Between these two meals, it’s less important to focus on when you eat and more important to focus on eating foods that support a healthy brain.”

Dr. Panda promotes the practice of Time Restricted Eating (TRE). His research shows that the body does not want to process food at night and instead use that time to repair and rejuvenate the body.

Time Restricted Eating (TRE) involves restricting your eating to a specific time period during the day. The optimal eating window, he points out, is between 8 and 12 hours.

Exercise and the Circadian Rhythm

Dr. Panda recommends “exercise for everyone and those with sleep disorders might find that it has a strong influence on their circadian code … They will go to sleep more quickly and wake up less often.”

Circadian Rhythm and Bone Health

Readers of this blog will be interested to know that the circadian rhythm has a direct influence on bone heath and osteoporosis. Here is a summary several key developments.

Insights into the Role of Circadian Rhythms in Bone Metabolism

In a study publish in 2018 in BioMed Research International, Chao Song and others state “disruption of the circadian clock due to shift work, sleep restriction, or clock gene knockout is associated with osteoporosis or other abnormal bone metabolism, showing the importance of the circadian clock system for maintaining homeostasis of bone metabolism.” (3)

The authors’ make the following conclusions:

Bones are organs under dynamic regulation of osteoblasts, osteoclasts, osteocytes, and bone lining cells. Disruption of the balance between these cells leads to diseases such as osteoporosis.
Increasing evidence demonstrates that the circadian clock systems, including the master pacemaker and peripheral circadian machinery, play pivotal roles in maintaining homeostasis of bone metabolism.
Circadian disruption due to sleep restriction, shift work, fasting, or knockout of clock genes results in disrupted homeostasis of bone metabolism.
[There is] evidence that the circadian system may be a promising target of clinical intervention for abnormal bone metabolism.

Dr. Panda’s Position on Circadian Rhythm and Osteoporosis

I’ll let Dr. Panda explain the relationship between bone health and circadian rhythm in his words.

“With regular wear and tear, bones go through a daily repair process. Our bones are made of minerals, including calcium, that are secreted by cells. Another type of bone cell eats up damaged bone; the circadian clocks in these cells are synchronized so that bone eating and bone making do not occur at the same time of day.

The balance between these two cell types is important. Too much bone eater cell activity can lead to bone loss, while too much bone making can push against the other bones and create additional damage near joints.

As we age or when our lifestyle is erratic, our circadian clock gets weaker. When this happens, the bone-making cells are not fully activated every day, so they don’t produce enough raw materials for making new bone. Similarly, the bone-eating cells are not fully activated, so they don’t clear all the damaged bone material completely. This ultimately leads to weaker bones that are prone to fracture. To maintain the healthiest bones, we need to have a strong sleep-wake cycle, eat at the right times, and exercise.”

Conclusion to The Circadian Code

The current research indicates that there are substantial benefits, including bone health, to getting your circadian rhythm in good operating form. While the researchers know the benefits, there is still work to be done on how to get one’s rhythm back.

If you are dissatisfied with your sleep and you are concerned about your bone health, you should consider how well you are managing your circadian cycle. Are you respecting your natural time and pace? To learn more, I encourage you to read Dr. Panda’s book.

Where to Purchase

You can purchase The Circadian Code on Amazon in paperback. Please note I receive small commission from Amazon if you purchase the book.

Best Sleep Training Books Summary

If your sleep is broken you should fix it. The health benefits are considerable. My conclusion after reading these sleep training books is that changing your nightly sleep from dysfunctional to natural is essential to your well being and should be a priority.

I also learned that sleep is something we were given and is, by default, a natural occurring daily event. Daily habits disrupt that natural cycle. Thoughts and anxieties about our sleep only make a difficult situation worse.

To fix our sleep, we will likely have to change our mindset and established patterns that disrupt our sleep. For example, the brain is an association machine and if we regularly read in bed, then our brain will associate our bed with reading time and diminish its association with the sleeping event. As a result, we should restrict our time in bed to sleep only and not any other activity (sex is the exception to this rule.)

Steps to Fix Your Sleep

Here is a quick summary of how to fix your sleep from the sleep training books reviewed in this article:

If you think you have a sleep problem, consult with your physician and request a sleep assessment.
Sleep medications do not work. They make a bad situation worse because of the grogginess they cause and the rebound effect when you withdraw the medication.
Cognitive Behaviour Therapy for Insomnia (CBT-I) is the route to better sleep. It requires that you:
1. Understand your sleep.
2. Eliminate bad sleep habits.
3. Follow proper sleep hygiene rules.
4. Reduce your anxiety towards your sleep.
5. Follow the sleep restriction therapy (SRT) protocol for a period of time to reset your internal clock and calibrate how much sleep you really need.

The challenge for most of us is finding the right resources, support and guidance to fix problem and not fall off the wagon. These sleep training books are a great start and, depending on your commitment and motivation, might be your path to great sleep. The rest of us should find a trained sleep professional who can lead us to the joy of a regular good night’s sleep.

References

Ochs-Balcom et al. Short Sleep Is Associated With Low Bone Mineral Density and Osteoporosis in the Women’s Health Initiative. Journal of Bone and Mineral Density. 06 November 2019.
Aspelund, et al. A dural lymphatic vascular system that drains brain interstitial fluid and macromolecules. Journal of Experimental Medicine, 29 June 2015. 212(7): 991
Choa Song, et al. Insights into the Role of Circadian Rhythms in Bone Metabolism: A Promising Intervention Target? BioMed Res Int. 2018. Published online 2018 Sep 27. doi: 10.1155/2018/9156478

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The post The Sleep Solution appeared first on MelioGuide.

Ten Osteoporosis Exercises to Avoid

Margaret Martin — Wed, 25 Oct 2017 19:00:49 +0000

This article identifies ten osteoporosis exercises to avoid. (The term “osteoporosis exercise contraindications” is the medical term for “osteoporosis exercise to avoid”). In addition to these osteoporosis exercise precautions, I cover several yoga and Pilates exercises to avoid if you have osteoporosis.

Introduction to Osteoporosis Exercises to Avoid

Research and clinical studies show that flexion of the osteoporotic spine, especially in situations where force is applied, can lead to compression fractures of the vertebrae. Unfortunately, this scientific fact is not well known within the fitness community and, as a result, there are Personal Trainers (and some medical professionals!) encouraging exercises (like traditional crunches) that cause flexion and potentially put you at risk of a compression fracture.

Ten Osteoporosis Exercises to Avoid

The following are ten osteoporosis exercises to avoid:

Crunches
Chest Fly
Chest Press
Knee Extensions
Lat Pulldown (behind the head)
Seated Rows
Toe Touch with a Twist (Rotation)
Hamstring Stretches
Back Stretches
Cardiovascular Exercises that encourage flexion

Each of these is described in detail in the section below.

Unfortunately, many fitness professionals do not know how to modify exercises programs for people with osteoporosis. It is up to you to take care of your bone health and either avoid the exercise or ask your Personal Trainer make appropriate modifications.

The book Exercise for Better Bones has a comprehensive list of osteoporosis exercises to avoid (or modify) with accompanying descriptions and photo illustrations. It also has (and this is important) exercises you should do if you have osteoporosis based on your activity level and risk of fracture. Consider sharing your copy with your Personal Trainer or encourage them to purchase their own.

Osteoporosis Exercise Contraindications

Clients with osteoporosis come to my clinic for a bone-friendly exercise program. These clients find that some Personal Trainers do not adequately considered their bone health when assigning them an exercise program. In fact, some of the exercises increase their risk of a fracture!

Flexion, Rotation, Osteoporosis and Exercise Contraindications

People with osteoporosis, osteopenia and low bone density should avoid movements and exercises with flexion and the combination of flexion and rotation (twist). Many of the osteoporosis exercises to avoid, covered in this blog, encourage either flexion or rotation (or, in some cases, both movements).

Many of these exercises have been with us for years. You have probably done a number of them in your past (hopefully for the last time!). You may be surprised by some of the exercises I am asking you not to do.

Let’s start with the most popular of exercises: the traditional crunch or sit-up – used by many people to build their abs.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Osteoporosis Exercises Not To Do

The following is a detailed description of the exercises you should not do if you have osteoporosis, osteopenia or low bone density.

1. Crunches

Traditional “crunches” (also known as sit-ups) are popular with most exercise programs for development and strengthening of the abdominal muscles. There are many variations of the crunch. The illustrations to the right demonstrate two of the many variations.

Due to the risk associated with vertebral fractures, this exercise is not advised for people with low bone density, osteopenia or osteoporosis. The crunch is one of a number of osteoporosis exercises to avoid.

There are many other exercises you can do to strengthen your abdominal muscles that are safe and do not place your spine at risk. These are covered in the Strength Exercises section of the Exercise for Better Bones program. This blog post lists several safer Abdominal Exercises for Osteoporosis.

You can also refer to my book, Strengthen Your Core, available in both Kindle and print formats, for a complete and safe program to strengthen your core.

2. Chest Fly

When using gym equipment, most women have to adjust their body position to accommodate the machines. The Chest Fly machine may cause undue stress on the vertebrae, possibly risking a compression fracture for people diagnosed with osteoporosis. I recommend you approach this exercise with caution.

3. Chest Press

When using gym equipment, this exercise (like its sister exercise, the Chest Fly) causes undue stress on the vertebrae, possibly risking a compression fracture for people with low bone density or osteoporosis.

I recommend that you avoid this piece of gym equipment altogether unless you can keep your spine in perfect postural alignment.

4. Knee Extensions

This exercise encourages a “slouched” posture, potentially risking a fracture of the vertebrae for people with osteoporosis.

If you are able to perform this exercise without the forward lean (the slouch position), then you should be okay with the exercise.

In my experience, most individuals find it difficult to maintain their posture while repeatedly doing this exercise and, over time, they gravitate back to the slouch position.

5. Lat Pull Down (Behind the Head)

Doing a lat pull down behind your head, as illustrated in the photo on the right, places excess stress on your shoulders, neck, and spine. I strongly advise that you do not do this exercise this way as it can cause a number of problems including shoulder pain. The lat pull down behind the head is one of a number of osteoporosis exercise contraindications.

A lat pull down, when done correctly, is an excellent exercise. The following are some simple instructions to follow for good “lat pull down” form.

The bar should be pulled down in front of you, just below your chin.
You should keep your breastbone high.
Tuck your shoulder blades towards your pockets on the back of your pants as your elbows descend.

6. Seated Rows

This exercise, when done incorrectly, encourages a “slouched” posture, potentially risking a fracture to the vertebrae for people with osteoporosis. This slouch position is illustrated in the photo. Note the curvature of the upper back caused by the model leaning forward to follow the cord. This position should to be avoided.

This exercise can be performed safely when the person assumes a better posture – as illustrated in the picture. Note that the model has kept her posture straight and aligned. There is no forward lean or slouch.

The challenge for most people will be to maintain a straight posture when they pull, pick up, and return the pulley to the rack. If you decide that this an exercise you want to keep in your routine, make sure that you maintain your posture throughout the execution of this exercise.

7. Toe Touch With A Twist

The toe touch with a twist is often the staple flexibility exercise in many Personal Training routines. The problem with this exercise is that it encourages a twist and bend in the spine, potentially risking a fracture to the vertebrae for people with osteoporosis.

This exercise is high up on the list of osteoporosis exercises to avoid because it combines both flexion and rotation. For most people, this exercise is best avoided altogether.

In this blog post on the hip hinge and standing forward bend, I explain why this movement is problematic. However, for those of you who insist on doing this exercise, I explain one way that you can safely modify the forward bend.

8. Hamstring Stretches

This stretch (and its variations) encourages flexion, potentially risking vertebral fracture for people diagnosed with osteoporosis. It is one of the more “popular” osteoporosis exercises to avoid.

The two photos illustrate common variations of this exercise.

The traditional hamstring stretch is frequently used to increase flexibility. Note that in the demonstrations, the model has a curvature of the back caused by the forward lean. This curvature or flexion needs to be avoided by people with low bone density and osteoporosis and is one of those osteoporosis exercises to avoid.

In the Flexibility section of the Exercise for Better Bones program, there are excellent and very effective hamstring stretches that do not put your spine at risk. Read this post on How to Stretch Your Hamstrings to learn safer and more effective ways to get flexible hamstrings.

I suggest you avoid the traditional hamstring stretch demonstrated on this page and instead use the exercises in the Flexibility section of the Exercise for Better Bones program.

The traditional hamstring stretch is one of a number of osteoporosis exercise contraindications and is one of those exercises to avoid with osteoporosis.

9. Back Stretches

This back stretch exercise position, illustrated in the photo, encourages flexion of the spine with a lot of loading – potentially risking vertebrae fracture for people with osteoporosis.

Since there are no modifications that can be made to this exercise to address its shortcomings, the exercise is best avoided. The back stretch is one of a number of osteoporosis exercise contraindications and is one of those osteoporosis exercises to avoid.

10. Osteoporosis and Cardiovascular Exercise Considerations

Good posture is important to maintain throughout your cardio routine. Osteoporosis exercise contraindications can happen while you perform weight bearing exercises.

Remember maintain proper posture and avoid positions that cause flexion of the spine while doing your cardiovascular (or weight bearing) exercises.

In the photo above, the model is deliberately slouching forward as she is using the cycling machine. She should change her seat position so that she maintains postural alignment while using the machine.

Exercise Machines to Avoid with Osteoporosis

I encourage you read my blog post on modifications for gym exercises. You can also look at the video below:

Osteoporosis Physical Therapy Contraindications

I frequently encounter very motivated people who, without the guidance of a trained professional, select exercises that increase their risk of fracture instead of decreasing the risk.

For example, I recently had two male clients who had been diagnosed with osteoporosis in the last year. Both of these motivated and well-intentioned men started exercise programs because of the diagnosis.

Unfortunately, the self-prescribed exercise programs they were following increased their fracture risk! Some of the well intentioned, but potentially dangerous, exercise choices that these gentlemen made were:

Gym machines that encourage flexion.

This was especially true with the use of the preacher curl bench. This device forces your upper back into a rounded (or flexed) posture. At most gyms, this bench is the starting point for both the bicep curl and the tricep extension. The preacher curl bench forces you into a slouched position – a posture that is associated with increased compression fractures of the spine.

Crunches.

I strongly advise people with low bone density not to do this exercise because it places the subject in a flexed position. Crunches are frequently done either on a mat or on a machine and neither of these variations is safe. This exercise is frequently used by people to build abdominal strength. The MelioGuide Exercise for Better Bones Program has safer alternative exercises that build strength appropriate for people with low bone density.

Standing and seated hamstring stretches.

This is another popular exercise used during the flexibility phase of an exercise program. The major problem with the exercise is that it encourages flexion. This is one I suggest you avoid. Instead the MelioGuide Exercise for Better Bones Program has many safe alternative exercises for flexibility.

Bench press on a bench.

The problem with this exercise is that it is virtually impossible to safely get on and off a bench without flexing your spine. The situation is even more challenging when you perform the dumbbell bench press. The dumbbell bench requires that you hold two heavy weights as you get onto the bench. The same exercise on the floor would allow you to roll down through your side and avoid the flexed position. The MelioGuide Exercise for Better Bones Program includes a list of exercise safety tips to help you perform your exercise program in a safe fashion.

Elliptical machine for cardio.

The elliptical machine creates no ground force and, as a result, is does not challenge your joints and bones enough to stimulate bone building.

It also encourages flexion of the spine when performed improperly. Note in the picture that the client is having to slouch or flex forward to reach the handles.

There are many cardiovascular exercises that are safer alternatives to the elliptical. In the MelioGuide Exercise for Better Bones Program, I suggest a variety of safe cardio activities based on your activity level and fracture risk.

Recommended Modifications to Their Exercise Programs

After consulting with the two gentlemen, I made the following modifications to their exercise programs to make them more effective and safe for someone with osteoporosis. If you are following a program similar to their program and have low bone density, osteopenia or osteoporosis, you should consider these modifications as well.

Incorporate more free weights into your routine.

This allows a more functional type of lift. You are working the main muscle but also all the smaller supportive musculature. The added bonus that free weights deliver, when done with good posture, is that they allow your deep spinal muscles to kick in and help you build stronger bones in your spine (vertebra).

Focus on strengthening the transverse abdominus.

Other than martial artists, and competitive tennis, soccer and volleyball players, few recreational athletes need to develop their rectus abdominus. The rectus abdominus is the muscle strengthened by crunches.

Your focus when it comes to abdominal strengthening should be on the transverse abdominus. This muscle is your built in corset. It wraps around your torso and attaches into the fascia that is directly connected to your spine. Training your transverse abdominus will not only eliminate the potentially dangerous crunches from your program but it will also reduce dangerous torques and shearing forces that place your spine at risk.

Eliminate stretches that place you in a flexed position.

Lying flat on your back to stretch your hamstrings will reduce your tendency of bending forward at the spine to touch your toes.

Modify your bench press position.

Executing a bench press from the floor allows you to roll down and back up in a safer manner. With guidance, the use of a burst resistant ball also allows you to execute a bench press with safer ascent and decent. Replacing a bench press with a push up has the added benefit of increased loading through your wrists.

Select a safer cardio alternative.

Both men would benefit more from brisk walking either outdoors on the sidewalk or trail. When the inclement weather sets in, they could use the treadmill.

Exercise Recommendations for Osteoporosis

Exercise is an essential ingredient to bone health. If you have osteoporosis, therapeutic exercise needs to be part of your osteoporosis treatment program.

I cover important topics related to osteoporosis exercise including:

Can exercise reverse osteoporosis?
Stop the stoop — how to avoid kyphosis and rounded shoulders.
Key components of an osteoporosis exercise program.
Key principles of bone building.
Exercises you should avoid if you have osteoporosis.
Yoga and osteoporosis — should you practice yoga if you have osteoporosis?
Core strength and osteoporosis — why is core strength important if you have osteoporosis?

Pilates and Osteoporosis Exercise Precautions

Individuals with osteoporosis need to practice caution when doing certain Pilates poses and exercises. Before starting a Pilates program with a new student, a qualified Pilates instructor should gather important information about the student’s physical condition and health—including if the student has, or is at risk of, low bone density or osteoporosis.

If your instructor is not aware of your condition, then you should alert him or her and inquire about appropriate modifications before starting a Pilates program or session.

As a general rule, students should modify their Pilates programs as they progress in age. For the student with low bone density or osteoporosis, it is critical that the student and teacher monitor the student’s spinal alignment to reduce the risk of vertebral fracture.

Forward bends of all kinds should involve flexion of the hip only. Students need to maintain a normal curvature of the spine throughout the pose. Bending at the hips, rather than at any point in the spine, is essential. Pilates instructors need to be aware of the risks to clients with low bone density of forward bends that involve spinal flexion. Modify or eliminate poses that cause negative stresses on the spine.

Certain Pilates poses can increase the risk of vertebral fracture for people with low bone density or osteoporosis. Pilates poses that involve forward flexion of the spine need to be modified or avoided. Avoid or modify these Pilates poses for clients with osteoporosis:

Hundred
Side Bend Exercise or Spinal rotation
Roll up
Spine twist

Yoga Osteoporosis Exercises to Avoid

Certain exercises, including some yoga and Pilates poses, can cause strain on the vertebrae of a person with osteoporosis — to the point where the risk of a compression fracture is quite high. As a result, certain yoga and Pilates poses need to be modified or avoided for people with osteoporosis.

My book, Yoga for Better Bones, is about yoga exercises for osteoporosis and specifically identifies osteoporosis exercise contraindications and poses that should be modified or avoided for people with osteoporosis.

Exercise for Better Bones

I am sure that you have done some of these osteoporosis exercises to avoid at one point in your life. Time to move onto an exercise program that builds bone strength and reduces the risk of fracture.

In Exercise for Better Bones I cover, in detail osteoporosis physical therapy contraindications exercises as well as exercises you should do to that are safe and effective for your activity level and fracture risk.

I encourage you to embark on your Exercise for Better Bones program!

Margaret Martin

Meditation Studio App and Buddhify Meditation App Reviews

Richard Martin — Wed, 12 Apr 2017 17:33:16 +0000

I recently committed to make daily meditation part of my health routine. I decided to achieve this goal with a mindfulness meditation app on my iPhone. Here are the Meditation Studio App and Buddhify Meditation App reviews to help you choose the app that is best for you. Each app has its own advantages and disadvantages.

Like many people today, I use my iPhone to read news, keep in contact with family and friends, and record personal information (including health data). With so many mindfulness meditation apps to choose from in the App Store, the challenge was to find one or two mindful meditation apps that met my needs.

My Mindfulness Meditation App Journey

Like many of us, I get restless at times and I want to have more control over my response to stress. After a busy day, my mind frequently races at night and I have a hard time settling down to sleep.

I use each mindful meditation app, described later in this blog, first thing each morning before I start my day. Within a week or so of using these meditation apps on a daily basis, I found that I have a better sense of calm, am more mindful in stressful situations, and can settle my active mind so that I can settle into a good night of sleep.

The two meditation apps I chose are well worth the modest amount I spent. I encourage you to give them a try.

[Note to readers: This blog post reflects my personal journey with meditation and meditation apps and is not representative of large scale studies. A reader pointed out via an email to me and in the comments below that the scientific literature encourages people who want to practice meditation “should be prescribed and monitored by professionals who have expertise in this field because adverse reactions (such as depression, psychotic events, and suicidal thought) can and do occur.” If you are planning on pursuing meditation, the prudent path is to consult with a qualified professional. Updated: June 26, 2018]

Seven Rules on Choosing a Meditation App

I set down seven rules before I chose my meditation app. Here they are:

I was willing to pay an upfront cost to purchase the app to avoid in-app purchase advertisements.
I was unwilling to sign up for a monthly subscription service. This eliminated two of the very popular meditation apps: Headspace and Calm.
I wanted the app to have some instruction on how to meditate.
I wanted more than a meditation sleep app. The app needed to have a library of meditations covering a range of topics including meditation for sleep, mindfulness, stress management, and other topics.
The app needed to present meditation in a secular fashion. I did not want any spiritual or religious content or agenda.
I wanted the app to log my meditation history, preferably in the built-in Apple Health app in my iPhone.
The app needed to run on my iPhone but I also looked for apps that worked on Google Android devices because many of our readers on this blog use Android.

[Note to readers: When I first wrote this blog post, Meditation Studio was available on the Apple App Store for a fixed, one time cost. Unfortunately, the Meditation Studio app has switched to a subscription only model. Is the Meditation Studio app worth the subscription? I think it is still a very good app but I would opt for Buddhify as long as Buddhify keeps its option for a single upfront charge and does not restrict it’s offering to subscription only. Updated: June 26, 2018]

Some Learnings on Mindful Meditation

I settled on two iPhone meditation apps that met my needs. Before I describe the two apps, here are some of my general observations about meditation:

Meditation is a way for us to familiarize ourselves with our mind and cultivate our mental and emotional abilities to meet life, and its challenges, head on.
Meditation has many benefits, including:
1. Gaining a healthy perspective
2. Strengthening the immune system
3. Developing resilience
4. Enhancing emotional and cognitive skills
Meditation, as one of the instructors in the Meditation Studio app said, is “not to do but to be”. In other words, it is not a task you have to do each day but is something that you experience daily — hopefully several times throughout each day.

Meditation Studio App and Buddhify Meditation App Reviews

I started my learning experience with the Meditation Studio mindfulness meditation app. Over 30 meditation instructors contributed content to the mindfulness meditation app. The app has three main courses (Meditation Essentials, Uncovering Happiness, and Changing Habits).

It also has a wide range of meditation collections touching on different topics and themes including sleep, stress management, change, anxiety, pain and more.

Meditation Studio mindfulness meditation app integrates with your built-in Health app in your iPhone and, should you decide to, updates your health calendar each time you complete a meditation.

The design is clean and easy to navigate and the instructors are excellent. This app is highly recommended and I suggest you, like me, start your meditation journey with this app.

Meditation Studio is available for both iOS (iPhone and iPad) and Android. ~~There is a small fee to purchase this app~~ and the app creators offer a subscription service to access value-added services.

[Note to readers: When I first wrote this blog post, Meditation Studio was available on the Apple App Store for a fixed, one time cost. Unfortunately, the Meditation Studio app has switched to a subscription only model. Is the Meditation Studio app worth the subscription? I think it is still a very good app but would opt for Buddhify as long as Buddhify keeps its option for a single upfront charge and does not restrict it’s offering to subscription only. Updated: June 26, 2018]

Buddhify Meditation App

Despite its name, Buddihfy is not associated with Buddha and is free of any spiritual or religious content.

Buddihfy mindfulness meditation app uses an intuitive approach (with a creative and beautiful navigation wheel) to explore its meditation themes. Once you select a theme you want, you choose a specific meditation session.

Its meditation themes cover a wide range of topics from being online, work breaks, difficult emotions, feeling stressed, can’t sleep, walking in the city, and many other common situations.

There are more than 80 tracks to explore, so you should find something that meet your needs at anytime.

Buddihfy is available for both iOS (iPhone and iPad) and Android. There is a small fee to purchase this app and the Buddhify creators offer a subscription service to access value-added services.

Meditation Exercise Without an iPhone Meditation App

Maybe you are not ready to pursue meditation through a smartphone app.

After all, people have been meditating since the beginning of time without the help of Apps.
If you have not explored left nostril breathing, give this stress-relieving meditation exercise a try.

There is a belief that our sympathetic nervous system — responsible for the fight or flight mechanism — is stimulated by breathing through our right nostril. Conversely, our parasympathetic system — responsible for the rest and digest response — is stimulated by breathing through our left nostril.

We can maintain our emotional balance by ensuring that we breathe through the left nostril when we are stressed. Give this a try when you are feeling a bit anxious:

Cover your right nostril
Inhale through your left nostril as you count to five
Hold at the top of the breath for a count of five
Exhale through the left nostril (keeping the right covered) for a count of five

Repeat this cycle five times. This helps to activate the parasympathetic system and will give you a sense of calm.

Are There Mindfulness Meditation Apps You Like?

If there are mindfulness meditation apps or resources that you like and have found effective, please comment below and let us know and share your thoughts and experiences with your fellow readers.

Ageing Well

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The post Meditation Studio App and Buddhify Meditation App Reviews appeared first on MelioGuide.

Prevention Archives - MelioGuide

OsteoStrong Review: What’s Wrong With OsteoStrong?

Table of Contents

What is OsteoStrong?

Review and Evaluation of The Recent OsteoStrong Study

Major Shortcomings of the OsteoStrong Study

1. Failure to Meet Basic Scientific Standards

2. Lack of Trial Registration

3. “Low Quality Study” with High Risk of Bias

4. Confounding Factors: Osteoporosis Medications

5. The Crucial Question: Does OsteoStrong Improve Bone Density Scores?

6. Lack of Proper Statistical Analysis

7. Follow the Money: Who Funded the Study?

8. Scientific Community Response

Exercise and Osteoporosis

OsteoStrong Review: July 2025

OsteoStrong Review Methodology

OsteoStrong Review: General Concerns

Does OsteoStrong Work?

Fractures

Falls

Bone Mineral Density (BMD)

Lumbar Spine BMD

Femoral Neck BMD

Total Hip BMD

Femoral Neck and Total Hip Volumetric BMD (vBMD)

Bone Material Strength Index

OsteoStrong Side Effects and Adverse Events

Study Limitations in Safety Assessment

The Verdict: Is OsteoStrong a Hoax? Is OsteoStrong Legitimate?

Discussion

OsteoStrong Efficacy and Effectiveness

Conclusion: Looking Forward

Margaret Martin

Further Readings

References

Can Osteopenia Be Reversed?

Table of Contents

Can Osteopenia Be Reversed?

What Is Osteopenia?

Evidence Based Guidelines for Treatment for Osteopenia

Targeted Osteoporosis Exercise Program for Osteopenia

Optimal Nutrition Program for Osteopenia

Lifestyle Modifications

Osteopenia Prevention and Treatment

Exercise Recommendations for Osteoporosis

Osteopenia, Bone Density and Bone Quality

Osteopenia and Fracture Risk

Risk Factors of Osteopenia Outside Your Control

Risk Factors of Osteopenia Within Your Control

Osteopenia and Fractures

Osteopenia: Hip, Femoral Neck and Spine

Osteoporosis Exercises

HRT and Osteopenia

Hormone Replacement Therapy and Osteopenia

Selective Estrogen Receptor Modulators (SERMS) and Osteopenia

Monitoring Your Progress

Osteopenia and Sarcopenia

Conclusion

Margaret Martin

Further Readings

References

Sarcopenia Exercise Program to Reverse Muscle Loss in Seniors

Table of Contents

Sarcopenia Exercise to Reduce Muscle Loss

Exercise for Sarcopenia: Walking

Four Resistance Exercises for Sarcopenia

Exercise for Osteoporosis Course

Bonus Sarcopenia Exercise: Balance

Conclusion to Sarcopenia Exercise

Margaret Martin

Further Readings

References

How to Prevent Sarcopenia and Muscle Loss

Table of Contents

Sarcopenia: Muscle Loss Associated with Getting Older

A Key to Sarcopenia Prevention: The Neuromuscular Connection

Exercise and Osteoporosis

How to Prevent Sarcopenia: The Promise of Low Intensity Vibration

What the Research Tells Us