Jumat, 11 Agustus 2017

osteoporosis weekly medication

osteoporosis weekly medication

(upbeat music) - [dr. kaufmann] tonight i would like to talk about menopause and also part of the programis about osteoporosis. i would also like to welcome the two gentlemen that are here tonight. thank you for coming. and especially the manwith the muhlenberg shirt because i went to muhlenberg.

(crowd laughs) so menopause. next slide, please. it's really just halftime. most of the things that women today are aware of commonly about menopause are stories from a generationor two generations ago. and they really don't apply anymore. a woman today who reaches the age of 50

who has not heart disease or cancer has a life expectancy of 93. and that's today. you can imagine what the future will hold. so we must be able to makethe second half of life as productive as possible. and that means not only the structure but the brain

and the parts of life that make life meaningful not only for ourselves butfor your extended families. what is menopause? well, menopause is a long process. it's not an overnight thing. as menopause approaches, the ovaries make less estrogen hormone and less progesterone hormone

and less testosterone hormone. we'll actually talk about all three. the definition of being post-menopausal is once there's no period for 12 months, a woman is considered post-menopausal. and really all that means isonce that definition pertains, pregnancy is not possible. so contraception, if that is chosen to be used by the couple,

no longer is necessary when there's been no menstrualperiod for 12 months. the median age for menopause is 52 years. and actually, that's been going up over the past few decades. it had been in the late 40s when i was in my training. and now it's at about age 52. i had talked about three hormones.

they're estrogen, weall know what that is. there's progesterone. progesterone is the hormone that makes the uterus receptive for the growing placenta,the growing baby. and testosterone. and testosterone is a male hormone. you all know that. but testosterone is whatcauses sexual interest

in all human beings, men and women. and the decline of testosterone at the time of menopause is what causes decreased libido or sexual interest. that, unfortunately, we don'thave a good supplement for. we obviously havesupplements for the estrogen. and progesterone is onlynecessary in some people. we can talk about that if you wish to. so decreased estrogen levels

are important in several ways. one is for the bone. and another is for the female genital structures. we'll talk about the bone first. what happens withdecreased estrogen levels is that the cells that remodel bone and take down old bone are unimpeded, but the cells that make new bone

are not stimulated as much, which is why estrogen, your own endogenous estrogen, of course, prior to menopause makes the bone mineral density higher than it is after menopause. and there's always a declinewith aging and with menopause. other things that help prevent bone loss from occurring as rapidly

are calcium intake. the recommendation on that, dr. chiappetta of course willbe talking about in a while. but usually it's best takenwith food twice a day. vitamin d supplements havebecome much more important than we ever thought they were. when i was in training, we were taught that you could overdose on four vitamins, a, d, e, and k.

and actually, we're finding out that that is not true with vitamin d. and vitamin d supplementationis very important with respect to using the calcium to put it into bone. but we're also finding that probably vitamin d supplementationis very important to reduce certain cancers,in both men and women. one of the people that i know

who goes out in the sun frequently, eats cheese and milk and should have a veryhigh vitamin d level had the lowest vitamin dlevel i have ever seen. and that person was me. so i have taken mega doses of vitamin d up to the point of 50,000units a week for six weeks followed by now 2,000 units every day. and in the common supplements,

there's usually only 500units, sometimes 1,000. so don't be afraid to take your vitamin d. it's quite necessary. hormone therapy is a very long topic. it's a topic that is not really scary. it's a topic that a lot of people think is scary and something to avoid at all costs. not true.

the data are there. the data were terribly misinterpreted, misunderstood by the lay press. but that's a very long conversation. suffice it to say that if people have been taking hormone therapy in approved doses, in the proper way, it's nothing scary at all. and i can talk about thatif there are questions.

and weight-bearing exercise. weight-bearing exercise, such as walking or walkingespecially with hand weights or other resistive type of exercises, very important to maintain bone structure. give another slack. so menopausal symptoms, hot flashes, decreased libido, vaginal dryness, bone loss.

we've talked somewhat about bone loss. dr. chiappetta will of coursetalk much more about that. vaginal dryness due to lack of estrogen, helped very, very well,especially by local estrogen. and the nice thing about thatis when we use it locally, intravaginally, it's not absorbed. so that can be usedfreely in a lot of people who perhaps think that they can't, but actually, they can.

hot flashes. hot flashes occur in mostwomen for several years. and most of the time then tend to wane after three to five years. and in most women theydo stop at some point, at some point. but that's different for different people. do hot flashes need to be treated? you have to tell me.

a woman who says they're a nuisance, need no treatment at all. a woman who says "i'm up fourto six times every night," "my sleep is impaired," "i can't function in the daytime," that's a woman that should think about treating the hot flashes. different for different people. decreased libido, sexual interest.

we thought we had a supplement. and unfortunately, backabout six months ago when the code was broken, it was not found to work. so more work is going into it. the supplements that are present today, unfortunately the ones that work cause weight gain, hair growth, hair loss in different places.

and they're really rather unpleasant. so i can't tell you we have agood solution for that today. but if anybody would like to talk about any of these topics, 'cause i think that's my last slide, i'll be happy to answer any questions. - [woman] i'm on a hormone therapy that takes the estrogen out of my body. and i always wondered

why no one ever really talked to me about like vitamin d. it's related to cancer. - are you on tamoxifen? - [woman] i was on that but i've had very bad bone side effects. - [dr. kaufmann] and now the next one. - [woman] i'm on premarin. - [dr. kaufmann] yeah, yeah.

the problem with those medicines is they really do work. they work very, very well forwhat we want then to work for. but they really do causebone demineralization. and it's not somethingthat just simple vitamin d supplementation is goingto do anything about. with those medicines, othermedicines are necessary, the arimidex, the femara. they're good medicines,but they're strong.

yeah. anything else? - [woman] but i mean, my question is-- - [dr. kaufmann] i'm sorry. - [woman] should i be on or is that a one-to-onedoctor patient thing? should i be on supplements for bone loss? - with not knowing exactlywhat you're taking,

not knowing exactly yourdose and your history, it's not possible for meto give an educated answer. - [woman] right. - to what you should bedoing with your medicine. of course you should talkwith your provider about that. but you might want to say i have heart the following tonight, and tell me what you think. - [woman] okay.- [dr. kaufmann] exactly.

- [woman] thank you. - yes? - [woman] how do you know the difference between the menopausal symptoms and thyroid? - [dr. kaufmann] that'sa very good question. - [woman] because they seem a lot alike. - [dr. kaufmann] and they are. it's funny.

thyroid disease can be overactive, underactive, and normoactivein the same person over an extended period of time. so you can have all the symptoms of either over or underactive. but the heat intolerance, the sweating, the inability to focuswith thyroid disease is very, very similar. and that's why blood testing sometimes

is very necessary, toanswer that question. - [woman] even if it's, the numbers are normal? - the numbers are normal,with the thyroid testing? - [woman] yeah. - i don't know whatquestion you're asking me. if the thyroid tests are normal... - and? - [woman] well, see, thething is, is i've seen like,

like on public tv,they've put on stuff about different issues, medical issues. and they've talked about even though your numberscan be totally normal, you could still have thyroid issues. because certain thingsaren't always tested. they usually just test, whatis it, your t3, t4, and tsh. - correct. and i don't feel expert enough

to comment on the thyroid issues. if i have a question about that, i am consulting an endocrinologist. i hate to cop out like that, but-- - [woman] no, that's fine, that's fine. i understand. - yeah, with normal testing, then what i normally do is say, thyroid studies are normal.

we suspect you're menopausal. you're having symptoms. let's treat that, see what happens. and then if that's not satisfactory, then we go to the endocrinologist. - hello, my name is dr. chiappetta. and i am a rheumatologistat coordinated health. so i'm going to betalking to you basically about the treatment optionsfor osteoporosis at this point.

when we talk about osteoporosis, as we know, it's basically diagnosed by, at this time, a bone density test. so right now when wetalk about treatments, we're looking atsomething called a t score or less than usually negative 2.5. and if any of you had a bone density test, these numbers may be familiar to you. or we're looking atsomething called osteopenia

with significant risk factorsin order to treat this. and risk factors do includefamily history of osteoporosis and also certain medicationsthat can actually cause further bone oraccelerated bone loss. so when we talk about thetreatment for osteoporosis, typically we start with thenon-pharmacologic therapy. and calcium and vitamind always comes to mind first of all as initial treatment. now, i do recommend this in every woman,

whether you do have osteoporosis or not to be on calcium and vitamin d. and the recommended dosesdo differ based on your age and based whether you arepost-menopausal or not. typically a pre-menopausal woman should be getting about 1,000milligrams of calcium a day. with vitamin d, and therecommendations do vary again, between 800 international units to 1,000 units a day.

a lot of times we probably are underdosing ourselvesin the united states, but those are the recommendations. post-menopausal women,anywhere between 1200 and 1500 milligrams ofcalcium a day is recommended. and when we recommend taking this, we do recommend over-the-counter drugs. usually the doses of the calcium are between 500 and 600milligrams a capsule.

and they should be divided. we find that takingmore than 600 milligrams of calcium at one point, you're not going to absorb most of that. so if you're taking liketwo tablets at once, you're not going to get the efficacy. so we really recommendsplitting those doses up. so really every woman should be on some sort ofsupplementation at this point.

now, diet as a means tohelp with osteoporosis. when we say diet, it'sto avoid certain foods. not many foods actually build up bone, and that hasn't really been studied. but foods to avoid areyour caffeinated beverages, your colas, your dark color colas, coffee, iced tea. and we recommend no more thantwo caffeinated beverages at one day basically.

anything more than twodoes lead to bone loss. so you can take two, no more than that. diet things also wouldbe alcohol consumption. we find that greater than two drinks a day does lead to bone loss. and that is an additiveeffect over many years. so, again, alcohol use, caffeine use should really be, you know, kind of minimized toprevent further bone loss.

exercise, this is a big thingthat everyone always asks me, when, you know, can itreat my osteoporosis with just exercising? and it is a minimal, minimaleffect on bone strength. the basic effect of exercise is to strengthen the muscles and to strengtheneverything around the bone so you don't really fall. does it really increase your bone density

when you get a bone density test? not that much, but it is important basically for muscle tone and to prevent future falls. and that's why we reallyencourage the use of exercise. and then smoking. smoking is probablyyour biggest risk factor for osteoporosis, as wellas many other things. so every patient that i have that comes in

for evaluation of osteoporosis,if they're smoking, they really need to reallyconcentrate on stopping that because it does lead toaccelerated bone loss. basically now we lookat who our candidates for therapy could be. not everybody, even though they may have some bone loss, is a candidate. one of the new basic tools we use is something called a frax score.

and it's f-r-a-x score. and it basically showsyour risk for a fracture based on your age, your bone density test, whether you are on steroids, whether you have rheumatoid arthritis. it's a poll list. and you put it into the computer. and it gives you acalculated risk of 10 years

whether you have a highrisk of fracturing or not. and based on that we could treat. now, this comes into effect a lot of times with women who i have whoare around 50, 55 years old who get a bone density testthat shows osteoporosis but yet a 55-year-old femaleis not at that high of a risk without any other riskfactors of fracturing. she's in good health. she exercises, so it'snot really much of a risk.

so someone like that, eventhough their bone density may show some osteoporosis, i may not treat based on this calculation. but then again, an 80-year-old woman who has maybe something called osteopenia, which is not quite osteoporosis, but is a smoker, who hasa strong family history, who's on steroids should bea perfect candidate to treat. so it's not just based onyour bone density test.

and that's kind of a misconception. we're now going basicallyto this whole kind of fracture risk assessment. and that's what this fracture, this frax score actually shows. so we'll go to the next one. but let's say we do decide todo therapy for osteoporosis. what do we have to offer? well, the most common drugs,

and the ones that everybodyprobably has heard of, they're on tv and everything, is your bisphosphonate drugs, the first one being fosamax. and now that fosamaxactually went off patent, it is generic, and that was asof i think two years ago now, february of two years ago. and alendronate is the generic form. and that's what's available right now.

so you can't get actual, thebrand name fosamax anymore. but alendronate is one of the medications. you can do it a dailydose or the weekly dose. now, the problem with allof this class of drugs, the oral forms of them, is that you have to take thepill on an empty stomach. you have to wait approximatelythey say a half hour, really an hour you should be waiting before eating any other,taking any other medications,

eating or even drinking. you only can take itwith one glass of water. so because of these restrictionswith taking this medicine, the daily dose is reallynot that convenient to do this every single morning. so the weekly dose is more efficacious and, well more easy. and the efficacy is really the same. so most people do the weeklydose of fosamax or alendronate.

another one is called risedronate or the other name is actonel. and the newer preparation of that is something called atelvia. the difference between the two, you could do either weekly, every day, or even as a monthly dose,i forgot to put up there. but the difference between the two is actonel you have to, again,eat on an empty stomach.

the newer one, the atelvia, which is basically the same medicine, you could take with food. so this is a kind of nicer option now because a lot of peopletake thyroid medications which you also have totake on an empty stomach and then which one do youtake first and everything. but at least this onewill give you an option. you could take this with food.

another one is boniva. boniva comes in two forms. it comes in a pill form and it comes through an intravenous form. so the pill form is aonce-a-month medication. the iv form is every three months you would go and get this infused in you. the infusion of boniva takesabout five minutes tops. it's really just a push.

so really, you know,by the time you're in, they take your blood pressure, it's about five, 10minutes you're in the place and you could leave. the last one, the mostrecent one to get approval is something called reclast. reclast is a once-a-year medication in this group of meds. it's five milligrams every year.

it was initially used in cancer patients or people who had high calcium levels due to chemotherapy. and they then saw benefitswith this medication for reducing osteoporosis 'cause it was in the same kind of class. and then it got theapproval for osteoporosis. it's used every year. and recent studies have shown this drug

being used for about three years in a row and then taking a littlebit of a break from it, and then reintroducing it if need be. but those are basically our options in the class of what we callthe bisphosphonate meds. now, what are the adverse effects? because these are also the drugs that have been studied the most, and these are the ones that have gotten

the big press of what could go on. number one is esophagitis. and that's basically fromthe pills that you take. fosamax, actonel, boniva, the pill form can cause reflux symptoms. it can irritate and really cause problems with the esophagus, called esophagitis. and it is a huge limitingfactor to these medications. so somebody who comes in

with a history of bad reflux disease, this is not the option really for them 'cause it really will exacerbate that. what else can you get? with the iv forms, likethe once-a-year one and the boniva every three months, flu-like illnesses can definitely happen. so people a few days after the infusion feel really achy, really tired.

you can get low-grade fevers with it. they also can lower the calcium levels. and what that causes issevere muscle cramping. and i have heard this happen. so it's very important that if you do get one of the iv forms is tomaintain your calcium intake and take it really regularlythat week of the infusion because it can lead tosevere muscle cramps. now, both, both the oralform and the iv form

can cause musculoskeletal pain. and i have seen this withthe oral pills especially causing chest pain withthe first few doses. muscle pain, joint pain. i know my mother had this, and she took the once-a-month actonel and was like, what's going on? i feel like i'm having a heart attack. and it was the med.

it is self-limiting,meaning after a few doses, it does go away. but it can be a problem for patients. and the biggest things thatpeople have heard about in the news is theosteonecrosis of the jaw, the jaw problems with these medications and the hip fractures, these spontaneous hip fractures. and everybody is like, well,

why would you get a hip fracture if it's supposed to helpreduce hip fractures? they find that with these medications more than really five to 10 years of use, it actually suppresses thebone enough from eating away that you're not actuallybuilding good bone. and the way to think about this is that everybody as you walk every day you do do microfractures to your bone.

and we have cells thatcome along and kind of clean that bone out andtake away the dead bone. these are the same cells thatare overactive in osteoporosis and they clean too muchout in osteoporosis. but if we suppress that completely, you make new bone on topof kind irregular bone, and you have a high chanceof fracturing over time. so the new recommendations basically, and this is not, youknow, through the board,

but it's really to kindof go on these meds for about five years, take a drug holiday, take a few years off. and they're finding that doing that may reduce the risk of thesepotential complications. so they do happen. i've seen it happen in three people, three of my patients already,the spontaneous fractures. and the only thing i could attribute it to

is the fosamax that they were on. and one was on, actually all three, one-week fosamax at that point. so it's something to consider. it's something to, you know, keep in mind. other potential options, are the serms or the selectiveestrogen receptor molecules. and this is something called evista. it's a sister drug to tamoxifen.

tamoxifen, which is the breast cancer, you know, drug to treat, it's not indicated for osteoporosis, but it's kind of asister drug of evista is. the good thing with evista is it does help lower the risk of fracture in the spine. the data for hip fracture reduction is not really quite there. so i do recommend this for women

who are going through basicallymy post-menopausal women who have osteoporosis, their hips look pretty good. their spine is kind of, uh, so-so. this would be a good drug for them. and it would avoid thepotential complications of the fosamax, the actonel, and boniva. they don't see those hip fractures or anything with this one.

(indistinct) also is nice. there was a trial that came out that showed that this does also lower the risk of breast cancer. so someone who is a highrisk of breast cancer, this may be a good drug for them. it does, though, increaseyour risk of blood clots. and it can also induce hot flashes. so those are your two side effects.

so again, it's not acompletely benign drug. estrogen and progesterone. this is no longer first-line therapy based on the woman's health initiative and the health studythat came out about 2002. basically they saidthis is not first-line. we have better drugs, because there were potential complications with long-term estrogen and progesterone use.

but may be good forsomebody who can't tolerate the other drugs and haspost-menopausal symptoms, such as hot flashes, this maybe a good option for them. again, estrogen, just like evista, has been shown to reducethe spinal fractures better than hip fractures, so. another one, and i don'treally use this much, is calcitone in nasal spray. but there is a nasal spray

that you can use for osteoporosis. it's one spray in a nostril and then you go to theother nostril the second day and kind of go back and forth. it can cause nosebleeds and i have seen thathappen with this drug. it has a weak effect on bone health, so it's not really great. but it's good for helping acute pain

from vertebral fractures. and this is why i do use it. people who have a compressionfracture from osteoporosis, you can use this to help with the pain for the first few weeks. and it does help. it's not 100%, but it doeshelp alleviate it a little bit. the next one is the parathyroid hormone. this is now we're getting into the kind of

more interesting and newer things. the one it's called forteo, and you may have heard of this drug. it's the only anabolic agent. so what does that mean for osteoporosis? it's the only agent that we have out there that actually builds bone. the rest of the drugs, includingfosamax, actonel, boniva, they never build bone.

they kind of stop the loss of bone. but this one actually builds it. and it was a kind of a cool concept. what they did is they looked at something called the parathyroid hormone, the same hormone thatactually at high levels when you have hyperparathyroidism,causes osteoporosis, but they find that if you giveit in short bursts every day and it only lasts in thesystem for a couple of hours,

it actually induces cells that build bone. if it's in the system longer than that, you actually recruit thecells that eat away the bone. so these short bursts on a daily basis actually help promote bone growth. it is an injection. that's one limiting factor. some people cannot give themselves a shot. and they do give themselveslittle shots here.

it's given for two years. and after two years, we put you on one of the othermedications to maintain it. and that would be like goingon reclast or fosamax or so. what is the problem with this medication? well, the biggest thingthat people worry about, and knock on wood i have never seen it, but is something called an osteosarcoma, which is a cancer of the bone.

now, this drug has been out for about 10, 11 years or so and studies have been out. the incidence of this osteosarcoma is about the same asthe general population on people on this drug. so they do not see an increased incidence in women taking this. they did see it in the trials in rats.

and the rats were givensuper therapeutic doses for their body size. they were given a human sized dose for a tiny body size, which they think mayhave contributed to it. they didn't see it untilthey were on the drug for about four to five years. so again, we only use it two years. they're using it longer.

and rats have also a different kind of skeleton too than humans. they have more of a skeleton like a child that's in a, kind of anoverproductive state. it's constantly turning over. and we do know children have a higher risk of bone cancer than adults do. so we're thinking thatmay be a risk factor too. but it's something to be mentioned.

everybody is always verycautious about taking this because of that incidence. okay, lynn, go to the next one. and the last one i do want to talk about is the medicine called prolia. prolia is the newest one out for the indication of osteoporosis. it has been really,really good to decrease both hip and spinal fractures.

this is also a subcutaneous injection. but it's done in the physician's office. it's every six monthsinstead of being every day. you come in twice a year to get this done, takes a few seconds and it's done. what this is is actually an antibody that kind of binds to the cells to stop their communicationand stop the development of the cells that will eat away bone.

what they found in some trials, and this is what the limitingfactor for some people are, but that it hasn't beenfound in all the trials, is that it may increaseyour risk of infection and maybe increase your risk of cancer. it's been disproven in trials, though. it's not across the board. so some saw an increased riskof like flu-like illnesses and urinary tractinfections and pneumonia.

some cancer risk went up, but again, it has notbeen continuously proven. so it does work pretty well. and what's nice is that this one is not excreted by the kidneys. so so far it's safe inpeople with kidney problems, which is also why we can't give a lot of other medicationsfor osteoporosis because we can't usethem in kidney disease.

so this would be an optionfor people with that. but i think that's, i think that's it. so those are our choices for treatment. is there any questionsabout medications or... yep. - [woman] i've beentaking osteo (indisctint) evista for years. and i have had three fractures since then.

- while you're on evista? and then i had a bone density test, and they said i have osteoporosis and arthritis in my back. my doctor put me on fosamax. and i couldn't take it because it start, i had trouble swallowing pills. - right. - [woman] because of my esophagus.

so now they're suggestingthat i go on reclast. and i'm a little afraid to go on it. - [dr. chiappetta] actually, the reclast is a very reasonable option at this point. obviously the evistais not working for you. and the fact that you've-- - [woman] he told me tokeep taking evista anyway. - you can. there is studies with combination therapy

that it may like augmentand may be better for you. is there any other reasonyou're taking evista, like is there a history ofbreast cancer in the family or you're at risk factorsfor that or anything? - [woman] no. - no, i mean, necessarily you can do both. it's not going to harm anything. you may not have to 'cause thedata with reclast by itself is actually pretty goodfor fracture prevention.

and reclast does work greatfor both spine and hip, while evista you're really just getting some spinal protection with it. so you don't have to take both of them. i know some physicians do. and there's nothing wrong with it. but you don't have to. now, reclast is greatbecause it's convenient. you take it for about three years.

again, this new studycame out, three years. and you can take a three year holiday. and they've found thatpeople taking this drug, reclast, six years continuously versus three years andstopping three years had the same bone density at the end. there was no change. so it's good. it actually it's nicethat you could do that.

take a break, so those riskfactors for hip fractures won't be there, at leastwe think so right now. that may change, who knows, in a few years they may see something happen, but, yeah. - yep. - [woman] are theredifferent bone density tests? i only see the machine whereyou put your heel in and-- - [dr. chiappetta] yes,that's actually called the pixi or a heel scan.

that's not what your criteriafor osteoporosis is based on. that's good almost as a screening test to say whether it's abnormal or normal. that's basically all it tells you. if it's abnormal, thenyour insurance will pay for a full-blown dexa scan. so a lot of timesinsurances won't pay for it until the age of 65 unless you have risk factorsfor osteoporosis, so--

- [woman] dexa scan. - a dexa scan, that's the full one. that's where you get the spine, the hip. (woman talking indistinctly) right, they do, it dependson which dexa scan too because there are many different models. but they'll do the spine. they could do one or two hips based on the bone density machine.

and they do your forearm. and that's pretty, a good assessment of potential fracture risk for different areas of boneand different types of bone. but a lot of insurances won't pay for it unless you're 65. and they'll start off with this heel scan. they'll pay for that. and then if that's abnormal,

then they'll pay for the dexa scan. - [woman] there's just onetype of heel scan, right? - yeah, they're basically the same. there's probably differentmakes and everything, but yeah. - hi, everybody, myname is melissa pittas. i'm a therapist here at coordinated. what i'd like to brieflyjust touch on today is what we can offer here at coordinated in our outpatient physical therapy program

for patients who are at risk for falls, osteoporosis, or osteopeniaor arthritis. (chuckles) basically, the osteoporosis program that we've developedhere is gonna involve, it's an individualized program for every patient thatcomes through the door. but generally what we do iswe start with an evaluation. and that would include a generalrange of motion assessment of arms, legs, back, prettymuch throughout the body.

we do a strength assessment, check flexibility of themuscles, of the joints. we check your enduranceto see how we think you'd be able to toleratean exercise program which helps us decide what kind of program we could design for you. the other thing we'd talk about, the two big ones i love to talk about are home safety management,

fall prevention, andalso postural alignment. posture is one of the reallybig things that we do here. i'm sort of the posture guru, posture nag. pretty much every patient that sees me whether they're comingfor a knee, an ankle, a back, a neck, or whatever, is gonna get some sort of posture lecture if they come to see me because i'm very, very big on posture.

when you're five feet tall,you stand up straight, so (laughs) okay, basically with the education, i think we've already touched on osteoporosis and osteopenia. so we know the osteopenia is weak or weakened bones whereasosteoporosis is brittle bones which increases yourrisk for the fractures. we talked about therisk fractures as well.

but with the posture, as you can see, the postural changesjust in this slide here, what happens as we get older, i know a lot of people havecome to me in the past. they've come to me with this diagnosis or just with back painor an arthritis diagnosis and they say, well,i've also been diagnosed with osteopenia or osteoporosis. that means that i'm gonna shrink

and i'm going to look likethis in a couple of years. that's where we come in. that diagnosis doesn't automatically mean that that's what's gonna happen. what we like to do is prevention. we have dr. chiappettatalked about the medicines. but as far as what we can do is we'll go in, we'll do the evaluation. we'll develop an exercise program

and a postural awareness program as well. we'll talk about how tostrengthen the muscles around the arthritic joints and the osteopenic or osteoporotic joints. what we want to do is you can only strengthen the bone so much. but you want to strengthenthe tissues around the bones. you want to make sure that the muscles, the ligaments aroundthose osteoporotic joints

are as strong and stable as they can be because they will helpto support those joints, which also will help to decrease the risks of the falls and alsodecrease the risks of injuries in the event that you do have a fall. so we would talk about doing different types ofstrength training exercise, which would include like light weights. what weight training will do

is causes the muscles to contract. those contractions cause the tendons, which attach the musclesto the bone, to contract, and that actually causessome stresses on the bone which help to strengthenthe bones a little bit. the other thing is the walking, which dr. kaufmann touched on. we'll talk about developinglike a walking program, which we would do here.

we could do it onequipment, on the treadmill. talk about how you cando a walking program around your developmentor on walking trails. there's some wonderful walkingtrails around the valley, which is a great way to get outside and get your vitamin d as well. so the other thing we would develop is posture exercises. and these are pretty simple exercises.

they're not intense exercises. most of them we can havepatients do in chair. so we have patients who can'tstand or walk very well. we adapt the program and modify it so that you can do theexercises in the chair. that way if you're taking a car ride or doing those bus trips to the casinos, you guys can do your strengtheningand postural exercises while you're sitting there on the bus.

balance is another one. if we have posturalchanges as we get older, throughout our lives, and we do tend to comeforward a little bit, we can do a posture assessment. we can help to correct that because what does happen is if we do have poor posture and we do start to come forward,

our center of gravity will shift, which in turn is gonna affect our balance and increase our risk for falls. so we would address that as well. and then we would transitionthat into the home. what i would do with youin a few simple sessions is we maybe talk aboutyour living arrangements. do you have stairs? do you have carpeting?

do you have hardwood floors? how your house is set up. and we would talk about the safest things that you would have in your house, like good lighting, rubber stops on stairsthat aren't carpeted. we would talk about, you know, clearing a room, keeping thingsaway so you wouldn't trip, keeping clear of clutter,things like that.

we would talk about, the bigthing i like to talk about is making beds and laundry. these are two very difficult activities if you have back pain or ifyou have a weakened back. so we would talk aboutsafer ways to do that, more efficient ways to do that, you know, depending on how yourwasher and dryer are set up, if they're stackable,if they're side by side, how the door swings out or down.

and we address that whole area. so everything is individualized. like i said, you know,we'll do the evaluation. we have our general exercises that we do. we put together a nice,condensed program for you. we usually do it in a few sessions. we can usually do itin about four sessions, sometimes two sessions. but insurance covers it, and we can do it

for as long as it's medically necessary for you to be there so that we can make sure that we address all the areas that we possibly can. if you would have questionsabout your insurance, we have the girls over there who always make surethey verify everything before you would come to make sure how it would be covered, if there would be

a small copay or co-insuranceinvolved with it. but basically, we worktogether with your provider, whatever doctor would like to send you. and it could be any doctorthat can send you for this. it could be dr. kaufmann. it could be dr. chiappetta. it could be your family practitioner. it could be your orthopedic surgeon. it could be a physiatrist.

it could be anybody that can recommend you for this program or anyof the therapy needs that you might have. does anybody have any questions? oh, yeah, don't sit like that. (crowd chuckles) when your mom alwayssaid, sit up straight, she meant it and she was right. i have two girls at home.

so i can honestly tell you my 13-year-old, who is now three inches taller than me, has probably some of the worstposture you've ever seen, which is terrible. and i remind her of itevery day, but, you know. you know how that goes. sometimes you're fightinga losing battle, yeah. but are there any questions? yes.

- [woman] at the ageof 86, is that too old to start a program like that? - [melissa] oh, you're never too old. - [woman] no? - [melissa] i have a couple of, i had one woman who was91, another one who was 92. and i also just did somebalance training with a woman prior to coming here who was 96. - [woman] because my mom's 86,

and i think she could use a program. - absolutely. and like i said, i've had peoplecome in with that question. i've had them come inwith resistance, you know. and usually, their childrenwould come with them, like in this case, you know, if you would want, you would come with her and, you know, sit inand 'cause a lot of 'em sometimes are, but i'm too old for this,

there's no hope for me. there's always something that we can do. everything is modified. anything that we do, any exercise, they're very, very gentle exercises. they're very easy. there's no special equipment. the only thing is maybe justsome bands and things like that which, you know, we'd provide for you.

there's nothing else specialthat she would have to do. we don't need any big spaceor anything like that. so, sure, any kind of education, any kind of simple things thati could give her, absolutely. - [woman] that would haveto be referred by who? - she would need a prescription, yes, from, like a said, a familyphysician or a specialist. it doesn't really matter. and it really wouldjust have to basically,

it could just say physicaltherapy, eval and treat, with a diagnosis of, it could be pain, it could be osteoporosis, it could be abnormal gait, balance issues, you know, anything like that, as long as it has a diagnosis on it and it's a prescriptionfor physical therapy, that would be fine.

and it's dated and signed by the doctor. that's always a help. - [woman] i can't walk very far. - okay. - [woman] and i can't stand for very long. and i've tried doing the walking. and it just doesn't work. - [melissa] right. - [woman] so how would iget into a walking program?

- [melissa] well, youmight not necessarily get into a walking program. but we can still do aweight-bearing program for you, which would include,as opposed to walking, we would do things, like in the clinic, we would do it by the parallel bars. at home i can show youhow you would do it, like at your tabletop or counter where you can hold on for safety.

and you can still do plentyof weight-bearing exercises, just not actually, you know,walking for long distances. or we could figure out, you know, test you out and see howyou do on a treadmill and see how long you actually can walk. - [woman] well, i havea treadmill at home. and i tried it a couple of times. and i didn't get very far. - is it cardiac?

is it weakness in your legs or what? - [woman] knees. - it's weakness in your legs. - [woman] legs too. - oh, well, i can help you with that. we'll address that. that goes part of the strength assessment. so we'll, you know, part of this is not just doing the osteoporosis program.

we need to find out, you know, that's why we do a whole evaluation because it's gonna involve everything. that's why i'm gonna testthe strength of your arms. i'm gonna test the strength of your legs. i'm gonna test the strength of everything so that we can see, well, you know, you got some, you know, you might be at a high risk for falls or, you know,

you have osteo, you saidyou had osteoporosis or even osteopenia,arthritis in your back. you know, if weakness inthe legs is contributing to balance issues or maybeit's the way you walk. maybe the weakness in the leg is affecting how you walk, you know, we kinda take it back a step. and instead of goingright into those things, we would address the strength issues

and address any flexibility or lack of range of motion issues and fix those first and then go into the rest of the program. so everything that we do could, you know, it's not just going into one thing. it's breaking it down, finding where all the deficits are, addressing those, and thenputting that together.

- [woman] i thought maybethe weakness to my legs was from using a cane all the time, that i (indistinct). - with a single-point cane, it gives you an extra point of balance. but it's not gonna cause that much weak, you're still relying onyour legs quite a bit, which you're still full weight-bearing with a single-point cane.

you just got that little extra to help you with your balance. but a single-point cane's notgonna make your legs weak.

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