Make No Bones About It...
Michelle Laging, PT, DPT
Monday, November 20, 2017
Hello all, this is Michelle Laging, the lead physical therapist on the ACUTE unit. It has been a while since I contributed an article but I’m patelling you this, I have some important information to share about bones and general bone health.
Did you know that our bones go through a normal process of maintenance, repair, and remodeling? Just to simplify the concept a bit, the key players in this process are osteoclasts and osteoblasts. I like to think of osteoclasts as little Pac-man cells that are active in breaking down bone tissue. These “Pac-man” cells, or osteoclasts, are imperative to bone resorption. Osteoblasts, on the other hand, are the construction workers. They are the builders of bone and are the cells responsible for bone formation. Typically, bone resorption and bone formation reside in a steady balance.
But, sometimes they don’t . . .
Most people have heard of osteoporosis and often think of it as a disease of the elderly. But let’s define what osteoporosis is so that we can understand how it might have an affect on those individuals struggling with severe malnutrition due to eating disorders. Quite simply, osteoporosis is a bone disease that results in bone resorption exceeding bone formation. The balance is off and is going in the wrong direction; one is working over-time and the other is taking too many breaks. The result is the progressive decrease in bone mass and density combined with loss of bone matrix and mineralization. Our bones become porous, fragile and are more susceptible to spontaneous fractures with minimal to no actual mechanism of injury 1. Osteoporosis is best diagnosed by a non-invasive scan test called DEXA (Dual Energy X-ray Absorptiometry). This test provides us information about your bone mineral density and we typically quantify this with what is called a z-score. The z-score is the comparison of your results with other individuals that are your age. A z-score of -2.5 or lower is considered osteoporotic 1. We coordinate DEXA information if you have had one before and/or schedule you for the test while on ACUTE. This is valuable information to us because there has been an increase in the diagnosis of osteoporosis in individuals with eating disorders. Regardless of the age of the individual, osteoporosis develops quite early in the illness, and tends to be severe. Approximately 50% of adult individuals with eating disorders have developed osteoporosis after a brief duration of the illness 2-5.
There are medications that can be prescribed to assist with the management of osteoporosis and I encourage you to discuss this with your doctor while here at ACUTE. Keep in mind; however, that these medications are not the equivalent of taking a Tylenol for a headache with the expectation of near immediate relief. Unfortunately, decreased bone density is one of the medical sequelae of eating disorders that does not resolve as quickly as it develops.
This is pretty scary stuff, right? It’s going tibia okay. Weight-bearing and strength-based exercises are typically considered appropriate non-pharmacological interventions for osteoporosis. But let’s think about this in more depth. Are you familiar with Wolff’s Law? Julius Wolff was a 19th century anatomist and surgeon who found that “bone density changes in response to changes in the functional forces on the bone, bones atrophy (hint: become osteoporotic) when they are not mechanically stressed and hypertrophy when they are stressed, bones in a healthy person will adapt to the loads under which they are placed. 6” So, it sounds like we need to jump on the treadmill and stress out our bones, right? Actually, one of the key words in that definition is “healthy”. I think it is hard to justify being “healthy” when you are battling an eating disorder and are severely malnourished. Not only do your bones atrophy, but so do your muscles. Muscles that are wasting away because of inadequate nutrition cannot be called upon to provide adequate stress to withering bones. This results in bones and muscles at much higher risk for injury.
We have to look at exercise and movement from a different framework. We need to honor where our body is and work toward rebuilding. This is accomplished with the interventions from your physical therapist at ACUTE and your hard work with your registered dietitian to “feed your muscles”. This does not mean that we forbid weight-bearing and strength-based movements; we just need to integrate them at a more graduated pace, a pace that follows more closely to your nutritional rehabilitation.
So what are some of the cool things that we do in the physical therapy world on ACUTE? First of all, we always assess grip strength upon admission to our unit. We use a tool called a hand dynamometer and it gives us general information in regard to your overall strength and it is also considered a marker of malnutrition 7-8. We use this as baseline information and compare your values to age-matched healthy individuals and we share this data with you. Something really great about this is that we typically see grip strength increase throughout the course of stay and we do not necessarily work any specific movements to improve upon it.
In regard to other specific physical therapy interventions, we work on several movements/concepts in our typical twice weekly visits. These include, but are not limited to, postural education that involves thoracic extension/strengthening and core stabilization, shoulder stabilization, and glute/hip strengthening. Some of my favorite movements in my “physical therapy tool-belt” include lying on the belly on a yoga mat while keeping the head/neck neutral and lifting the torso, this helps to strengthen the back extensor muscles and assist with better posture.
Additionally, I do a lot of education in regard to core musculature and will give you a whole anatomy lesson on the muscles involved in this area. Specifically, I discuss the transverse abdominis muscle and instruct in regard to appropriate activation. In tandem, stabilization at the shoulder complex is also super important and integrates the muscles of the core for support. I specifically prefer to use light resistance bands in a standing position and vary the heights of the bands to change the load at the shoulder.
Lastly, one of my all-time favorite movements is the infamous monster walk. If you have every worked with a physical therapist, you may be familiar with this move. This is an awesome glute activator and is super effective with light to no resistance.
Typically, this movement without is done without the mini squat as indicated in the picture and it is just as effective.
Thank you for taking the time to read this information on bone health from the physical therapy perspective. I know that several of my jokes are trying hard tibia good pun, but all joking aside, I truly do hope that you find this article beneficial. Bone health is extremely important to consider and discuss during recovery from your eating disorder. By asking a lot of questions we can help you get on the correct path toward better bone health.