Copyright Protected
Choices FOR BETTER BONE HEALTH®
© Procter & Gamble Pharmaceuticals, 2002.
All rights reserved.
Permission granted by Procter & Gamble Pharmaceuticals to reproduce
this patient education material for a non-commercial effort, provided
that the Procter & Gamble Pharmaceuticals copyright remains in place.
No other uses are permitted.
Supported through an unrestriced grant from
Choices
FACILITATOR'S
WORKBOOK
FOR BETTER BONE HEALTH®
Session 4
LIVING SAFE AND SOUND
Choices
DEVELOPMENT TEAM
Deborah T. Gold, PhD
Barbara E. Miller, PhD
Stuart L. Silverman, MD
Choices A D V I S O R Y
BOARD
Stanley B. Cohen, MD
Cathy R. Kessenich, DSN, ARNP
Barbara P. Lukert, MD
Michael J. Maricic, MD
Betsy L. McClung, RN
Kathy M. Shipp, PT, MHS, PhD
Mima Siegel, PT
Ellen H. Silverman, OTR
Stanley Wallach, MD
Nelson B. Watts, MD
Colette L. Wong, BS
The information provided in
Choices FOR BETTER BONE HEALTH® is intended solely as general information, and should
not be relied upon for any diagnosis, treatment, or care. Always seek the advice of your health care professional prior to starting
any new medications, other treatments, an exercise program, or with any questions you may have regarding a medical condition.
Supported through an unrestricted educational grant from
The Alliance for Better Bone Health
About the art on the cover: each of the five figures in the logo shown on the front cover represents one Session
of
FOR BETTER BONE HEALTH®. The figures are linked together in a ring to emphasize that the Bone
Health Behaviors learned in
work together to make bones healthier. You will learn about the five
elements of better bone health in the five sessions of
.
Choices
Choices
Choices
© Procter & Gamble Pharmaceuticals. All rights reserved.
Permission granted by Procter & Gamble Pharmaceuticals to reproduce this patient education material for a non-commercial
effort, provided that the Procter & Gamble Pharmaceuticals copyright remains in place. No other uses are permitted.
Introduction to Facilitators’ Workbook
Course Objective:
The objective of Choices FOR BETTER BONE HEALTH® is to provide an organized
learning experience for people diagnosed with osteoporosis. Choices empowers participants to self-manage their osteoporosis so that they can maintain an active lifestyle. This
program offers an understanding of osteoporosis, how it can affect people’s lives, and
how participants can meet the challenges caused by osteoporosis. Choices gives participants the opportunity to 1) develop a personal PLAN FOR BETTER BONE HEALTH to
make their bones healthier and 2) practice the skills necessary to implement this PLAN.
Theoretical Basis:
The Choices approach to self-management is based on Bandura’s Self-Efficacy
Theoretical Model. Following this model, empowerment occurs when individuals believe
(1) that a new health behavior will make their bones healthier, and (2) that they can
implement and maintain the new Bone Health Behaviors in ways that are right for them.
In addition, this model emphasizes that successful and permanent health behavior
changes need time and reinforcement to occur. These are key messages in Choices .
It takes at least three weeks to change a behavior and make it a good habit; therefore,
not all of the Bone Health Behaviors can be turned into habits during the Choices course.
Thus, in the final session, participants develop their own PLAN FOR BETTER BONE
HEALTH so that they can continue their efforts to turn these health behaviors into habits
after the course ends. This PLAN will also help participants maintain behaviors that are
already part of their lifestyle.
In Choices , we utilize five steps that will help individuals turn a Bone Health Behavior
into a good habit. We call these five steps of bone health behavioral change the 5 C s.
The 5 Cs:
1. C OMPREHEND the importance of the new Bone Health Behavior
2. C HOOSE between options for implementing the new behavior
3. C ONQUER the challenges brought about by the change in behavior
4. C OMMUNICATE the change in behavior to others, including a medical professional
5. C OMMIT to changing the selected Bone Health Behavior
Each of these steps is applied to each of the Bone Health Behaviors. The four Bone
Health Behaviors taught in Choices are outlined under Course Overview.
Course Overview:
The course is designed to consist of five 2 - 3 hour sessions and includes group and
subgroup discussions, demonstrations, and individual activities. Alternatively, the program
may be conducted in 4 sessions by giving the Living Safe and Sound workbook as homework.
In this case you would conduct Sessions 1, 2, 3, and 5 in person and assign sections
from Living Safe and Sound throughout the remaining sessions as outlined in the facilitator
notes for Sessions 1, 2, and 3. (See facilitator note on page 54 of Session 1 to begin
the homework assignment.)
Each session is formatted into three sections.
1. Key Learnings–This section opens the first four sessions and provides information
on a topic relevant to bone health and osteoporosis. This section of the
course lends itself to subgroup and large group discussions. The Key
Learnings sections throughout the course provide information on 1) the disease,
2) osteoporosis therapies, 3) the psychosocial impact of osteoporosis and
the value of support groups, 4) how to fall-proof the home and other ways
to prevent fractures, and 5) how to remain stylish with osteoporosis.
2. Postural Alignment -The second section teaches how to maintain correct
postural alignment during daily activities so as to reduce the load on
the spine, help reduce back pain and improve appearance. This section
of the course is best facilitated first by demonstration and then by giving
the participants an opportunity to practice the alignment technique. This
section teaches how to bend over, sit, stand, and perform daily activities
using correct postural alignment.
3. Bone Health Behavior-The third section offers a behavior that can help
participants live well with osteoporosis and make their bones healthier.
This section involves individual activities and large group discussions.
It is in this section where the 5 Cs format is utilized. The four Bone
Health Behaviors taught in this program include 1) getting enough calcium
and vitamin D, 2) taking an osteoporosis medicine as recommended,
3) managing chronic back pain, and 4) exercising for healthier bones.
At the end of each session, the participants develop an Action Guide for that session’s
bone health behavior. The Action Guides are built from the self-assessment questionnaires
at the end of each of the 5 Cs (e.g., p.32). The Action Guides are critical to developing
each participant’s unique bone health plan which is the tool for changing behavior.
If you run out of time, you may give the Action Guide as homework, but use the beginning
of the next session to review and discuss the homework.
Choices works best when participants are seated in small subgroups of 5 or 6 at round
tables. This creates support groups where subgroup discussions can easily occur. It is
recommended that participants stay with their table throughout the course.
The health care facilitator may want to select a co-facilitator, ideally someone with
osteoporosis, who has experience with leading groups. This provides participants with
both a health care expert and someone with experience in managing the disease.
A Participant’s and a Facilitator’s Workbook are provided for each session. The
Participant’s Workbook is designed to be a resource both during and after the class
and covers the topics discussed during the session. The Facilitator’s Workbook offers
suggestions on how to lead discussions, identifies the key messages to be covered during
each session, and provides background information and resources. The suggestions on
how to facilitate each session resulted from actual sessions that were conducted with
osteoporosis patients while the course was being developed. The Facilitator’s Workbook
also contains the information provided in the Participant’s Workbook. The numbered
pages in the Facilitator’s Workbook correspond to those in the Participant’s Workbook
so that you can easily refer your group to specific pages.
In the Bone Health Behavior section of each session, affirmations are provided to help
participants turn the behavior into a habit. Affirmations are words used to trigger positive
mental images that lead to motivational feelings. For an affirmation to be helpful, it is
important that the participants find it meaningful. Your participants may want to write
their own affirmations rather than use the ones provided. If so, be sure to share the
guidelines below.
Guidelines for Writing Good Affirmations.
Write affirmations...
1. that are personal. Write I statements.
2. in a positive tone. Example: I am making my bones healthier.
3. in the present. Example: I take my osteoporosis medicine as recommended.
Avoid: I will take...
4. that use words such as I am, I have. Avoid: I can.
5. that are realistic and honest.
6. that use words that evoke emotion. Example: I easily, I enjoy, I love to
7. that avoid implying perfection. Avoid: I always....
Tips for Successful Facilitation:
1. Participants learn best from each other.
a. Encourage everyone to share their thoughts and experiences. Ask for
volunteers to share their results from their individual activities.
b. Facilitate the Key Learning section by asking questions about the topic
being covered in that session. Sample questions are included in the
facilitator’s notes for each session. Ensure that the discussion that follows
covers the key messages on each topic.
c. Avoid lengthy time periods where you do all the talking. To get the
group involved, ask open-ended questions that require more than a ‘yes’ or
‘no’ answer.
2. Be sure to keep track of time.
a. There will not be enough time to cover all the information on every page
in the participants’ workbook. Key messages from the workbook should be
communicated during the discussions. Key messages have been identified in
boxed inserts. These inserts do not appear in the Participant’s Workbook. Ask
participants to read their workbooks at home to cover materials not discussed
in class.
b. Create a ‘Parking Lot’ to capture questions that come up but are not relevant
at the time. The Parking Lot can be a flip chart page that is posted at each
session, or notes that you maintain. Come back to these questions during the
session where the topic is relevant. At the end of the course, be sure that all
Parking Lot questions have been answered. The Parking Lot can also be used
to capture questions for which you may not have an answer. Try to find an
answer by the next session.
c. Allow a discussion to continue as long as it is meaningful. Move on to the next
item once the topic has been covered.
d. Some participants may start to monopolize the discussions and bring up topics
not relevant to that day’s session. Some of these topics will be important to
address with the group. Some will only be relevant for that individual. One
way to handle this is to use the Parking Lot so that these topics can be covered
at another time (in later sessions, during breaks, in one-on-ones).
e. Read through all the materials for the 5 sessions before Session 1. This will
enable you to defer questions to the appropriate session and will make you
more comfortable with the course in general.
f. Allow time for participants to perform the Self-Assessment exercises. These
exercises are designed to help the participants think about the relevance
of the materials to them and are critical to developing the Action Guide in
each session, and ultimately to developing their PLAN FOR BETTER BONE
HEALTH.
3. Make sure everyone understands how to complete the Action Guide at the end of
Sessions 1 through 4. These Action Guides are critical to designing the PLAN FOR
BETTER BONE HEALTH in Session 5. Sample completed Action Guides as included
in the Appendix of each session. Walk participants through these examples before
giving them time to complete their own.
4. Keep the course informal.
a. Invite participants to get up and move about during the course or to leave
to use the restroom. Advise them that you will be taking a break
mid-session, but that they should feel free to move around at any time.
Take an unscheduled break if you find the group needs it.
b. Invite participants to ask questions at any time. Encourage group discussion.
Don’t feel you have to answer every question. Ask for group input on how to
answer a question. Correct any misinformation in a way that helps the group
understand that there are a lot of misunderstandings about this disease.
c. Use the Postural Alignment section as a way to get participants moving after
a period of sitting.
5. Make sure the meeting room meets the needs of the older person.
a. Check that the room temperature is comfortable.
b. Make sure that the lighting is adequate.
c. Arrange for chairs that are comfortable and have arms, if possible.
d. Arrange for a room close to the restrooms.
6. Be creative.
a. Use other materials during the course, such as videos and brochures from the
NOF, journal articles that reinforce the session’s topic, and any other related
materials will help make the course interesting for both the participants and
you. Reinforce verbal teaching with visual aids whenever possible.
b. Use humor to make the course more enjoyable. This also helps participants
remember the key messages. For example, we have used a puppet to enhance
the postural alignment demonstration.
7. Be aware that participants may feel overwhelmed during parts of the course and
show sadness and hopelessness. Handle this with empathy and understanding. It may
be appropriate to have one facilitator go to those individuals or even escort them
from the room to allow them to recover in privacy. Continue the course as planned,
allowing these individuals to return when ready.
8. Share roles across both facilitators. Avoid having one facilitator always taking the
lead or doing all the talking. Build upon each other’s strengths. Both facilitators
have unique contributions to make.
9. Enjoy yourself! The participants will learn more when they see that both facilitators are
interested, involved and enjoy what they are doing.
The Core Development Team for Choices want to thank you for bringing this course to
your patients and peers. With your help, many will benefit from these materials.
Thank you!
Choices
FOR BETTER BONE HEALTH®
Session 4–Choices: Living Safe and Sound:
Choices: It’s Never Too Late
Session 2 Choices: There’s More You Can Do
Session 3 Choices: Taking Charge
Session 4 Choices: Living Safe and Sound
Session 5 Choices: Putting It All Together
Session 1
1
Facilitator Notes - Prework
Before the Session Starts
Materials needed
• Name tags and place cards
• Tables and chairs
• 2 flip charts
• Markers for flip chart
• Session 4 participant and facilitator workbooks
• Pens or pencils
• Notepads for participants, optional
Suggestion for optional props for this session:
A reacher, theraband (physical therapy elastic), weights (to demonstrate with, not for
participants to use), ambulatory devices (canes, walkers)
Pre-class preparation:
• On a flip chart write ‘Choices FOR BETTER BONE HEALTH®’
• On the next flip chart page, write the title of the session: ‘Choices : LIVING SAFE AND
SOUND’
• Using a new flip chart sheet for each question, write the following four core
questions to help facilitate the Key Learnings section of Session 4. These questions
can be written on flip chart pages located beneath the course and session titles as
they will be used after the opening of the session.
• What changes can you make in the kitchen, bathrooms, and laundry area
of your house that would reduce your risk of falls?
• What changes can you make in the living and dining rooms, and in the
pathways of your house that would reduce your risk of falls?
• What changes can you make in your garage and yard that would reduce
your risk of falls?
• What can you do to reduce your risk of falls when walking?
Session timing
• Welcome and review: This will take approximately 20 minutes
• Part 1: Key Learnings. This will take approximately 25-30 minutes
• Break: 20 minutes. Ask participants to begin taking their seats after 15 minutes
• Part 2: Postural Alignment. This will take approximately 15-20 minutes (optional:
postural alignment could be covered before the break) NOTE: This postural
alignment exercise may take longer than those in earlier sessions.
• Part 3: Bone Health Behavior. This will take approximately 60 minutes
2
Choices
FOR BETTER BONE HEALTH®
Table of Contents
Session 4—Choices: Living Safe and Sound: Key Learnings . . . 5
Reduce Your Risk of Falling and Fracture . . . . . . . . . . . . . . . . . 6
Reduce Your Risk of Falling and Fracture: Home Safety . . . . . . . . 7
Reduce Your Risk of Falling and Fracture:
Other Suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Session 4—Choices: Living Safe and Sound: Postural
Alignment-Performing Daily Activities . . . . . . . . . . . . . . . . . . 11
Session 4—Choices: Living Safe and Sound: Bone
Health Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
The 5
C s of Exercise
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
C OMPREHEND the Importance of Exercise for
Healthier Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
C HOOSE the Exercises That Are Right For Your
Bone Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
C ONQUER the Challenges of Exercise . . . . . . . . . . . . . . . . 39
C OMMUNICATE to Get Information and Help With
Your Exercise Program . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
C OMMIT to Exercise for Healthier Bones
. . . . . . . . . . . . . . 44
My Action Guide – Exercise for Healthier Bones . . . . . . . . . . . 46
Appendix 1: Do’s and Don’ts of Daily
Activities to Help Prevent Fractures . . . . . . . . . . . . . . . . . . . . . . 49
Appendix 2: Postural Alignment, the Hip Hinge,
Sitting, and Standing Reviewed . . . . . . . . . . . . . . . . . . . . . . . . 52
Appendix 3: Daily Activities and Exercise List . . . . . . . . . . . . . . . 57
Appendix 4: Frequently Asked Questions About Exercise . . . . . . . 59
Appendix 5: Sample Session 4 Action Guide . . . . . . . . . . . . . . . 60
3
Facilitator Notes for Welcome and Introduction
to Session 4
Welcome the participants back to Choices FOR BETTER BONE HEALTH®. Display the course
and session names on the flip chart.
Review the Key Learnings and Bone Health Behavior from Session 3. Ask if participants have any
questions. If participants have questions that are not specific to Session 3, place them in the
Parking Lot to be addressed at the appropriate time in the course.
Ask if participants are making progress on their Action Guides for Choices: TAKING CHARGE
(managing chronic back pain). Ask who has completed the Next Steps. Ask participants to share
their experiences and new insights.
Give an overview of the Session 4 Key Learnings and Bone Health Behavior that will be covered
today.
Remind participants that a goal of the course is for each to prepare an individualized PLAN FOR
BETTER BONE HEALTH, and that today they will be adding the specific Bone Health Behavior of
exercising to improve bone health. This PLAN can serve as a guide to help participants develop
new behaviors and sustain current behaviors that will lead to healthier bones.
This now takes you to the beginning of Session 4, Key Learnings.
How Are You Doing?
In Session 3,
Choices: Taking Charge, you learned...
Key Learnings
• Osteoporosis can create social isolation and negative feelings.
• You can meet these challenges with help from a personal
support system.
Bone Health Behavior
Osteoporosis can cause chronic back pain. You identified ways to
manage this discomfort.
Taking the Next Step
In Session 4,
Choices: LIVING SAFE AND SOUND, you will learn...
Key Learnings
• You can further reduce your risk of fractures by fall-proofing your home.
• You can perform daily activities safely to reduce fractures.
Bone Health Behavior
Exercise can improve balance and make bones healthier. You will
learn the types of exercises that are most beneficial to your bones.
Key Message:
• You can reduce your risk of falling and fractures by making your home environment safer.
• Exercises designed for those with osteoporosis can make your bones healthier.
4
Facilitator Notes for Key Learning
The four core questions below will help you present the Key Learnings of Session 4.
• What changes can you make in the kitchen and bathrooms of your house that would
reduce your risk of falls?
• What changes can you make in the living room, dining room, bedroom, and pathways
of your house that would reduce your risk of falls?
• What changes can you make in your garage and yard that would reduce your risk
of falls?
• What can you do to reduce your risk of falls when walking?
Display the four questions. Assign one question to each table if you have four participant tables,
or two questions to each table if you only have two tables. Ask the participants at each table to
work together as a group to develop answers to these questions. Suggest that they identify one
person at the table to report back to the larger group. Give the groups five minutes to work on
this if they have one question, 8-10 minutes if they have two questions.
Move from table to table to offer help and encouragement when needed. When finished, ask
for a volunteer from each table to share their group’s answers. Have one facilitator capture the
participants’ answers on the flip chart while the other facilitates the discussion. We suggest that
the facilitators switch roles during this process.
Take time to elaborate on key messages and offer suggestions for key points that the group may
have missed. Use the discussion to communicate the key points about each topic that are outlined
in the Session’s workbook. This will encourage participant interaction and reduce the need to
lecture.
Carefully correct any incorrect answers that may be offered. Do it in a way that doesn’t make the
participants feel bad. For example, if someone says that only exercises that involve weight-lifting
are good for your bones, point out that this answer reflects a common misunderstanding about the
disease. Ask how many others believe this. Point out that there are several types of exercise that
have a positive impact on your bones. Choices will cover these.
Choices
FOR BETTER BONE HEALTH®
Session 4—Choices: Living Safe and Sound:
Key Learnings
5
Reduce Your Risk of Falling and Fracture
As you learned in previous sessions of Choices, you can do a lot to
reduce your risk of fractures and improve your life with osteoporosis!
Things you can do include the following:
• Getting enough calcium and vitamin D
• Taking your osteoporosis medicine as recommended
• Managing your chronic back pain
However, even with calcium, vitamin D, and an osteoporosis medicine,
people can still fracture if they fall.
There are more things you can do to reduce your risk of fractures:
• You can modify your home to reduce your chances of falling.
• You can align your body for safe movement and pain reduction.
• You can do exercises that will help reduce your risk of falling and
decrease your risk of fracture.
Key Message:
• You can modify your home to reduce your risk of falling.
• You can align your body for safe movement and chronic back pain reduction.
• You can do exercises that will help reduce your risk of falling and decrease your risk
of fracture.
6
Choices
FOR BETTER BONE HEALTH®
Reduce Your Risk of Falling and Fracture:
Overview
Home Safety
You can eliminate hazards from your home to reduce your chances of
falling. This is important because falling increases your risk of fractures.
Here are some ways in which you can make your home safer:
• Reduce clutter, especially in pathways.
• Increase or improve lighting, especially in halls and stairways.
• Make sure you have easy access to light switches; for example,
arrange your furniture so that light switches on walls or lamps
are easy to reach.
• Make sure you have easy access to the phone; for example, keep
your phone in a place where you don’t have to twist or bend to
reach it. Use a portable phone.
• Remove any loose electrical or telephone cords from pathways.
• Clean up spills immediately so that you don’t slip.
• Remove area rugs or replace with non-skid rugs.
• Make sure both indoor and outdoor stairs have sturdy railings.
• Put nonskid strips on your uncarpeted stairs.
• Be careful not to trip over your pet or its toys.
See Appendix 1 of this workbook for more ways to prevent falls in your
home.
Key Message:
Removing hazards from all areas of your home can reduce your risk of falling and fractures.
7
Activity: Eliminate Hazards in Your Home
What specifically can you do to reduce your chances of falling in your
home?
• First, check your home, room by room, for the fall hazards listed in the
table below.
• Next, identify the steps you can take to fix them.
Example:
Check All That Potential Fall
Hazards
Apply
Potential Changes
(List the hazard and how you will
change it.)
✔
Objects such as
furniture make walking
difficult.
Check All That Potential Fall
Hazards
Apply
Bedroom hallway is overcrowded.
Have furniture moved to spare
bedroom.
Potential Changes
(List the hazard and how you will
change it.)
Objects such as
furniture make walking
difficult.
More lighting is
needed in halls and
stairways.
Light switches are hard
to reach.
The telephone is
difficult to reach.
Loose electrical or
telephone cords are in
walkways.
8
Choices
FOR BETTER BONE HEALTH®
Activity: Eliminate Hazards in Your Home
Continued:
Check All That Potential Fall
Hazards
Apply
Potential Changes
(List the hazard and how you will
change it.)
Area rugs are not
“skid-proof”
Stairs do not have
sturdy railings.
Uncarpeted stairs do
not have nonskid
strips.
Pets and their toys
are underfoot.
Other:
Other:
Other:
See Appendix 1 for more suggestions.
9
Overview
Reduce Your Risk of Falling and Fracture: Other
Suggestions
If you have poor balance and fall frequently, you may have a high risk
of fracture. In order to prevent fractures from falls, you may want to
consider using certain protective wear and aids. One such type of
protective wear is hip pads. These pads do a good job of reducing
the likelihood of a hip fracture, should you fall. Other aids to consider
include canes and walkers. These provide additional support that can
help prevent falls. Speak to your medical professional (especially a
physical therapist) about which tools may be right for you.
Canes
• Use a cane that gives you adequate
support.
• Avoid using a cane that is too heavy.
• Check with your physical therapist
about the right cane length for you.
Walkers
• Use a walker if you don’t feel secure
with a cane.
• Add a basket to help you carry things
around.
• A rolling walker with wheels may
decrease back strain.
• Discuss which walker you should use with
your physical therapist.
See Appendix 1 of this workbook for more suggestions on how you can
protect yourself.
10
Key Messages for previous page:
• If you have poor balance or fall easily, a cane or walker may help you reduce your
risk of fracture.
• Hazards around your home should be eliminated because they can cause falls and
fractures.
The Key Learnings materials in this session may go quickly and not take all the allocated time.
If so, remember that the Postural Alignment section is a little longer than those in earlier
sessions. Also, you can fill in with a brief discussion of fall hazards away from home. Include
in this discussion issues such as poor vision, walking at night, trying to keep up with people,
etc. Emphasize how important it is that participants have their vision corrected to the best
possible level. This can help prevent falls both inside and outside the home.
Have participants list the places they are most likely to go (hospitals, grocery stores, malls,
other people’s houses). Put these up on a flip chart. Then, for each, list potential hazards and
specific ways to deal with them. For example, in malls, the most serious hazard is often other
people. When the mall is busy, it is easy to be pulled along with the crowd at a rate faster
than you would usually go. One way to handle this is to avoid malls at the busiest times
and go early in the morning or around dinner time. Another is to go with someone who
is a steady walker and who will walk slowly with you.
Facilitator Notes for Postural Alignment
Remind participants of the importance of good postural alignment, especially for the patient
with osteoporosis.
Review the postural alignment sections from the last three sessions: Hip Hinge, sitting, and
standing correctly. Using good posture to bend over, stand, and sit can reduce back pain and
improve appearance.
Explain that today’s postural alignment topic is how to perform daily activities safely.
Demonstrate the following: reaching correctly, bending down correctly, and lifting correctly.
Make sure everyone in the group can see you.
Choices
FOR BETTER BONE HEALTH®
Session 4—Choices: Living Safe and Sound:
Postural Alignment
11
12
Reduce Your Risk of Falling and Fracture: Postural
Alignment
How may correct postural alignment help reduce your
risk of fractures?
Fractures occur when your bones are overloaded. Osteoporosis weakens
your bones so that they fracture with lighter loads than they normally
would. When your body is not aligned correctly (for example, when
you slouch), it places a heavier load on your spine than when you
are correctly aligned. This heavier load may cause fractures. Correct
postural alignment not only reduces the load on your back, but it also
spreads the load out evenly across your spine, so that no one
individual bone is overloaded.
How does correct postural alignment reduce chronic pain?
Poor alignment puts loads on parts of your body that weren’t built to take
these loads. This causes pain. Correct alignment puts these loads where
they should be.
Guidelines for correct postural alignment while bending, sitting, and
standing were discussed in Sessions 1, 2, and 3. This information is
repeated in Appendix 2 of this workbook. The following pages show
how to correctly align your body while performing your daily activities.
Remember, correct alignment does not mean holding yourself rigid.
Rigid posture can lead to muscle strain.
Key Message:
Remember, correct alignment does not mean holding yourself rigid. Rigid posture can lead
to muscle strain.
13
Postural Alignment-Performing Daily Activities
Maintaining correct postural alignment as you perform your daily
activities will help protect you from fractures. The next few pages
contain guidelines for performing some routine daily activities.
Reaching DO
Reaching
• Secure your feet on the
ground.
• Stand as close to the
object as possible.
• Face the object squarely
with head, shoulders
and feet pointing toward it.
• If you cannot reach something
easily, use a reacher or a
sturdy stepstool.
• Reach with both the hands,
unless using a reacher.
14
Reaching DON’T
Overview
Postural Alignment-Performing Daily Activities
• If you can’t reach easily, get help.
• Avoid overstretching your back.
• Do not twist your body while reaching because this puts a heavy load
on your spine.
Use a reacher to avoid overstretching
15
Overview
Bending Down
• Bend down from your
knees and hinge from
your hips. Remember
the Hip Hinge from
Session 1!
• Use one arm to hold a
rail or sturdy support if
necessary.
• As you bend down,
maintain the curve in
your lower back.
• Do not bend from the waist. This can place a heavy load on the spine.
• Do not twist your body while bending down.
16
Bending DO
Bending DON’T
17
Lifting
• Face the object.
Lifting DO
• Stand securely with your feet
shoulder-width apart.
• Bend your knees and hinge from your
hips (see Hip Hinge in Appendix 2
of this workbook).
• Keep one foot flat on the ground.
• Using both the hands, bring the
object close to your body.
• Straighten your knees.
• Do not try to lift heavy objects by yourself.
Get help if you need it.
• Use both hands to carry the object.
• Do not bend from your waist.
• Do not twist your body while lifting.
Lifting DON’T
Carrying
Carrying DO
• When carrying two objects, balance
them on both sides of your body.
• Divide loads in half so that you can
balance them on both sides of your
body.
• Do not carry heavy objects. Make
several trips or ask for help.
Key Messages:
Carrying DON’T
18
• Postural alignment should be a part of everything you do.
Facilitator Notes for the 5C s of Exercise
Transition to the next section: This morning we have been discussing the ways in which people
can change their environments to avoid fractures. We have specifically talked about changing our
houses and overall environments to avoid falling. Now we are ready to start the Bone Health
Behavior section of Session 4.
Remind participants about the 5C s and that they are five steps to help them turn each Bone
Health Behavior into a good habit.
Transition to today’s Bone Health Behavior. Let’s look today at the fourth Bone Health Behavior
that will help to make your bones healthier: exercising to reduce the risk of falls and fractures.
Briefly discuss the 5
C s as they apply to exercise.
Begin discussing each C in detail as it relates to avoiding falls and fractures, starting with
C omprehend. Try to elicit participant discussion and personal contributions whenever possible.
Be aware of talking to the participants for too long without their involvement; lecturing is not an
effective teaching method with adult learners.
At the end of each C , ask participants to complete the Self-Assessment Questionnaire. This is an
individual activity, but they may benefit from interacting with others at their table as they complete
each questionnaire for themselves. Be available to answer questions, especially from those who
may be confused about completing this task.
End the individual activities by asking for volunteers to share what they have discovered while
completing their self-assessment questionnaires. Through this discussion, participants will learn
from each other. For example, after completing the Self-Assessment Questionnaire for C onquer,
ask if anyone identified obstacles to exercising that were not already discussed. Also ask
volunteers to share new solutions to obstacles. At the end of this section, all the participants will
develop their Action Guides for exercise. Refer to Appendix 5 for an example of a completed
Action Guide. Participants will identify new behaviors they need to begin in order to achieve
their exercise goals; they will also identify current behaviors that they need to continue. This
reinforces the need to maintain current behaviors.
Advise participants that completing the Action Guide is important as it is the first step towards
developing their PLAN FOR BETTER BONE HEALTH.
Background: There are three sources that provide additional exercise information:
• A video called "Tai Chi: the Gift of Balance" by Tingsen Xu, Ph.D., available from Tai
Chi Health and Science Research Center, PO BOX 98426, Atlanta, GA 30359.
• An exercise video called, "Be Bone Wise: Exercise!" with Lisa Hoffman, MA, available
from the National Osteoporosis Foundation (www.nof.org or call 202-223-2226).
• For the names of physical therapists with specialty certifications in geriatrics and
women’s health, contact: The American Physical Therapy Association, 1111 North
Fairfax Street, Alexandria, VA 22314-1488.
Choices
FOR BETTER BONE HEALTH®
Session 4—Choices: Living Safe and Sound:
Bone Health Behavior
19
Exercise Can Help Reduce Your Risk of
Overview
Falling and Fracture
We all know that exercise is important for good health and a sense of
well-being. But did you know that exercise can also help prevent falls
and fractures?
C s of Exercise
The 5 C s of this session of Choices FOR BETTER BONE HEALTH® focus
The 5
on the bone health behavior of exercise.
C OMPREHEND the importance of exercise for healthier bones.
C HOOSE the exercises that are right for your bones.
C ONQUER the challenges of exercise.
C OMMUNICATE to get information and help with your exercise program.
C OMMIT to exercise for healthier bones.
20
C OMPREHEND the Importance of Exercise for
Overview
Healthier Bones
An active lifestyle helps make your bones healthier. Inactivity leads to
bone loss. People on bed rest lose about 1% of their total bone each
week. Once they’re up and about again, they replace this lost bone
but only at a rate of about 1% each month.
It is important to avoid prolonged periods of inactivity if possible.
Key Message:
It is important to avoid prolonged periods of inactivity if possible.
Should You ‘Work-Out’ to Manage your Osteoporosis?
Many people think exercise must include vigorous work-outs at the gym,
but most people cannot or will not exercise at this level. Most of the
health benefits of an active lifestyle can be achieved through moderate
amounts of exercise that can be included in your everyday routine.
Generally, you should exercise for 20-30 minutes at least 3 to 4 times
per week. You may not need to do all 20-30 minutes of exercise at
one time to help your bones. Short periods of exercise have been
shown to help the cardiovascular system and may also help your
bones.
Remember to maintain correct postural alignment as you perform your
daily activities and exercise.
Note: Even though you exercise, you still need to take your calcium and
vitamin D, as well as your osteoporosis medicine. These behaviors work
together to make your bones healthier.
Key Message:
Exercise can improve the health of your bones but not without help from the other Bone
Health Behaviors such as taking calcium and vitamin D, and taking your osteoporosis
medicine as recommended.
21
Overview
C OMPREHEND
Exercise Is One Way to Make Sure You Have an Active Lifestyle
Exercise can help you manage your osteoporosis by:
• Helping to maintain bone density so you are less likely to fracture.
• Improving muscle strength so you can maintain good postural
alignment.
• Improving your balance so you are less likely to fall.
• Decreasing chronic pain.
• Preventing or minimizing deformities caused by osteoporosis.
Key Message:
Exercise is good for people with osteoporosis. It helps reduce chronic back pain, maintain
good postural alignment, improves balance, and may prevent fractures.
22
C OMPREHEND
Not all exercises help your bones. Swimming is great for your heart but
provides little benefit to your bones. Be sure your exercise program is
well balanced and includes exercises for your bones.
Exercises That Help Your Bones
Two types of exercise can be used to maintain bone density and muscle
strength: weight-bearing exercises and strength-training exercises. These
exercises also help you stay fit and strong and maintain good body
alignment.
Weight-bearing exercise: Weight-bearing exercises that do not involve
jumping are the best starting point for an effective exercise program.
These exercises include walking, hiking, dancing, and low-impact
aerobics.
23
Strength-training exercise: Strength-training exercises include lifting free
weights, using weight machines, and pulling resistance rubber bands.
Who Can Help You Develop An Exercise Program?
Your medical professional (especially an occupational or physical
therapist) can help you identify which type of exercise is best for you.
Key Message:
Weight-bearing and strength-training exercises improve bone health.
24
C OMPREHEND
Exercises That Improve Your Balance
• To improve your balance, you should do exercises that challenge your
balance. These exercises should only be done under the supervision of
a medical professional.
– T’ai Chi is a form of martial arts that gently challenges the
balance. It has been shown to reduce falls. A version of T’ai Chi
has been developed especially for seniors; this version is the
safest for people with osteoporosis.
• Weight-bearing and strength-training exercises also help improve
balance. Staying generally fit and strong and maintaining good body
alignment helps maintain balance.
Self-Assessment Activity: Balance
Review this checklist to assess your balance. Check all that apply.
❏ I am afraid of falling.
❏ I have fallen in the last year.
❏ I sometimes become dizzy when I change positions, such as when
I sit or stand up quickly.
❏ Turning is difficult for me. For example, if I reach a wall, I cannot
turn gracefully and change direction without faltering.
❏ I drink more than one alcoholic beverage per day.
❏ I take medicines that make me dizzy.
❏ I need to hold on to furniture or walls when moving through my home.
If you checked any of the above statements, ask your medical
professional about exercises and other interventions that will help
improve your balance.
25
Overview
C OMPREHEND
Exercises That Decrease Chronic Back Pain and Prevent or Minimize
Deformities Caused by Osteoporosis
People with osteoporosis often undergo changes in the shape and
alignment of their bodies, especially the neck and back. These
deformities can occur after fractures of the spine. The seriousness
of the deformity depends on the number and location of these
spinal fractures.
Besides changing one’s appearance, these deformities also affect
breathing and digestion, and can lead to chronic neck and back pain.
Physical activities that strengthen certain muscles can help maintain the
body’s alignment to minimize these deformities. These activities can also
decrease chronic pain of the neck and back.
Exercises that prevent or minimize deformities caused by osteoporosis
focus on certain areas of the body:
• Neck—to maintain good alignment and keep your head over your
shoulders instead of in front of your shoulders
• Middle back—to reduce the forward curve known as kyphosis or
dowager’s hump
• Shoulder blades—to maintain their normal position close to the
middle back
• Lower back—to maintain the normal inward curve of the spine
• Chest—to lift the chest off the abdomen
• Abdominal and back muscles—to help support the back
Key Message:
• Do not start these exercises without consulting with your medical professional.
26
C OMPREHEND
Examples of exercises that will improve deformity and decrease chronic
pain are shown below.
(Used with permission ©The Saunders Group, Inc., 2001)
Remember, maintaining good body alignment will strengthen the muscles
that help minimize certain deformities caused by osteoporosis.
It’s never too late to start an exercise program to make your bones
healthier.
Key Message:
It’s never too late to start an exercise program to make your bones healthier.
27
C OMPREHEND the Importance of Exercise for
Overview
Healthier Bones
Self-Assessment I
The following self-assessment questions will help you determine whether
you need to get more exercise for your bone health and what your new
goals should be.
1. How much exercise are you currently getting?
❏ Less than 20-30 minutes at least 3-4 times per week
❏ 20-30 minutes or more at least 3-4 times per week
If you are currently exercising 20-30 minutes or more 3-4 times per
week, CONGRATULATIONS, and keep it up!
2. If not, what do you need to change? (check both if they apply)
❏ The number of days per week that you exercise
–How many more days each week do you need to exercise?
___________________________
❏ The amount of time you exercise each day
–How much longer do you need to exercise each day?
___________________________
Your answers to question 2 should be included in your new goal for
this Bone Health.
28
C OMPREHEND
3. What type of exercises for your bones are you currently doing?
❏ Exercises that will maintain bone density, such as weight-bearing
or strength-training
❏ Exercises that will improve balance
❏ Exercises that will minimize pain and deformity
4. What type of exercises for your bones do you need to add to your
exercise program?
❏ Exercises that will maintain bone density, such as weight-bearing
or strength-training
❏ Exercises that will improve balance
❏ Exercises that will minimize pain and deformity
❏ None, my current exercise program addresses all of my bone
health needs
If you are getting enough of the right type of exercises for your bone
health, CONGRATULATIONS! You do not need to include this as a new
health behavior in your PLAN FOR BETTER BONE HEALTH. Be sure to
continue the good work! While you don’t need to change this behavior,
you may still find useful information in the following C s of this section.
If you are NOT exercising each day for your bones, your answers
to question 4 should also be included in your new goal for this
Bone Health Behavior.
The next section (C HOOSE) will help you decide how to get more
exercise.
29
C HOOSE the Exercises That Are Right For Your Bone
Overview
Health
What You Need to Know Before You Start An Exercise Program
Some physical activities can be harmful to bones that are weakened by
osteoporosis. It is important to avoid any exercise that:
•
•
•
•
Increases your risk of falls
Involves bending your spine forward
Involves twisting your spine
Involves high impact
Facilitator note:
Ask participants to identify some
common exercises which do involve the
actions above (e.g., golf, tennis,
high-impact aerobics, gymnastics).
Keep in Mind:
(Used with permission ©The Saunders Group, Inc., 2001)
• You should increase the amount of physical activity you do only after
consulting your medical professional.
• Start slowly. Pay attention to how long you can exercise comfortably
and start with that, no matter how modest you think it is. Starting with
even a few minutes of exercise each day will allow you to progress
over time.
• How hard, how often, and how long you exercise should be
determined by your overall physical health and fitness, and should
be increased gradually over time to prevent injury.
Key Message:
Do not start exercising without checking with your medical professional about the type,
frequency, and duration of the exercises you should do.
Speak with a physical therapist if you have any concerns about your risk
of experiencing a fracture from an activity or sport.
30
C HOOSE
Which Type of Exercise Is Right for You?
The exercise you choose depends on:
• The severity of your osteoporosis
• Whether you have other health problems
• Your current overall level of fitness
Consult with your physical or occupational therapist to determine which
types of exercise are right for you.
Design an Exercise Plan
There are 3 aspects of exercising to consider when you are working with
your medical professional to develop an exercise PLAN FOR BETTER
BONE HEALTH:
• How hard you should exercise (intensity)
• How often you should exercise (frequency)
• How long each exercise session should last (duration)
Intensity
It is important to start out with an exercise intensity that you can manage.
You should be able to carry on a conversation easily while exercising.
Your medical professional can help you select exercises of the right
intensity for you. Monitoring your heart rate is one way to know that
you are exercising at the right intensity.
Frequency
Generally, exercise frequency should be a minimum of 2 sessions each
week (with at least 1 day of rest between each session) for strengthtraining exercises and 3 sessions each week for weight-bearing
exercises.
31
C HOOSE
Overview
Duration
Generally, the total amount of time per exercise session for strengthtraining exercises is 20 minutes and for weight-bearing exercises is 30
minutes.
You must consider your overall health and fitness, as well as presence of
any pain, the extent of your osteoporosis, and your lifestyle before
selecting your exercise program.
Remember, you and your medical professional should determine
which exercises or activities are best for you.
It all depends on you!
Key Message:
• You should determine the type, intensity and duration of any exercise and check with
your medical professional before you start an exercise program.
• Participants will only continue exercising if they want to. Therefore, it’s important to
discuss what motivates people to exercise, such as an increase in energy, feelings of
well-being, improved health, etc.
32
C HOOSE
Is it possible to over-exercise?
Yes. Research has shown that excessive exercise can contribute to bone
loss. Athletes are at the greatest danger of over-exercising.
Guidelines for Safe Exercise
Consult with your medical professional before starting any exercise
program.
• Move smoothly and slowly for calisthenics and strength-training
exercises. Avoid jerky motions.
• Avoid twisting and bending forward while you exercise.
• Breathe normally as you exercise, Don’t hold your breath. Counting
out loud will help you remember to breath while you exercise.
• Exhaling as you weight lift may help increase your truck support.
• Stop exercising if you:
– Have pain
– Become light-headed
– Become nauseated
– Become unusually tired
– Become extremely short of breath
If any of the above occur, contact your medical professional.
Key Message:
Do not over-exercise. Be careful and consult your medical professional if you have any
questions.
33
C HOOSE
Overview
Suggestions for Turning Daily Activities into Exercise
• Stretch your arms and legs before you get out of bed.
• Be sure to sit on the side of the bed with your feet firmly planted
on the ground before you get up. Avoid twisting.
• Walk tall and practice "growing taller" with every step as you
walk to the bathroom.
• Hold onto the bathroom sink while keeping your feet flat. Do
partial squats. Inhale as you come up and exhale as you go down.
• If you have a home with stairs, go up and down them a few times—
slowly. Be sure to hold onto the banister.
• Remember, walking is an excellent exercise.
Suggestions for a Walking Program
• Determine how long or how far you can/will walk.
• Find a partner to walk with.
• Schedule a specific time to walk with your partner 3 to 4 times a week.
• Choose a safe location that you will enjoy.
• Choose suitable walking shoes and clothes.
• Drink a full glass of water before each walk.
• Do NOT carry weights or attach them to your ankles.
• Start slowly to warm up. Increase your speed gradually until you are
breathing harder than when you are at rest. You should still be able to
carry on a conversation.
• Maintain an activity diary.
• Record your progress.
Key Message:
Follow the recommendations listed here to exercise safely and make your bones healthier.
34
Activity: Exercise Worksheet
Worksheet for Beginning a Safe, Effective Walking Program
1. Discuss your exercise goals and plans with your medical professional.
2. Determine your beginning walking duration by filling in the Walking
Activity Table below and answering the question at the end of this
section.
3. Instructions for filling in the table:
• Walking activity column—think back over the past week. What activities
did you do that involved sustained walking (walking without stopping,
such as walking your dog)? List 3 of these activities in the first column
of the table below.
• Minutes column—estimate the maximum number of minutes of sustained
walking you did during each of these activities. Write the number of
minutes in the second column.
• Comfort column—if the minutes of sustained walking with each activity
were comfortable to you, write "yes." If this amount of walking made
you winded, tired or increased your pain, write "no."
Walking Activity Table
Walking
Activity
Minutes Walked
Without Stopping
Comfortable?
35
C HOOSE
How much sustained walking should you do during the first week of your
walking program? _________minutes*
* Enter the maximum amount of time from the Minutes column of the
Walking Activity Table that was comfortable for you. If none of your
sustained walking was comfortable, enter the amount of time that you
estimate would be comfortable. It’s OK to start with only a few minutes.
This is your starting point!
Key Message:
Choose an exercise that you (1) will do, and (2) can do safely. Consult your medical
professional with any questions.
36
C HOOSE
How to Increase Your Amount of Walking
Add between 2 and 5 minutes to each of your walking sessions each
week, until you are walking 30 to 45 minutes per session. If your start
time is 10 minutes or less and walking for exercise is new to you, add no
more than 2 minutes to each session.
Walk Slowly to Cool Down
If your pace has been brisk, spend the last 3 to 5 minutes of your session
walking slowly to cool down and let your heart rate and breathing return
to normal.
Mark Your Walking Calendar
Go to your wall calendar and mark the amount of time spent walking
each day. Look back over the calendar to see your progress over time
and reward yourself.
Key Message:
Use a calendar or other tracking tool to reinforce the importance of exercise and to chart
progress.
37
C HOOSE the Bone Health Exercises That Are Right
Overview
For Your Bone Health
Self-Assessment II
C HOOSE how you will increase your level of exercise. The following
self-assessment questions will help you decide what is right for you.
I will increase my exercise by:
❏ Increasing the amount of time spent on weight-bearing exercises
(such as walking, dancing, or low-impact aerobics)
❏ Increasing the amount of time spent on strength-training exercises
(such as lifting weights)
❑ Increasing the amount of time spent on balance exercises (such as
T'ai Chi)
A sample exercise plan that will provide you with enough weight-bearing
and strength-training exercises is shown in Appendix 3 of this workbook.
Later in this session, you will develop your Daily Plan to achieve your new
exercise goals.
38
C ONQUER the Challenges of Exercise
Getting enough exercise may present some challenges for you. Here are
examples of some of the challenges you may face, as well as suggestions
for dealing with them.
Challenge
What you can do (Solutions)
Finding time to exercise
• Remember how important exercise is to your
health.
• Make exercise a part of your daily routine.
• Look for ways to exercise in shorter sessions that
total 30 minutes a day.
Forgetting to exercise
•
•
•
•
Finding the motivation
• Start again each time you forget.
• Remember the benefits of exercise.
• Set realistic goals, track your progress, and
reward yourself.
• Support another person who is trying to become
more active.
• Join an exercise class.
• Repeat affirmations that motivate you
Not feeling well enough to
exercise
• If you have a temporary illness such as a cold,
wait until you feel better.
• Talk to your medical professional about how you
can become more active.
Feeling self-conscious while
you exercise
• Exercise with a friend.
• Exercise in your home (just be sure you are
exercising correctly).
• Make exercise a part of your daily routine.
Exercise equipment is not
available
• Select exercises that do not require expensive
equipment, such as walking.
Exercise with a friend.
Exercise at the same time each day.
Join an exercise class.
Reward yourself for exercising.
39
C onquer
Overview
Answers to frequently asked questions about exercising are given in
Appendix 4 of this workbook. These may help you find additional ways
to stay active.
Remember, even a few minutes of exercise on a regular basis may
help your bones become healthier.
Key Message:
• Start slowly.
• Build up your exercise time and speed gradually.
• Maintain good body alignment while you exercise.
• Track your progress.
• Listen to your body. Stop if you have pain!
40
C onquer the Challenges of Exercise
Overview
Self-Assessment III
Another step in turning a behavior into a habit is to anticipate the
challenges the new behavior may present and develop a plan to
address them. The following self-assessment question will help you
do this.
In the table below, write down your potential challenges of getting
enough exercise for your bones and ways you can overcome them.
My Potential Challenges
What I Can Do (Solutions)
Key Message:
Ask for volunteers to share challenges and solutions not already discussed.
41
C OMMUNICATE to Get Information and Help
Overview
With Your Exercise Program
Always consult your medical professional before starting any exercise
program. If you have specific concerns or questions about starting an
exercise program, write them down so you can remember to ask your
medical professional.
Some questions you may wish to ask your medical professional are
suggested below.
• Is it safe for me to begin an exercise program?
• What types of exercise are best for me?
• How long should I exercise each day?
• How many days a week should I exercise?
• What kind of shoes should I wear?
Talk to your family and friends to gain support for your bone health
exercise program.
• Tell them about your plan to be more active.
• Make plans with a friend to exercise together.
– Choose an activity and a location you will both enjoy.
– Choose specific times and days you will meet to exercise.
Key Message:
• Communicate with medical professionals to increase your knowledge about exercising.
• Communicate with family and friends about your exercise plan to help gain their
support; this may encourage them to exercise with you!
42
C OMMUNICATE to Get Information and Help
Overview
With Your Exercise Program
Self-Assessment IV
Complete the following table to identify your communication needs.
With Whom Will I Communicate?
What Will I Ask or Tell Them?
Key Message:
Ask for volunteers to share with whom they will communicate with and what they
will ask or tell them.
43
C OMMIT to Exercise for Healthier Bones
The first step toward increasing your physical activity is to decide to do it!
Commitment is crucial to making a habit of exercising for your bone
health. One way to encourage follow-through on commitments is to use
affirmations. Affirmations are positive statements that can help motivate
you to change behaviors into habits. Some examples of affirmations to
help you develop and stick to your exercise and activity plan are listed
below.
• Exercise is very important to my bone health.
• I enjoy the energy I feel when I am active.
• I am healthier when I am active.
• With every step I am getting stronger.
Repeat your affirmations several times daily until exercise becomes a
habit.
Another way to encourage follow-through on commitments is to
reward yourself. Use rewards as incentives that reinforce your success.
It is important to select something that you enjoy. Rewards can include
taking time out of a busy schedule for your favorite activity, or taking
a walk in the park with a friend.
Remember, it’s important to set realistic exercise goals.
Key Message:
Remember, it’s important to set realistic exercise goals.
44
C OMMIT to Exercise for Healthier Bones
Self-Assessment V
A. I commit to exercising a total of 20-30 minutes 3 to 4 times a week.
❏ Yes
❏ No
B. If no, what is preventing you from making this commitment?
_____________________________________________________________
_____________________________________________________________
C.Write the affirmation(s) that motivate you to exercise.
Affirmation:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
D. Reward Your Efforts
Think about what you can do to reward yourself for exercising. List
things that are meaningful to you, for example, treat yourself to your
favorite dessert—preferably one that is high in calcium!
_____________________________________________________________
_____________________________________________________________
Suggestion:
Ask participants to share their affirmations (if they wrote their own) and their rewards.
45
My Action Guide – Exercise for Healthier Bones
This concludes the 5 C s section of Session 4. The goal of this section
was to help you identify ways to get enough of the right exercise to help
your bones. The self-assessment exercises in Session 4 have helped you
decide whether you need to work on this Bone Health Behavior. If you do,
complete the Action Guide below. This Guide will be used in Session 5
to develop your PLAN FOR BETTER BONE HEALTH.
In the table on the next page, write the actions you will take to exercise
for healthier bones. Use the Exercise and Daily Activity Plans in Appendix
3 and the Sample Action Guide in Appendix 5 as guides.
• Use Self-Assessment I to determine the changes you need to make in
order to get enough of the right type of exercise for your bones.
Write these in column 2, My New Goal for This Behavior, of your
Session 4 Action Guide.
• Use Self-Assessment II to identify how you will reach your new goals for
exercise. Write these actions in column 3, My Daily Plan to Achieve
My Goal, of your Session 4 Action Guide. Include any changes you
need to make, along with behaviors you need to maintain. Be as
specific as possible when describing your Daily Plan. Providing details
gives you specific activities to follow and will help you be successful in
changing behaviors.
• Identify steps you need to take before you can start your Daily Plan,
such as discussing your plan with your medical professional. List these
steps under Next Steps.
• Set a date by which you will complete these Next Steps.
• Create an Action Guide that will meet your unique needs and that
you can follow.
Suggestion:
Walk participants through the process of developing their Action Guide. Refer participants
to the Sample Action Guide in Appendix 2. Walk them through this example.
46
My Session 4 Action Guide
Bone Health
Behavior
Obtain 20-30
minutes of exercise
at least 3-4 times
per week
My New Goal
For This Behavior
My Daily Plan to
Achieve My Goal
New Behaviors:
Current Behaviors
to Continue:
Include exercises
that improve my
balance
New Behaviors:
Current Behaviors
to Continue:
Next Steps
By When?
See Appendix 5 of this workbook for an example of a completed
Action Guide.
47
Close today’s session by reviewing the next session:
There’s more you can do to live well with osteoporosis. In the next session you will learn
how to be stylish with osteoporosis and will finish the process of designing your PLAN FOR
BETTER BONE HEALTH.
Review the key messages from Sessions 1,2, 3 and 4 listed under ‘Remember’.
Ask if there are any additional questions from today’s session.
Ask participants to bring all 4 Action Guides to Session 5. Remind them that it is very
important that all Action Guides be completed before the next session.
Remind participants of the date for the next session. Invite them to bring fashion ideas (hats,
scarves, etc) to share with the group.
CONGRATULATIONS!
Choices
You have completed Session 4 of
FOR BETTER BONE
HEALTH®, where you have learned that you can reduce your risk of
fractures while performing your daily activities, and that daily activity
and exercise are important to your bone health.
You will learn more about how to manage osteoporosis in the final
FOR BETTER BONE HEALTH®.
session of
Choices
In the final session, Session 5, Choices: PUTTING IT ALL TOGETHER,
you will learn…
Key Learnings
• Fractures can change your body shape; this change can create the
Osteoporosis Fashion Challenge.
• You can meet the Osteoporosis Fashion Challenge and look stylish.
Bone Health Behavior
You will develop your PLAN FOR BETTER BONE HEALTH based on
the needs you have identified in previous Choices sessions.
Remember:
• Eat foods rich in calcium and vitamin D or take supplements.
• Take your osteoporosis medicine as recommended by your
medical professional.
• Manage your chronic back pain.
• Exercise to make your bone healthier.
It’s never too late to make your bones healthier!
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Choices
FOR BETTER BONE HEALTH®
Appendix 1: Do’s and Don’ts of Daily Activities to
Overview
Help Prevent Fractures
Bathroom
• Do install shower, tub or toilet rails. Don’t hold onto towel racks or soap
dishes for support.
• Do make sure your rails are properly installed.
• Do keep the floor of the bathroom dry to avoid slipping.
• Do use a rubber mat or nonskid strips in the tub.
• Do use a seat in the tub or shower.
• Do check the water temperature before stepping into the tub.
• Do use a long-handled device to help you wash your back and your feet.
• Don’t stretch or twist to reach your back or your feet.
• Do bend your knees and hinge your hips when brushing your teeth or
shaving to avoid losing your balance and overloading your back. You
may also lean on the counter for support. If you have room in your
bathroom for a chair, you may wish to sit in the chair to brush your
teeth or shave. You can hang a mirror at eye level for these tasks.
• Do consider installing a raised toilet seat if your toilet is too low.
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Overview
Appendix 1: Do’s and Don’ts of Daily Activities to
Help Prevent Fractures
Bedroom
• Do use a firm, supportive mattress. Remember that firm doesn’t
necessarily mean hard or vice versa.
• Do have a light switch and a telephone within easy reach of
the bed.
• Do use a night-light.
• Do put a pillow between your knees if you feel back strain while
sleeping on your side.
• Do put a pillow under your knees when sleeping on your back.
• Don’t twist your body while getting out of bed. Roll onto your side first,
move your feet out over the side of the bed, then push up with your
arms so that you come to a sitting position.
• Don’t read or watch TV in bed. If you must, use a wedge or a study
pillow, rather than bed pillows, to position yourself.
• Do use a light comforter or bedspread so you can easily make
your bed.
• Do make one side of the bed at a time, and then move to the other
side.
• Don’t twist your body or stretch as you place sheets or blankets
over the bed.
• Do hinge at the hips and bend slightly at the knees while making
your bed.
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Choices
FOR BETTER BONE HEALTH®
Appendix 1: Do’s and Don’ts of Daily Activities to
Overview
Help Prevent Fractures
Kitchen
• Do work at a counter height that is comfortable for you. If necessary,
sit on a bar stool while you work.
• Do store frequently used items within easy reach.
• Do keep heavy items at waist level or ask for help in moving them.
• Do keep the floor dry. Clean up spills promptly.
• Don’t wax the floor. Be sure the floor is NOT slippery.
• Don’t clutter your pathway. Be sure you have enough room to move
around freely.
Laundry Room
• Do carry your laundry in small loads or use a cart with wheels to
move laundry.
• Do purchase smaller and lighter boxes of detergent.
• Don’t stretch or reach for detergents. Keep them within easy reach,
preferably at waist level.
Other
• Do be sure you know where your pet is so that you don’t trip or fall
over him/her.
• Do gather up all loose electrical and telephone wires. You may wish to
invest in a wire winder.
Outside Your Home
• Do watch for icy, wet, irregular, or uneven surfaces.
• Do get in and out of a car correctly:
– To get in, sit down on the seat first, then swing your legs in.
– To get out, swing both legs out first, then stand up.
51
Overview
Appendix 2: Postural Alignment, Bending Over,
Sitting and Standing Reviewed
Bending Over
Remember, do not bend at the waist. Rather, use a technique known as
the Hip Hinge to reduce the stress on your back as you perform your
daily activities.
Hip Hinge DO
Hip Hinge DON’T
Think of your hip joints as being a hinge and your trunk as being a
door. Tighten your belly and back muscles, and keep your head and
trunk aligned. As you bend, move your entire trunk forward in one
piece, keeping your ear, shoulder,
and hip in a straight line. This way,
the bending occurs at your hip joint,
not at your waist. Your back should
stay straight. Your shoulders should NOT
round forward.
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Proper Sitting Posture
Sitting DOs
Sitting DON’Ts
• Use your back and
abdominal muscles to sit
tall. Keep your chest up
and tighten your abdominal
muscles to reduce the
strain on your back.
• Make sure that your ear,
shoulder, and hip form a
straight vertical line when
viewed from the side. You
should have a small
hollow (inward curve)
at your lower back.
• Consider using a folded towel or small pillow between the back of your
waist and the back of the chair to help support the small hollow of your
lower back.
• Your hips should touch the back of your chair, and your feet should
rest flat on the floor.
• Use a neck rest when driving.
• Use a foot stool to raise your foot to an appropriate height for tying
your shoes or drying your feet. Do not bend over.
• Check your sitting posture throughout the day and correct it when
necessary.
53
Sitting Down
• Facing forward, stand close to the chair so that the backs of your legs
touch the seat of the chair.
• Position your feet hip width apart with your toes pointing straight
ahead. Place one foot slightly further away from the chair than the
other. Do not put your feet together.
• Hinge forward from your hips, not your waist, keeping your back
straight and bending your knees. Your buttocks will "lead" toward the
seat as you sit down.
• As you lower yourself into the chair, take hold of the armrests to
steady yourself.
• Sit close to the front of the seat, then scoot your buttocks back in
the chair.
54
Standing Up
• Sit erectly—keep your ear, shoulder, and hip in a straight line.
• Move your buttocks close to the front of the seat.
• Position your feet hip width apart with your toes pointing straight
ahead. Place one foot slightly further away from the chair than the
other. Do not put your feet together.
• Hinge forward from your hips, not your waist, transferring your body
weight onto your feet (feel your toes push into the ground).
• Keep your knees apart so that your knees track over the middle of
each foot.
• Rise from the chair using the arm rests to help steady you.
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Proper Standing Posture
Standing DO
Standing DON’T
• Lift your chest to stand tall and
maintain the natural arch of your
lower back.
• Hold your head up and back;
imagine that you are wearing a
crown that you don’t want to fall
off.
• Bring your shoulder blades
together slightly.
• Position your feet so that they are
apart with one foot slightly in front
of the other (feel the entire bottom
of your foot and toes against the
ground).
• Point your feet straight ahead with your knees slightly bent.
• While standing in one place for longer than a few minutes, put one foot
up on a stool. Switch to the other foot periodically.
• Check your standing posture periodically throughout the day and
correct it, if necessary.
• Use the Hip Hinge exercise that you learned in Session 1 to help you
maintain good postural alignment as you move between the sitting
and standing positions.
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Choices
FOR BETTER BONE HEALTH®
Appendix 3: Daily Activities and Exercise List
Below is an example of an exercise plan
Exercise
Total Number of
Minutes Per Day
Monday
Stretch
Walk
5 minutes
30 minutes
Tuesday
Increase daily activities, for example,
don’t use the TV remote control!
Wednesday
Stretch
Lift free weights
Thursday
Increase daily activities,walk
instead of driving somewhere
Friday
Stretch
Walk
5 minutes
30 minutes
Saturday
Stretch
Lift free weights
5 minutes
20 minutes
Sunday
Increase daily activities, use stairs
instead of elevators
Day of the
Week
5 minutes
20 minutes
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Appendix 3: Daily Activities and Exercise List cont.
Use the table below to help you determine the amount of exercise you are
currently getting.
Current
Behavior
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
58
Exercise
Total Number of
Minutes Per Day
Appendix 4: Frequently Asked Questions
Overview
About Exercise
Many people have questions about exercise, especially when they are
just beginning an exercise program. Here are answers to some frequently
asked questions that may help you find ways to stay active.
Does housework, gardening, shopping, and walking up and down
stairs instead of taking the elevator count as exercise?
Yes, daily activities such as these do contribute to bone health. Find
ways to include exercise while doing these activities. For example,
slowly increase the distance you park from the market.
Are golf and tennis safe for people with osteoporosis?
Golf and tennis involve forward bending of the back, twisting of the back,
and impact with the ball. Therefore, these are not the best activities for
people with severe osteoporosis. Consult your medical professional for
individual advice.
Are exercise classes safe for people with osteoporosis?
Many exercise classes are safe. Classes can provide personal support to
help you stay with your exercise program. During any class, you need to
avoid forward bending of the back, twisting the back, and impact
(jumping).
Are there types of exercise equipment in gyms or at home that
should not be used by people with osteoporosis?
Equipment that makes it easy to bend the back forward or twist the back
should be avoided unless you are sure you are using the equipment
without bending or twisting the back. Examples of equipment that make
it easy to bend or twist the back are rowing machines, cross-country ski
machines, bicycles with reciprocal arm movements, and weight machines
to strengthen the biceps muscles of the arms.
59
Appendix 5: Sample Session 4 Action Guide
The table below provides a sample Action Guide to help you as you
develop your own. Remember, your Action Guide should fit your unique
needs and lifestyle.
Bone Health
Behavior
My New Goal
For This Behavior
My Daily Plan to
Achieve My Goal
Obtain 20-30
minutes of exercise
at least 3-4 times
per week
My new goal is to
increase the number of
days that I exercise by
2 days per week*
New Behaviors: I will
join a T’ai Chi class.
I will walk to the mail
box each day.
Current Behaviors
to Continue: I will
continue to walk with
Maria at the mall for
30 minutes on Mondays
and Wednesdays.
Include exercises
that will maintain
my bone density
and improve my
balance
My goal is to include
exercises that will
improve my balance*
New Behaviors: I will
join a T’ai Chi class.
*determined in Self-Assessment I
Next Steps
By When?
I need to determine when the T’ai Chi classes
start.
By next Friday
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