The myths that we busted with the LIFML trial and the MedXOP trial is that you can't load an osteoporotic person with heavy resistance training. It's not the truth. Not only can you do it, but you should do it because it's the absolute best thing for bone. But if you do, it needs to be supervised and needs to be supervised by somebody who knows what they're doing.
SPEAKER_01:The myths busted in the LIFTMORE trial is that you can't load osteoporosis with heavy resistance training. Not only can you do it, but you should do it with supervision. So the questions we ask today is how do we load those adequately with osteoporosis And what are some more of the myths in the world of bone research? We get to dive into these questions today with Belinda Beck. Belinda Beck is a professor in the School of Health Sciences and Social Work and a member of the Menzies Health Institute Queensland at Griffith University on the Gold Coast, where she has taught musculoskeletal anatomy and conducted bone research for over 20 years. She has an extensive publication list, And her work is primarily related to the effects of mechanical loading on bone. Belinda established the Bone Clinic to roll out this groundbreaking program of research known as O'Nero, which has now been licensed to practitioners all around Australia on a mission to prevent osteoporotic fractures. I think you're going to love today's episode that has tons of clinical gems. I'm Sarah Ewell, your host, and this is Physio Explained. Hi, Belinda. Welcome to the Physio Explained podcast. All right. Lovely to meet you. Now, reading your rather impressive list of publications and achievements, it looks to me like you fit nine days into seven. So I'm rather curious what your week looks like.
SPEAKER_02:Very much depends on the week, but a large proportion of it at the moment involves research and mounting my research team. We're working on a big study called the Stop Frightening Triumph. I'm there, of course, because the Bone Clinic is a health service. It's a lot of work backwards and forwards with my office manager, trying to manage nearly 20 staff and hundreds of clients.
SPEAKER_01:Wowee, that's a busy week indeed. Well, we'll launch straight into it. So what are the challenges related to exercise for osteoporosis?
SPEAKER_02:Probably the biggest challenge is the fact that when you have osteoporosis, it means that your skeleton is somewhat fragile, more apt to break with less trauma. So that's why they refer to osteoporosis fractures as minimal trauma fractures. They're the ones that you get if you fall or pick up a couple of heavy shopping bags or sometimes even roll over in bed or if you've got a bad cough, you can contract your ribs and so on. It means that you're trying to load a skeleton that is inherently fragile. And the catch-22 is that the low-intensity exercise is not osteogenic, meaning it's not going to actually help to build your bone. So we have to load it heavy, and that makes it even more perilous.
SPEAKER_01:Because I feel like the results certainly of the Lift More trial and much of your research probably makes you a bit of a myth buster in trying to challenge those ideas around brittle bones and how that might intersect with your more, as you said, higher intensity, that progressive resistance training. So I suppose on that, what do you feel are the biggest myth or myths that you address clinically consistently that is worthwhile for a clinician knowing?
SPEAKER_02:Well, the biggest myth is the one that I just described, that you can't load an osteoporotic skeleton because of a risk of fracture. In fact, that's not the case at all. We showed that very clearly in our clinical trials. The key to doing it safely is supervision. And oftentimes in this demographic, we do have people coming to us who have never done exercise before. So it's very new to them. But not only are we asking them to begin exercise, we're asking them to begin and impact training. And that means that we have to start at a very modest level, teach them the technique, be very, very rigorous with that technique monitoring and incrementally increase the load so that they body adapts to it sufficiently. And so depending on the person, that's going to take longer or shorter amounts of time depending on their previous experience. But Certainly, the myths that we busted with the LIFML trial and the MED-XOP trial is that you can't blood an osteoporotic person with heavy resistance training. It's not the truth. Not only can you do it, but you should do it because it's the absolute best thing for bone. But if you do, it needs to be supervised and needs to be supervised by somebody who knows what they're doing. They have experience. Clinical training, which in Australia, that would be a physiotherapist or a clinical exercise physiologist. That way, you're able to assess a person for their comorbidities or the other things that are wrong with them and then account for that when you're loading them. And it's also the reason why we rolled the program out into the bone clinic as a neuro, as an actual program. Because that way we can keep track of who is actually delivering it as a licensed project. We can screen who buys the license and only allow people who are physios or EPs to deliver it. So then we know that their clients are safe.
SPEAKER_01:Absolutely. And I suppose for those clinicians listening, in terms of the supervision, what do you think are the most important things to look out for when you are guiding someone into suitably loading them?
SPEAKER_02:You absolutely need to do a thorough assessment before you do anything. We, of course, do that because my clinic was a research clinic, so we spent two and a half hours doing that. We did an Edexil scan, so we'd find out what the Edexil is. And then we do a really thorough analysis of their function and their kill stream. So we find out what else is wrong with them. If somebody has just had pelvic floor surgery, that's a real important fact we need to know before we start applying the exercise program. If someone has a frozen shoulder, then that's something we're going to have to work with. So the assessment is absolutely vital. And as I say, we have all sorts of people coming into the clinic because This is not a randomized controlled trial anymore. This is real life. So people have all sorts of reasons why they have low bone mass. It could be because they've just never got really bad genes. And so when I say bad genes, I just mean bad from the standpoint of osteoporosis. They just have low bone mass genetically. And being age-related, you know, your bones are likely to get worse as you age. But it could be that somebody has been a marathon runner all their lives and they have had chronic energy restriction and imbalance, which we also know is really bad for bones. So even though they're actually very active and quite strong, their bones are bad. Those two different people would be managed very differently then you have people for example who have recovered from breast cancer having had the breast cancer treatment which is horrible for bone and so these are people not only are feeling a little bit bruised and battered from what they've just gone through And then they've discovered that the treatment has destroyed their bones as well. So now they've recovered from breast cancer, but now they've got to deal with their osteoporosis. So then it becomes a matter of helping them regain their confidence and showing evidence that we have helped people before and creating a community that's very supportive. O'Neill is a class-delivered osteoporosis exercise program. So they gain a lot of motivation for it from their classmates.
SPEAKER_01:Fantastic. And there's certainly that power in groups, isn't there?
SPEAKER_02:Yeah, exactly. Some of my licensees do one-on-one training and there's nothing to stop them from doing that culturally, just in some places that's more appealing to their clients. But you really do lose something not having at least one other person who is turning up every time and helping just by having a conversation with you between sets. How was your granddaughter? Did she get her karate grading done? Just having a little conversation where people find their tribe and they have this mutual goal of improving their bone mass, but the social side of it is just a little ancillary
SPEAKER_01:support. Which makes all the difference. It's sounding like it highlights that necessity to have that thorough screening of the history of corticosteroid use or their athletic history or those sorts of things. But you can certainly see that multidisciplinary care will be quite crucial in this as well.
SPEAKER_02:Yes. So we also have a dietician at the clinic. And so after they see the EP, they go to the dietician and Most people think it's all about just calcium, vitamin D with bone, and it largely is. But as you would know, protein is so incredibly important to nutrition, particularly as you add into your diet and you utilize that protein, converting it to muscle is somewhat fatale. And people, as they get older, eat less and less of it. So, you know, there's all sorts of hints and tips that we can give people. It's really important to remember protein. that just taking a calcium supplement, even vitamin D, which is important for absorption, is not going to save you from osteoporosis. It's not going to get you out of that osteoporosis zone. But it's important that you're getting enough that when you're doing these other activities, aka exercise, you've got the building blocks so you can actually build more bone. Because if you don't have it in your diet, the place where you're getting calcium from for all those other physiological, functions is the calcium bank, which is your skeleton. So it's all about having enough of those nutrients. So in terms of the rest of the multidisciplinary community, whoever shows somebody in, we always make sure we send a full, probably way more information than they want, a report of our assessment back to them, including what their dietary consumption and those important nutrients are. So that when they do go back to their doctor, they can have this really informed conversation. And oftentimes that's coming from the endocrinologist as well.
SPEAKER_01:Fantastic. And then at least they've got the fuel to do the resistance training you're asking them to do as well. Yeah, exactly.
SPEAKER_02:And we've been open nearly nine years now. And the great thing about that is it means that we've got so much data that has supported the clinical trials that started this whole thing. But now we've got real-world data. And because we do, all the doctors, particularly in Brisbane, around the world, they know about us. And they're so relieved that there is somewhere to send their patients who either won't or can't take the medication, which is the only other weapon in their arsenal for dealing with autism. So as soon as they adopt, be they the GP or a specialist, knows that there's somewhere to send these people. They just, you know, it sort of opens up the floodgates really. And that's actually what the stock fracture study that we're doing now is all about. It's an implementation trial raising the profile of our neuros. So the doctors know that it's like the bone Pilates. It's somewhere to send somebody that they know there's evidence where not only will they get effective training, but they'll actually be looked after and protected.
SPEAKER_00:This podcast is sponsored by Cliniko.
SPEAKER_01:We can certainly physically see the dynamic nature and change of muscle with hypertrophy or with atrophy, but bone is certainly lesser. I think it's easy to sometimes forget that bone is not so inert and it's a pretty active and dynamic tissue.
SPEAKER_02:Yeah, absolutely. Most people don't even think about their bones until they have their trans fracture, by which time it's sort of too late. In the past, I have done quite a few studies in schools because that is absolutely the time to not only begin with this bone target loading, but educate kids that this is the tissue in their body that they also need to look after. And it is kind of effective, but you have to sort of keep at it. You know, it's something you learn in school, you don't necessarily retain, but there are ways we can do that. And it was encouraging that those exercise interventions were effective. and simple, very brief, because you don't need to do a lot combined. You just need to do it at a high enough intensity. I think the will has to be with the education departments to actually implement that sort of education and physical activity into physical education classes.
SPEAKER_01:at that sort of grassroots level. As you say, our role certainly as clinicians is to continually educate people on the health of their bone. They don't have to be osteoporotic for us to actually have that conversation as well.
SPEAKER_02:Well, that's absolutely the way I look at it because we want to prevent those fractures. Now, we do all the time manage people who already have had at least one fracture, oftentimes multiple fractures, but I would say probably when we first opened that was the average age of the person coming to the bump and it was mid-70s. These days it is much, much younger as people realise granny or even mum had a hip fracture and ended up in a nursing home and died within six months. So all they had this terrible kyphosis for most of the last 20 years of their life or something and it really prohibited mobility really, and they just want to avoid it. So we have a much more informed population now looking for some way to prevent that from happening. The great thing about these exercises, one of the amazing things about the Whitmore study, which still makes me smile when I think about it, whenever you do a clinical trial, the first two things that you always measure is height and weight. You don't think that anything's going to happen with those unless you're doing a diet intervention, I guess, but You just do it because you're trying to get a sense of what this person's morphology is. Little did we know that it was going to become a really important outcome when height actually increased in our intervention group. Obviously, when your average age is about 64, you're not growing. So this was postural. People actually were standing up straighter in their natural position, not when they were sort of standing at attention, but naturally they regained some height because they of the much stronger postural muscles by doing these exercises. And of course, that is a very use it or lose it effect. It's the same with any bone or muscle. It's a life sentence. And that's why we've had people training with us for nine years. They realize that they're going to lose it if they stop.
SPEAKER_01:That's fantastic. What an objective data point
SPEAKER_02:that is. Yeah, so cool. We just thought you see it in people's posture, but you don't realise that that is actually translating to an increase in height. And one of the other things that people don't think about when, as you age and you do lose height, all sorts of things will begin to increase your risk of fracture. If your clothing gets closer to the ground, starts dragging on the ground, like a dressing gown, it's much more likely you'll have to trip over it. And so as you're shrinking, that is going to happen. How many old people get a new dressing gown when they're old? They're wearing that moth-eaten thing they've always had. You know, if you have a tisotic curvature, it completely throws out your centre of mass from where it used to be in our view basis. So the risk of falling is much, much greater. As we all know, falls are the nemesis of osteoporosis. So you just want to do everything you can to prevent those falls.
SPEAKER_01:Absolutely. Always nice to know we have an option other than throwing out the old favourite dressing gown we can strengthen instead. Well,
SPEAKER_02:there
SPEAKER_01:are
SPEAKER_02:sewing machines, but it's much... Just retain the heart and, you know, everything. You have to reach that shelf in the kitchen that you've always been able to reach. You know, you have a couple of compression fractures. You can lose centimetres. And what ends up happening is you go, well, I can't reach anything. I'm going to put a step stool in my kitchen. What happens then is in the middle of the night when you go out to get a glass of water, they forget the step stools there. They trip over that. So... Yeah, it's a really dangerous cascade.
SPEAKER_01:You mentioned intensity. What sort of intensities are you looking at in terms of repetition max for these sorts of studies?
SPEAKER_02:Yeah, we are at the high end of intensity. So we're looking at 85% one repetition max. So this is pretty heavy. Now, I say this is heavy for you and me. We're still relatively strong, but... 85% 1RM for a 95-year-old who hasn't done anything but carry around a one bag for the last 50 years is probably very light, but so then it's heavy. So that's the key. I sometimes have people asking me, how much do I need to load? How much do I need to lift? And I can never give them a number because it depends on them. And I think that's a really important concept. You know, the lower they are, the more they will improve. And the improvements happen early on. You sort of slow down as you reach your actual physical capacity, but it should always feel like it's happening.
SPEAKER_01:It's always all relative, isn't it? Belinda, thank you so very much for... your time today i think all of that information is very transferable into clinical practice so it's much appreciated and i think your research is is very much well worth boring over as well so thank you for your contributions as well my pleasure